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A woman in her 80s presented with an 8-month history of a growing, painful tumor on her right buttock. The patient felt well otherwise and denied experiencing fevers, chills, sweats, weight loss, or malaise. Her medical history was notable for chronic kidney disease and genital herpes simplex virus (HSV). She reported no history of genital warts, HIV, or inflammatory bowel disease. A biopsy was performed, and results were consistent with a noninfectious, granulomatous ulcer. Based on the clinical appearance and prior pathologic findings, the patient received treatment of oral antibiotics, intralesional steroids, topical steroids, and immunomodulators, without improvement. Findings from colorectal surgical evaluation of the internal anal mucosa were negative for malignant neoplasm.
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C. Herpes vegetans
Histologic results showed epithelial hyperplasia, ulceration, and focal multinucleated keratinocytes (Figure 1B and C). Immunostaining was positive for HSV (Figure 2) but negative for varicella-zoster virus. Microbial cultures were negative for deep fungal infection and acid-fast bacteria but positive for HSV type 2. Given the clinicopathologic findings, herpes vegetans was diagnosed.
Herpes vegetans is a verrucous presentation of HSV in immunocompromised patients, including those with HIV, congenital immunodeficiency disorders, malignant neoplasm, and organ transplants.1 The condition is exceedingly uncommon in immunocompetent patients.2 Coinfections of HSV with other cutaneous infections, such as fungal and human papillomavirus (HPV) infections, have also presented as verrucous plaques, which can complicate the diagnosis.3 Herpes vegetans is frequently reported to be recalcitrant to oral antiviral therapy,4 and although, to our knowledge, precise rates of drug resistance have not been elucidated, antinucleoside resistance has been associated with several characteristics of the disease, including prolonged symptom duration, recurrent outbreaks, and prior failed therapy attempts.5
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Corresponding Author: Erika L. Hagstrom, MD, Department of Dermatology, Oregon Health and Science University, 3303 SW Bond Ave, Center for Health & Healing Bldg 1, 16th Floor, Portland, OR 97239 (firstname.lastname@example.org).
Published Online: February 12, 2020. doi:10.1001/jamadermatol.2019.4823
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient for granting permission to publish this information. We also thank Kevin P. White, MD, Department of Dermatology, Oregon Health and Science University, for his assistance with histopathological diagnosis, and Jina Makadia, MD, Division of Infectious Diseases, Oregon Health and Science University, for her assistance with treatment in this case. They were not compensated for their contributions.
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