Correspondence Clinical Letter
Clinical letter Vegetating foot ulcer as presenting sign of acquired immunodeficiency syndrome
DOI: 10.1111/ddg.12255
Dear Editors, Herpes simplex virus (HSV) type 1 and 2 are common and well known human companions. In the immunocompromised host, however, mucocutaneous lesions can be extensive or appear at unusual sites with atypical presentation [1, 2] thus posing a diagnostic challenge, as shown in the following case. A 62-year-old Caucasian man presented with a 5 × 5 cm large interdigital ulcer on his right foot involving also the distal metatarsal zone. Medical history was inconspicuous and the patient denied any recreational drug use. The ulcer developed within a week, was painful, with polycyclic edges and erythematous swollen perilesional skin (Figure 1). Fever or other constitutional symptoms were absent. The patient denied any trauma or diabetes. Swabs from the ulcer revealed massive growth of Pseudomonas aeruginosa. Therapy with ciprofloxacin and subsequently intravenous ceftazidime for suspected gram negative foot infection was initiated. The ulcer did not improve despite antibiotic therapy and a biopsy was performed to exclude malignancy. Histological examination revealed an ulcerated epidermis with a mixed inflammatory infiltrate of neutrophils, lymphocytes and macro-
Figure 1 Large interdigital ulcer on the right foot involving also the distal metatarsal zone, with polycyclic, sloping edges and erythematous swollen perilesional skin.
phages. Higher magnification showed keratinocytes with ballooned nuclei and giant multinucleated keratinocytes, which suggested the diagnosis of herpes infection (Figure 2a). Immunochemistry confirmed the presence of HSV type 1 (Figure 2b) and the diagnosis of “chronic, vegetating herpes simplex infection” was made. The patient was treated with valacyclovir 1 000 mg t.i.d. for two weeks, along with topical antiseptic therapy (10 % povidone iodine solution), leading to complete resolution of the ulcer within two weeks (Figure 3). Laboratory tests to exclude immunodeficiency and other sexually transmitted diseases revealed HIV positivity, with a CD4 count of 180 cells/μL and a positive syphilis serology (VDRL 1 : 32, TPPA > 1 : 10 240). Highly active antiretroviral therapy was started and after negative cerebrospinal
Figure 2 Histological examination, showing ulcerated epidermis, keratinocytes with ballooned nuclei with a ground-glass appearance and giant multinucleated keratinocytes (H&E original magnification x 400) (a). Positive immunochemistry for HSV type 1 (original magnification x 400, Polyclonal, Novocastra dilution 1 : 400, pH6) (b).
© 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014/1203
265
Correspondence Clinical Letter
Jenny Deluca1, Franco Perino1, Josefine Maier 1, Reinhard Kluge2, Guido Mazzoleni2, Klaus Eisendle1 (1) Teaching Department of Dermatology, General Hospital of Bolzano, Bolzano/Bozen, Italy (2) Department of Pathology, General Hospital of Bolzano, Bolzano/Bozen, Italy
Correspondence to Jenny Deluca General Hospital of Bolzano Teaching Department of Dermatology L. Boehler Str. Nr 5 39100 Bolzano/Bozen Italy
Figure 3 Complete healing of the ulcer after two weeks treatment with systemic valacyclovir.
