Print version ISSN 0365-0596
An. Bras. Dermatol. vol.85 no.4 Rio de Janeiro July/Aug. 2010
WHAT IS YOUR DIAGNOSIS?
Mônica SantosI; Carolina TalhariII; Lisiane NogueiraIII; Renata Fernandes RabeloIV; Luiz Carlos de Lima FerreiraV; Sinésio TalhariVI
IDoctorate degree in Infectious and Parasistic Diseases - Dermatologist of "Fundação de Medicina Tropical do Amazonas"; Professor of Dermatology of the State
University of Amazonas (UEA) - Manaus (AM), Brazil
IIDoctorate degree in Infectious and Parasistic Diseases - Professor of Dermatology of the State University of Amazonas (UEA) - Manaus (AM), Brazil
IIIMedical Doctor - Dermatology Resident of "Fundação de Medicina Tropical do Amazonas" - Manaus (AM), Brazil
IVMedical Doctor - Dermatology Resident of "Fundação de Medicina Tropical do Amazonas" - Manaus (AM), Brazil
VDoctorate Degree in Pathologic Anatomy - Head of the Research Department of "Fundação de Medicina Tropical do Amazonas" - Manaus (AM), Brazil
VIDoctorate Degree in Dermatology - Director of "Fundação de Medicina Tropical do Amazonas" - Manaus (AM), Brazil
Since the first reports and descriptions of AIDS in the early 1980s, herpetic infection has been considered as one of the most prevalent and opportunistic aids related infections in patients with retroviral diseases Infection by Herpes simplex type 2 (HSV-2), the etiologic agent responsible for 60% to 90% of the cases of genital herpes, is very common among patients suffering from AIDS. Herpes simplex type 2 infection may cause severe and prolonged (over a period of time of one month) mucocutaneous onset of the disease, being characterized as an aids defining clinical condition.
Keywords: Acquired Immunodeficiency Syndrome; Herpes Simplex; Herpesviridae Infections
HISTORY OF THE DISEASE
Male patient, mulatto, aged 28, with a diagnosis of AIDS since January, 2009 Admitted to the hospital 2 months after the diagnosis had been made with decrease in the conscience level, convulsions and respiratory syndrome. He had been presenting cutaneous ulcers for 3 months. The dermatological exam showed lesions with a gelatinous aspect on the borders, central ulceration and necrotic fundus on the scrotum and internal part of the right thigh. (Picture 1); flat ulcer on the preputium and ulcer with high borders and whitish fundus, of approximately six cm of diameter on the posterior region of the right thigh. (Picture 2). On the moment of the physical exam, the T-CD4+ lymphocytes count was 69 cells/mm3 and the viral loading 397.000 copies/ mm.3 The VDRL was non reagent. The histological exam showed area of ulceration and necrosis, presenting, as its greatest enlargement, cells with voluminous nucleus, chromatin repelled to the border and greyish central region, named "Gray cells" (Picture 3). It was still observed fibrinoid vascular necrosis and "gray cells" adjacent to the vas walls. Polymerase chain reaction (PCR) to herpes type 2 virus was positive in the two lesions, as for herpes type 1 virus was negative (Picture 4). Based on clinical and histological exams and on molecular biology, the diagnosis of simple ulcerated chronic herpes was confirmed. The patient died after 12 days of hospitalization and one day after he had been examined by dermatologists possibly due to herpetic meningitis.
Infection caused by herpes type 2 simple virus (HSV2), etiological agent of 60 to 90% of the cases of genital herpes, is fairly common in patients suffering from AIDS.1 The prevalence of seropositiviness for HSV2 in the general population is of approximately 10 to 60%.2 However, within the population that carries the infection by the virus type 1 of the human immunodeficiency (HIV1), the co-infection HSV/HIV occurs in 50 to 95% of the individuals according to studies carried out in different parts of the world.3 Since the first descriptions of AIDS, in the begining of the 1980s, herpic infection is considered one of the most prevalent opportunist diseases in patients presenting retrobug.4 The mucocutaneous onset by HSV2 can be severe and can last for long (persisting for more than one month), being characterized as a defining disease for aids.5 The HSV2 is pointed out as the main causal agent of chronic genital ulcers in aids patients, being responsible for 65% of the cases.6 Patients with AIDS, with lymphocytes count T-CD4+ < 100cel/mm3, can present lesions with characteristics diverse from the ones found in immunocompetents.The slow evolution and absence of response to specific treatment are characteristics of these conditions and may lead to death.7 As for the case presented here, the first clinical hypothesis, considering the gelatinous aspect of the borders was cryptococcosis. The other hypotheses drawn were histoplasmosis and herpes simplex. The diagnosis of chronic ulcerated hepes simplex was confirmed with the histopatological exam and ratified by positive PCR for HSV2.
This case shows that in imunodepressed patients, the dermatologic lesions may present clinical conditions different from their usual presentations, being necessary strict correlation between the physical exam and the complementing exams, apart from a most precocious therapeutic intervention, that might change dramatically the prognostic of the patient.
1. Van de Perre P, Segondy M, Foulongne V, Ouedraogo A, Konate I, Huraux JM, et al. Herpes simplex virus and HIV-1: deciphering viral synergy. Lancet Infect Dis. 2008;8:490-97. [ Links ]
2. Lupi O. Herpes simples. An Bras Dermatol. 2000;75:261-75. [ Links ]
3. Schacker T. The role of HSV in the transmission and progression of HIV. Herpes. 2001;8:46-8. [ Links ]
4. Gupta R, Warren T, Wald A. Genital Herpes. Lancet. 2007;370:2127-37. [ Links ]
5. Gbery IP, Djeha D, Kacou DE, Aka BR, Yoboue P, Vagamon B, et al. Chronic genital ulcerations and HIV infection: 29 cases. Med Trop. 1999;59:279-82. [ Links ]
6. Cusini M, Ghislanzoni M. The importance of diagnosing genital herpes. J Antimicrob Chemother. 2001;47:9-16. [ Links ]
7. Aoki FY. Management of Genital Herpes in HIV-infected Patients. Herpes. 2001;8:41-5. [ Links ]
Approved by the Editorial Board and accepted for publication on 07.05.2010 * Work carried out in "Fundação de Medicina Tropical do Amazonas" - Manaus (AM), Brazil.
Conflict of interest: None
Financial funding: None
Approved by the Editorial Board and accepted for publication on 07.05.2010
* Work carried out in "Fundação de Medicina Tropical do Amazonas" - Manaus (AM), Brazil.