Abstract

Herpes simplex virus 2 (HSV-2) is the main causative agent of genital herpes infection and less commonly orolabial herpes infection. In patients with HIV, herpes infection can be extensive with treatment resistance, prolonged duration of disease, and recurrence risk. Rarely, hypertrophic, lymphomatous, or tumoral-like lesions can appear in the setting of proliferative HSV-2 infection. Herein we present a case of acyclovir resistant tumoral HSV-2 infection of the lip and penis. A 48-year-old man presented with a 4.5 x 2.5 cm exophytic ulcerated tumor of the left upper lip and a concurrent 5 x 5 cm multilobulated exophytic ulcer of the distal dorsal penile shaft. He was initially started on oral acyclovir empirically and experienced progression of disease. Punch biopsies of both sites were performed. Histopathologic examination revealed epidermal ulceration with viral cytopathic effect, consistent with herpes viral infection in a background of inflammation. To further characterize the process, additional incisional biopsies were performed in conjunction with viral cultures and antiviral resistances studies. Histopathologic examination of these samples showed ulceration with characteristic herpes viral inclusions with a background of a prominent lymphoplasmacytic infiltrate. Thus T. pallidum immunostain was performed, which was negative, and IgH gene rearrangement was negative for a lymphoproliferative disorder. Cultures and sensitivities showed HSV-2 infection with acyclovir resistance. The patient was trialed on cidofovir 5 mg/kg/dose IV for 3 doses, which resulted in minimal improvement of the ulcerated lip and dorsal penile plaques. Monthly intralesional cidofovir was then initiated with improvement in disease; this treatment is ongoing.