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Atypical Presentation of Exophytic Herpes Simplex Virus Type 2 With Concurrent Cytomegalovirus Infection: A Significant Pitfall in Diagnosis

Researchers here find an association in an older study population between the presence of cytomegalovirus (CMV) – and other common herpesviruses – and the observed degree of cognitive decline. With the same cases we extended the investigation to cytomegalovirus (CMV) and herpes simplex virus (HSV) infections. Initial clinical differential included genital warts, syphilis, versus cutaneous malignancy. Les HSV et le VZV ont de plus une thymidine kinase virale, le CMV et l’HHV-6 une phosphotransf rase qui phosphorylent les nucl osides naturels ou les nucl osides synth tiques antiviraux. Six seroconversions were observed: two VZV, one CMV and three parvovirus infections. These data suggest that HCMV, like HSV-1 and VZV, can be (re)activated under stress conditions. 8 herpesvirus types that infect humans: herpes simplex viruses 1 and 2, varicella-zoster virus, EBV (Epstein-Barr virus), human cytomegalovirus, human herpesvirus 6, human herpesvirus 7, and Kaposi’s sarcoma-associated herpesvirus.

In addition, we review the existing literature on these rare entities and compare our cases with prior reports. As we learn more about the role that infectious agents play in the brain, we might develop new prevention strategies for cognitive impairment.” Now, the researchers are trying to determine if there are subgroups of people whose brains are more vulnerable to the effects of chronic viral infection. Briefly, 5-mm sections were obtained from formalinfixed, paraffin-embedded block preparations. After antigen retrieval with 0.02 M citrate buffer (pH 6.0) CC1 at 120°C for 30 minutes for HSV and 97°C for 20 minutes for CMV, immunostaining was performed using prediluted HSV I and II antibodies (Cell Marque) and CMV DDG9 and CCH2 clone (DAKO) at 1:200 dilution. The immunostaining for the HSV was performed on a semiautomated immunostainer from Ventana Inc using a streptavidin–biotin–peroxidase approach and for CMV on a Labvision 720 semiautomated immunostainer from Thermo Scientific using UltraVision LP polymer system. The tissues were counterstained with hematoxylin. Appropriate positive and negative control slides were prepared.

CMV is a common infection that is usually harmless. Patient #1 was a 50-year-old African American woman with a history of unrelated donor kidney transplant who presented to the nephrology clinic with a 1-year history of cutaneous lesions that gradually developed into fungating exophytic skin plaques on her upper thighs, inguinal folds, mons pubis, and lower abdomen (). Clinical differential diagnosis included Candida infection and hematologic and cutaneous malignancies. The patient was referred to inpatient dermatology consultation service where a biopsy was performed. After HSV/CMV coinfection diagnosis, the patient was treated with intravenous ganciclovir and mupirocin, and the immunosuppressive therapy was reduced. The lesions showed clinical improvement with resolution of erythema and suppuration at 6 days after treatment. Repeat CMV testing by polymerase chain reaction (PCR) after 3 weeks of treatment showed 1 year (4 years for patient #2) while seeing multiple physicians before correct diagnosis by the dermatologist and dermatopathologist.

In view of this clinical scenario, histological evaluation may overinterpret the pseudoepitheliomatous hyperplasia seen in some of these cases as a well-differentiated squamous cell carcinoma and overlook focal viral changes. Human herpes virus 1 (HHV1) is also known as herpes simplex virus 1 (HSV1). It is worth mentioning also that both patients #1 and #2 were CMV positive recipients at the time of renal transplant and had been treated posttransplant with acyclovir prophylaxis. In both cases, the lesions developed only after this antiviral prophylaxis had been discontinued. In conclusion, the 3 cases described highlight the atypical presentation of cutaneous HSV type 2 and CMV coinfection as fungating exophytic lesions. Because CMV and HSV are among the most common infections occurring in immunocompromised patients, they should always be in the differential diagnosis for infectious processes in these patients. Heightened awareness of atypical presentations of HSV and CMV infections in immunocompromised patients and a high index of suspicion will result in rapid diagnosis and prompt broadcoverage antiviral treatment leading to a better patient outcome.

We encourage reporting of further cases of concurrent CMV and HSV cutaneous infections, particularly those that have an atypical presentation or occur in non-HIV immunocompromised patients.