Case for Diagnosis
Ulcerative nodules on the perineum
Nódulos ulcerados perianales
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Yen, K.-L. Chen, T.-F. Tsai" "autores" => array:3 [ 0 => array:3 [ "nombre" => "C.-F." "apellidos" => "Yen" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "K.-L." "apellidos" => "Chen" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:4 [ "nombre" => "T.-F." "apellidos" => "Tsai" "email" => array:1 [ 0 => "tftsai@yahoo.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Dermatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Dermatology, National Taiwan University Hospital, Taipei, Taiwan" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nódulos ulcerados perianales" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 500 "Ancho" => 385 "Tamanyo" => 73534 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical history</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 34-year-old, homosexual male patient with a history of infection with human immunodeficiency virus (HIV), disseminated tuberculosis, Salmonella infectious diarrhea, herpes zoster and neurosyphilis presented to our dermatology clinic with a 3-week history of painful perianal nodules. At first, he had been taking 250<span class="elsevierStyleHsp" style=""></span>mg of oral cephalexin four times a day and using topical chloramphenicol ointment for several weeks without improvement. He had been under treatment with antiretroviral therapy regularly: 600<span class="elsevierStyleHsp" style=""></span>mg of efavirenz daily and one tablet of lamivudine/zidovudine twice daily for HIV for seven years.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination showed two painful, 1-cm wide, erythematous nodules in the perianal area (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The nodules were hard with superficial ulceration and much discharge.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">A punch biopsy of a nodule in the perianal area was performed. Hematoxylin•eosin staining showed pseudoepitheliomatous hyperplasia with exocytosis and parakeratosis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). In the dermis, acute and chronic inflammation with mixed lymphohistiocytes, eosinophils, neutrophils and plasma cells were noticed (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Additional tests</span><p id="par0020" class="elsevierStylePara elsevierViewall">His latest CD4 count, measured one month prior to the development of ulcerative nodules, was 427/α/4L (normal range: 500•1500/α/4L). The spirochete immunostain and periodic acid-Schiff stain were both negative. Moreover, the venereal disease research laboratory test showed 1:1 (weakly reactive), and viral isolation by culture from the tissue specimen was positive for herpes simplex type 2 (HSV-2).</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What is your diagnosis?</span></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Nodular perianal herpes simplex.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical course and treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">After diagnosis with herpes simplex, he was treated with 1<span class="elsevierStyleHsp" style=""></span>g of valcyclovir twice daily for two subsequent months with the nearly complete resolution of the cutaneous lesions.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Comment</span><p id="par0040" class="elsevierStylePara elsevierViewall">HIV-positive patients have high rates of HSV-2 infection, ranging from 50% to 90% in different studies.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> The relationship between genital HSV-2 and HIV has been termed a syndemic. Genital HSV-2 infection is the leading cause of genital ulcers worldwide, particularly in immunocompromised patients. However, the clinical presentations of genital HSV-2 infection in HIV are variable.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Clinical manifestations of HSV-2 in HIV include nodular, hypertrophic, tumor-like, vegetative or ulcerative growths simulating neoplasms. It has been suggested that an overstimulated inflammatory response that follows immune restoration after highly active antiretroviral therapy (HAART) initiation could be responsible for nodular and vegetative presentations of genital herpes infection.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> However, our patient developed nodular HSV lesions seven years after HAART initiation, in marked contrast to what most studies have reported.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The nodular HSV lesions were of atypical morphology and mimicked other opportunistic infections such as syphilis, molluscum contagiosum, Kaposi sarcoma, and other lymphoproliferative tumors. Thus, biopsy was often necessary for correct diagnosis. Because HIV-positive individuals are also at higher risk of developing anogenital malignancies and lymphomas, when an HIV-infected individual presents with a nodular mass that lacks the characteristic clinical and histopathological features of herpes, HSV is often overlooked and the concern for lymphoma or anogenital malignancies rises.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Histopathologically, features of herpes generally show a dense chronic inflammatory infiltrate composed mainly of plasma cells mixed with eosinophils and lymphocytes. Typically, there are also multinucleated giant cells with steel-gray molded nuclei, ground-glass chromatin, and acantholytic keratinocytes.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Nonetheless, the histology may fail to show typical viral inclusion bodies or multinucleated giant cells, and HSV cultures are often negative. Polymerase chain reaction and immunohistochemistry may be necessary to detect the virus.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> Our case showed a large number of plasma cells mixed with eosinophils and lymphocytes in the dermis, and viral isolation by culture from the tissue specimen was positive for HSV-2.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In previous studies, most cases of HSV in HIV-positive patients have presented with a prolonged clinical course of disease and only a few were rapidly growing masses. The present case showed a relatively rapid growth of only three weeks duration. Two 1-cm painful nodules exhibited superficial ulceration.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Treatment of atypical HSV infection in HIV-positive individuals requires a high-dose and long-term therapy with acyclovir.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> Antiviral therapies are effective and safe for suppressive and episodic treatment of HSV in HIV-positive patients.