Abstract
A 42-year-old man with a past medical history of drug-resistant HIV and Kaposi sarcoma presented with a growing plaque on the scrotum that was purulent and painful. On physical exam, he had an exophytic beefy plaque with fibrinous exudate on the inferior scrotum. Tissue culture showed light growth MRSA with few colonies of coagulase-negative staphylococcus. Fungal, acid-fast bacterial, and HSV cultures were negative. Histopathology showed skin with ulceration, focal epidermal necrosis, greyish nuclear inclusion bodies, as well as acute and chronic inflammation consisting of eosinophils, plasma cells, lymphocytes, and neutrophils. Cells with viral cytopathic changes were positive for HSV staining, while negative for CMV, PAS, GMS, and spirochete stains. The patient was diagnosed with herpes vegetans. At follow up, he declined hospital admission for IV treatment and thus was prescribed valacyclovir 1 g PO BID. After two weeks, valacyclovir showed no improvement in symptoms. Repeat tissue culture performed which no HSV isolated. Inpatient IV foscanet was recommended and patient currently pending treatment. This case highlights herpes vegetans, a rare variant of cutaneous HSV that presents as chronic ulcerations, eroded plaques, papular eruptions, or verrucous lesions.1.2 Histopathology typically shows multinucleated keratinocytes and eosinophilic intranuclear viral inclusions with inflammatory infiltrate.2 Biopsy is crucial in the workup, as superficial viral cultures are often negative, and HSV immunostaining confirms the diagnosis.2 Acyclovir-resistant herpes vegetans presents a clinical challenge as it leads to more frequent and severe recurrences.2 The literature reports IV or intralesional cidofovir, IV foscarnet, topical imiquimod, or topical trifluridine as treatment options.2,3