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. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 9 | 7 | 16 |
| 2024 Octubre | 80 | 34 | 114 |
| 2024 Septiembre | 62 | 19 | 81 |
| 2024 Agosto | 97 | 59 | 156 |
| 2024 Julio | 61 | 30 | 91 |
| 2024 Junio | 62 | 31 | 93 |
| 2024 Mayo | 50 | 31 | 81 |
| 2024 Abril | 70 | 34 | 104 |
| 2024 Marzo | 53 | 22 | 75 |
| 2024 Febrero | 51 | 35 | 86 |
| 2024 Enero | 49 | 31 | 80 |
| 2023 Diciembre | 37 | 11 | 48 |
| 2023 Noviembre | 50 | 21 | 71 |
| 2023 Octubre | 42 | 18 | 60 |
| 2023 Septiembre | 36 | 31 | 67 |
| 2023 Agosto | 30 | 17 | 47 |
| 2023 Julio | 44 | 30 | 74 |
| 2023 Junio | 32 | 18 | 50 |
| 2023 Mayo | 41 | 20 | 61 |
| 2023 Abril | 41 | 26 | 67 |
| 2023 Marzo | 47 | 22 | 69 |
| 2023 Febrero | 35 | 27 | 62 |
| 2023 Enero | 30 | 37 | 67 |
| 2022 Diciembre | 33 | 38 | 71 |
| 2022 Noviembre | 20 | 18 | 38 |
| 2022 Octubre | 15 | 19 | 34 |
| 2022 Septiembre | 23 | 34 | 57 |
| 2022 Agosto | 19 | 31 | 50 |
| 2022 Julio | 17 | 36 | 53 |
| 2022 Junio | 19 | 22 | 41 |
| 2022 Mayo | 26 | 27 | 53 |
| 2022 Abril | 38 | 37 | 75 |
| 2022 Marzo | 55 | 42 | 97 |
| 2022 Febrero | 45 | 29 | 74 |
| 2022 Enero | 38 | 45 | 83 |
| 2021 Diciembre | 39 | 46 | 85 |
| 2021 Noviembre | 40 | 53 | 93 |
| 2021 Octubre | 30 | 52 | 82 |
| 2021 Septiembre | 37 | 57 | 94 |
| 2021 Agosto | 33 | 45 | 78 |
| 2021 Julio | 35 | 43 | 78 |
| 2021 Junio | 36 | 39 | 75 |
| 2021 Mayo | 34 | 57 | 91 |
| 2021 Abril | 73 | 91 | 164 |
| 2021 Marzo | 76 | 52 | 128 |
| 2021 Febrero | 60 | 37 | 97 |
| 2021 Enero | 47 | 42 | 89 |
| 2020 Diciembre | 37 | 45 | 82 |
| 2020 Noviembre | 33 | 47 | 80 |
| 2020 Octubre | 37 | 18 | 55 |
| 2020 Septiembre | 24 | 23 | 47 |
| 2020 Agosto | 22 | 23 | 45 |
| 2020 Julio | 26 | 27 | 53 |
| 2020 Junio | 30 | 41 | 71 |
| 2020 Mayo | 17 | 13 | 30 |
| 2020 Abril | 20 | 15 | 35 |
| 2020 Marzo | 15 | 14 | 29 |
| 2020 Febrero | 1 | 0 | 1 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 8 | 0 | 8 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Septiembre | 10 | 0 | 10 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 4 | 0 | 4 |
| 2019 Mayo | 6 | 0 | 6 |
| 2019 Abril | 6 | 0 | 6 |
| 2019 Marzo | 2 | 0 | 2 |
| 2019 Febrero | 2 | 0 | 2 |
| 2018 Diciembre | 2 | 0 | 2 |
| 2018 Noviembre | 5 | 0 | 5 |
| 2018 Septiembre | 2 | 0 | 2 |
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