Atypical Perianal Herpes Simplex Infection in HIV-Positive Patients

Anal lesions affect up to 34% of patients with Acquired Immunodeficiency Syndrome (AIDS), and are more frequent in males who have sex with males (MSM). The most common anal infection in human immunodeficiency virus (HIV)-positive patients is caused by human papillomavirus (HPV). It is suggested that the appearance of this illness is related to the conversion of HIV into AIDS. Even with the introduction of highly-active antiretroviral therapy (HAART), the prevalence of HPV infection in HIV-positive patients has not decreased, nor has anal cancer incidence. It is well-known that HPV infection in HIV-positive patients is a risk factor for the development of squamous cell cancer of the anus. Routine screening is strongly recommended in this population in order to identify premalignant lesions. 6 HPV infection frequently manifests as verrucous lesions (warts) that cause pruritus, discomfort, and, more rarely, pain or bleeding. However, some other infectious agents such as varicella-zoster virus (VZV), cytomegalovirus (CMV), molluscum contagiosum (MC), and particularly herpes simplex virus (HSV), can also cause verrucous skin lesions in HIV-positive patients. Herpes simplex virus is found in 29% of MSM with symptomatic anorectal disease, although the majority of confirmed herpes simplex cases are reported in asymptomatic individuals. The most frequently encountered findings are ulcerated aphthous lesions, vesicles and inguinal lymphadenopathy. Additional signs and symptoms include pain, pruritus, lymphadenopathy, superficial ulcers, vesicular erosion, urinary retention and constipation. A very small number of cases of verrucous herpes of the perineum have been reported in the English medical literature and treatment options varied, including the use of acyclovir, valacyclovir and surgical resection. We report a case of a perianal verrucous lesions that was initially suspected to be anal neoplasia, but was revealed to be a herpes infection. The patient required surgical resection after antiviral therapy failure. This article reviews the literature in order to describe the main characteristics of patients with verrucous perineal herpes infection and the outcomes of different treatment modalities.