Anus & perianal
Benign / nonneoplastic lesions
Hypertrophic HSV in HIV+ patients

Topic Completed: 1 May 2014

Minor changes: 20 August 2019

Copyright: 2002-2019,, Inc.

PubMed Search: Hypertrophic HSV

Elliot Weisenberg, M.D.
Page views in 2019: 646
Page views in 2020 to date: 211
Cite this page: Weisenberg E. Hypertrophic HSV in HIV+ patients. website. Accessed May 24th, 2020.
Definition / general
  • Unusual chronic anogenital herpes simplex virus (HSV) infection in patients infected with human immunodeficiency virus (HIV) associated with prominent verrucoid / pseudoepitheliomatous squamous hyperplasia
  • Also known as progressive hypertrophic genital herpes, chronic hypertrophic herpes, hypertrophic herpes simplex genitalis
  • Very rare
  • Patients may be on highly active antiretrovirus therapy (HAART) with CD4+ T cell counts from 14 to over 600
  • HIV viral loads range from undetectable to very elevated
  • May occur as part of immune reconstitution inflammatory syndrome (IRIS) when HAART therapy is instituted
  • Most cases involve HSV type 2, however, HSV type 1 has also been reported
  • Anogenital, same sites as usual anogenital HSV, rarely other sites
  • Poorly understood
  • Possible factors include (a) cytokines released by chronic inflammatory cells, (b) altered function of plasmacytoid dendritic cells, (c) defect in host immunity (supported by response to imiquimod, a compound that increases antiviral immune response)
Clinical features
  • Painful nodules, papules, vegetative or condylomatous lesions, usually with ulceration
  • May mimic condyloma, lymphoma, squamous cell carcinoma
  • Biopsy demonstrates characteristic inclusions that may be lacking in superficial biopsies
  • Immunohistochemical or molecular confirmation of HSV (note: HSV cannot be distinguished from herpes varicella zoster by morphology alone)
  • Viral culture or PCR for HSV
Case reports
  • Usual antiviral agents against HSV (acyclovir, famciclovir, valacyclovir) may not be effective
  • Immunomodulating agents (imiquimod, thalidomide) have been reported to be effective
Clinical images

Case of the Week #53

Vulvar mass

Microscopic (histologic) description
  • Prominent pseudoepitheliomatous hyperplasia / acanthosis of squamous mucosa or perianal skin
  • Base of lesion contains a dense lymphoplasmacytic infiltrate
  • Variable ulceration or granulation tissue, HSV nuclear inclusions or multinucleation, squamous intraepithelial lesion
  • Rare reports of associated invasive malignancy
  • Small or superficial biopsies may not show evidence of HSV infection
Microscopic (histologic) images

Case of the Week #53

Vulvar mass

HSV immunostain

Images hosted on other servers:

Labial mass

Positive stains
  • HSV
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