fluid examination to exclude neurosyphilis, the patient was additionally treated for latent syphilis with intramuscular benzathine penicillin 2.4 million units weekly for 3 weeks. Chronic non-healing ulcers of more than one month of duration despite adequate therapy require biopsies to exclude malignancy or chronic infections. In the case of vegetating herpes infections, immunosuppression should be excluded. Herpetic infections of the foot are rarely described in the literature, most of them representing herpetic whitlows [3–6]. This is the first report of a chronic herpetic lesion of the foot in a HIV-positive patient. The only other case of a chronic herpetic foot ulcer was described in a patient with acute leukemia [7]. A possible direct inoculation of the virus [8] (e. g. autoinoculation or sexual practices like fetishism) seems likely; another possible explanation could be a zosteriform neural transmission from infected sacral ganglia [9], which might lead to herpetic eruptions in the corresponding dermatome [4]. Although the patient did not have any concomitant herpetic lesions, he did have a history of genital herpes. Special attention is needed for elderly patients. The availability of drugs that make possible sexual activity in the elderly also prolongs the age at risk for sexually transmitted infections. In advanced age, HIV compromises an immune system already weakened by aging, facilitating a more rapid progression of the disease [10]. HIV infection associated with CD4 T-lymphocyte count of
Clinical letter Vegetating foot ulcer as presenting sign of acquired immunodeficiency syndrome
DOI: 10.1111/ddg.12255
Dear Editors, Herpes simplex virus (HSV) type 1 and 2 are common and well known human companions. In the immunocompromised host, however, mucocutaneous lesions can be extensive or appear at unusual sites with atypical presentation [1, 2] thus posing a diagnostic challenge, as shown in the following case. A 62-year-old Caucasian man presented with a 5 × 5 cm large interdigital ulcer on his right foot involving also the distal metatarsal zone. Medical history was inconspicuous and the patient denied any recreational drug use. The ulcer developed within a week, was painful, with polycyclic edges and erythematous swollen perilesional skin (Figure 1). Fever or other constitutional symptoms were absent. The patient denied any trauma or diabetes. Swabs from the ulcer revealed massive growth of Pseudomonas aeruginosa. Therapy with ciprofloxacin and subsequently intravenous ceftazidime for suspected gram negative foot infection was initiated. The ulcer did not improve despite antibiotic therapy and a biopsy was performed to exclude malignancy. Histological examination revealed an ulcerated epidermis with a mixed inflammatory infiltrate of neutrophils, lymphocytes and macro-
Figure 1 Large interdigital ulcer on the right foot involving also the distal metatarsal zone, with polycyclic, sloping edges and erythematous swollen perilesional skin.
phages. Higher magnification showed keratinocytes with ballooned nuclei and giant multinucleated keratinocytes, which suggested the diagnosis of herpes infection (Figure 2a). Immunochemistry confirmed the presence of HSV type 1 (Figure 2b) and the diagnosis of “chronic, vegetating herpes simplex infection” was made. The patient was treated with valacyclovir 1 000 mg t.i.d. for two weeks, along with topical antiseptic therapy (10 % povidone iodine solution), leading to complete resolution of the ulcer within two weeks (Figure 3). Laboratory tests to exclude immunodeficiency and other sexually transmitted diseases revealed HIV positivity, with a CD4 count of 180 cells/μL and a positive syphilis serology (VDRL 1 : 32, TPPA > 1 : 10 240). Highly active antiretroviral therapy was started and after negative cerebrospinal
Figure 2 Histological examination, showing ulcerated epidermis, keratinocytes with ballooned nuclei with a ground-glass appearance and giant multinucleated keratinocytes (H&E original magnification x 400) (a). Positive immunochemistry for HSV type 1 (original magnification x 400, Polyclonal, Novocastra dilution 1 : 400, pH6) (b).
© 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014/1203
265
Correspondence Clinical Letter
Jenny Deluca1, Franco Perino1, Josefine Maier 1, Reinhard Kluge2, Guido Mazzoleni2, Klaus Eisendle1 (1) Teaching Department of Dermatology, General Hospital of Bolzano, Bolzano/Bozen, Italy (2) Department of Pathology, General Hospital of Bolzano, Bolzano/Bozen, Italy
Correspondence to Jenny Deluca General Hospital of Bolzano Teaching Department of Dermatology L. Boehler Str. Nr 5 39100 Bolzano/Bozen Italy
Figure 3 Complete healing of the ulcer after two weeks treatment with systemic valacyclovir.
fluid examination to exclude neurosyphilis, the patient was additionally treated for latent syphilis with intramuscular benzathine penicillin 2.4 million units weekly for 3 weeks. Chronic non-healing ulcers of more than one month of duration despite adequate therapy require biopsies to exclude malignancy or chronic infections. In the case of vegetating herpes infections, immunosuppression should be excluded. Herpetic infections of the foot are rarely described in the literature, most of them representing herpetic whitlows [3–6]. This is the first report of a chronic herpetic lesion of the foot in a HIV-positive patient. The only other case of a chronic herpetic foot ulcer was described in a patient with acute leukemia [7]. A possible direct inoculation of the virus [8] (e. g. autoinoculation or sexual practices like fetishism) seems likely; another possible explanation could be a zosteriform neural transmission from infected sacral ganglia [9], which might lead to herpetic eruptions in the corresponding dermatome [4]. Although the patient did not have any concomitant herpetic lesions, he did have a history of genital herpes. Special attention is needed for elderly patients. The availability of drugs that make possible sexual activity in the elderly also prolongs the age at risk for sexually transmitted infections. In advanced age, HIV compromises an immune system already weakened by aging, facilitating a more rapid progression of the disease [10]. HIV infection associated with CD4 T-lymphocyte count of
