19 July 2006 – Case of the Week #53

 

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We thank Dr. Sarah Webb, Harris Methodist HEB, Bedford, Texas (USA) for contributing this case.  We invite you to contribute a Case of the Week by sending an email to NPernick@PathologyOutlines.com with microscopic images (any size, we will shrink if necessary) in JPG or GIF format, a short clinical history, your diagnosis and any other images (gross, immunostains, EM, etc.) that may be helpful or interesting.  We will write the discussion (unless you want to), list you as the contributor, and send you a check for $35 (US) for your time after we send out the case.  Please only send cases with a definitive diagnosis. 

 

Case of the Week #53

 

Clinical history

 

The patient is HIV positive and from Ghana.  She had a large, fungated vulvar mass that clinically was thought to be malignant.  However, three biopsies showed only acanthosis and inflammation.  It was finally excised.

 

Gross images: gross image (note - very graphic)

 

Microscopic images: image1image2HSV immunostain

 

What is your diagnosis? 

 

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Diagnosis:

 

Hypertrophic herpes simplex virus in HIV positive patient

 

Discussion

 

There are only a few reports of herpes simplex virus lesions in HIV patients that present as chronic, hyperproliferative plaques or masses, as opposed to the classic ulcerative lesions.  In 2003, Fangman reported a 44 year-old African American man with a hypertrophic gluteal cleft plaque of two months duration (J Drugs Dermatol 2003;2:198) .  Treatment was ineffective for this patient.

 

In 2005, Nadal reported on 5 patients with painful verrucous perianal lesions, all caused by HSV (Dis Colon Rectum 2005;48:2289).  All patients had chronic AIDS and were receiving highly active antiretroviral therapy.  Biopsies showed epithelial hyperplasia and a brisk inflammatory infiltrate composed mainly of lymphocytes and plasma cells.  Immunohistochemistry was positive for HSV.  Three patients had recurrences.

 

Finally, also in 2005, Holmes et al. reported on 3 similar cases which were also difficult to treat (BHIVA Conf 2005 Apr 20-23;11:PA8).

 

Pathologists should be aware of this apparently new clinical entity in HIV positive patients, which may clinically appear malignant.

 

 

 

Nat Pernick, M.D.
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