Hypertrophic genital herpes in an HIV-infected female patient: Imiquimod as an alternative treatment

Herpes Simplex Virus (HSV) is the leading cause of genital ulcers worldwide. In Human Immunodeficiency Virus (HIV) co-infected individuals, rare hypertrophic pseudo-tumoral forms have been described as simulating squamous cell carcinoma or other viral infections such as those caused by Varicella zoster, Molluscum contagiosum and HPV induced lesions. Here, we report a case of hypertrophic genital herpes in an HIV-infected patient effectively treated with surgery and topical 5% imiquimod after the recurrence of lesions. A 45-year-old woman, HIV-positive for 17 years and on regular antiretroviral therapy, presented with a painful 2 cm vulvar sessile lesion, a 1 cm ulcerated lesion on the clitoral hood, and a slightly elevated lesion in the middle third of the tongue. Excisional biopsy and surgical removal of lesion were performed for histopathological exam. Histopathology of genital lesions showed evidence of chronic lymphoplasmacytic inflammation, intense ulcerated plasmacytosis, and squamous cells displaying HSV cytopathogenic effect. After three months, the patient presented with a new ulcerated perineal lesion. Histopathology showed evidence of chronic ulcerative-vegetative herpetic dermatitis. Consequently, topical 5% imiquimod was administered with successful results. Relapsing character and atypical genital disease evolution with an exophytic pseudotumoral injury have been noted in patients co-infected with HIV and HSV, necessitating anatomopathological recognition for diagnostic confirmation and exclusion of malignancy. Local immunotherapy should be considered as treatment approach. (C) 2020 The Author(s). Published by Elsevier Ltd on behalf of International Society for Infectious Diseases.