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical history" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Histopathology" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Additional tests" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnosis" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical course and treatment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Comment" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:3 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 500 "Ancho" => 385 "Tamanyo" => 73534 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1133 "Ancho" => 872 "Tamanyo" => 329189 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin•eosin í100.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1133 "Ancho" => 872 "Tamanyo" => 451984 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin•eosin í200.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology of herpes simplex virus type 2 infection in the developing world" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "H. Weiss" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Herpes" "fecha" => "2004" "volumen" => "11" "paginaInicial" => "24A" "paginaFinal" => "35A" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15115627" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0040" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Genital and perianal herpes simplex simulating neoplasia in patients with AIDS" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Mosunjac" 1 => "J. Park" 2 => "W. Wang" 3 => "T. Tadros" 4 => "M. Siddiqui" 5 => "M. Bagirov" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1089/apc.2008.0143" "Revista" => array:6 [ "tituloSerie" => "AIDS Patient Care STDS" "fecha" => "2009" "volumen" => "23" "paginaInicial" => "153" "paginaFinal" => "158" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19302018" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0045" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dermatologic manifestations of immune reconstitution inflammatory syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R. Lehloenya" 1 => "G. Meintjes" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.det.2006.06.007" "Revista" => array:6 [ "tituloSerie" => "Dermatol Clin" "fecha" => "2006" "volumen" => "24" "paginaInicial" => "549" "paginaFinal" => "570" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17010783" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0050" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nodular perianal herpes simplex with prominent plasma cell infiltration" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "E. Gubinelli" 1 => "B. Cocuroccia" 2 => "T. Lazzarotto" 3 => "G. Girolomoni" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Sexually Transm Dis" "fecha" => "2003" "volumen" => "30" "paginaInicial" => "157" "paginaFinal" => "159" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0055" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tumour-like presentations of anogenital herpes simplex in HIV-positive patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "H. Ranu" 1 => "J. Lee" 2 => "M. Chio" 3 => "P. Sen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1258/ijsa.2010.010204" "Revista" => array:6 [ "tituloSerie" => "Int J STD AIDS" "fecha" => "2011" "volumen" => "22" "paginaInicial" => "181" "paginaFinal" => "186" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21515747" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0060" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of herpes simplex virus type 2 infection in HIV type 1 infected persons" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L.B. Strick" 1 => "A. Wald" 2 => "C. Celcum" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/505496" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2006" "volumen" => "43" "paginaInicial" => "347" "paginaFinal" => "356" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16804851" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010900000004/v1_201805040442/S1578219018301409/v1_201805040442/en/main.assets" "Apartado" => array:4 [ "identificador" => "6154" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case for Diagnosis" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010900000004/v1_201805040442/S1578219018301409/v1_201805040442/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219018301409?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 7 | 14 |
| 2024 October | 80 | 34 | 114 |
| 2024 September | 62 | 19 | 81 |
| 2024 August | 97 | 59 | 156 |
| 2024 July | 61 | 30 | 91 |
| 2024 June | 62 | 31 | 93 |
| 2024 May | 50 | 31 | 81 |
| 2024 April | 70 | 34 | 104 |
| 2024 March | 53 | 22 | 75 |
| 2024 February | 51 | 35 | 86 |
| 2024 January | 49 | 31 | 80 |
| 2023 December | 37 | 11 | 48 |
| 2023 November | 50 | 21 | 71 |
| 2023 October | 42 | 18 | 60 |
| 2023 September | 36 | 31 | 67 |
| 2023 August | 30 | 17 | 47 |
| 2023 July | 44 | 30 | 74 |
| 2023 June | 32 | 18 | 50 |
| 2023 May | 41 | 20 | 61 |
| 2023 April | 41 | 26 | 67 |
| 2023 March | 47 | 22 | 69 |
| 2023 February | 35 | 27 | 62 |
| 2023 January | 30 | 37 | 67 |
| 2022 December | 33 | 38 | 71 |
| 2022 November | 20 | 18 | 38 |
| 2022 October | 15 | 19 | 34 |
| 2022 September | 23 | 34 | 57 |
| 2022 August | 19 | 31 | 50 |
| 2022 July | 17 | 36 | 53 |
| 2022 June | 19 | 22 | 41 |
| 2022 May | 26 | 27 | 53 |
| 2022 April | 38 | 37 | 75 |
| 2022 March | 55 | 42 | 97 |
| 2022 February | 45 | 29 | 74 |
| 2022 January | 38 | 45 | 83 |
| 2021 December | 39 | 46 | 85 |
| 2021 November | 40 | 53 | 93 |
| 2021 October | 30 | 52 | 82 |
| 2021 September | 37 | 57 | 94 |
| 2021 August | 33 | 45 | 78 |
| 2021 July | 35 | 43 | 78 |
| 2021 June | 36 | 39 | 75 |
| 2021 May | 34 | 57 | 91 |
| 2021 April | 73 | 91 | 164 |
| 2021 March | 76 | 52 | 128 |
| 2021 February | 60 | 37 | 97 |
| 2021 January | 47 | 42 | 89 |
| 2020 December | 37 | 45 | 82 |
| 2020 November | 33 | 47 | 80 |
| 2020 October | 37 | 18 | 55 |
| 2020 September | 24 | 23 | 47 |
| 2020 August | 22 | 23 | 45 |
| 2020 July | 26 | 27 | 53 |
| 2020 June | 30 | 41 | 71 |
| 2020 May | 17 | 13 | 30 |
| 2020 April | 20 | 15 | 35 |
| 2020 March | 15 | 14 | 29 |
| 2020 February | 1 | 0 | 1 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 8 | 0 | 8 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 10 | 0 | 10 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 6 | 0 | 6 |
| 2019 April | 6 | 0 | 6 |
| 2019 March | 2 | 0 | 2 |
| 2019 February | 2 | 0 | 2 |
| 2018 December | 2 | 0 | 2 |
| 2018 November | 5 | 0 | 5 |
| 2018 September | 2 | 0 | 2 |
Show all
