PSD04 Recurrent and persistent genital ulcers in an immunocompromised man: an uncommon presentation of herpes zoster

Abstract A 39-year-old married man presented with persistent painful ulcers on the penile shaft for 8 months. He had been diagnosed with HIV infection 16 years ago and has been on antiretroviral therapy for the last 16 years. He is currently on an oral daily dose of tenofovir 300 mg, lamivudine 300 mg, dolutegravir 50 mg, atazanavir 300 mg and ritonavir 100 mg. He had recurrent painful ulcers on the penile shaft for 3 years. The ulcers in previous episodes had a tendency to improve spontaneously or with oral aciclovir within 7 days, only to recur again in the next 2–3 weeks. He had received multiple courses of oral aciclovir 400 mg three times a day for 7 days in the past, with clinical suspicion of recurrent herpes genitalis with short-lasting response. He denied any recent high-risk sexual exposure or similar conditions in his spouse. On examination, multiple ulcers of size varying from 0.5 × 0.5 cm to around 1 cm were present on the shaft of the penis and prepuce. The ulcers were nonindurated and their floor was covered with necrotic slough. The smaller ulcers were coalescing to form larger ones with polycyclic margins. The CD4 count was 0.43 × 109 cells L−1 and viral load was not detectable. Punch biopsy showed nonspecific changes, with infiltration by lymphocytes and plasma cells. Considering the immunocompromised status of the patient, resistant herpes genitalis, cytomegalovirus (CMV) infection or herpes zoster were considered. Polymerase chain reaction (PCR) was done for herpes simplex virus (HSV), CMV and varicella zoster virus (VZV). PCR was reported to be positive for VZV. A diagnosis of persistent herpes zoster was made. The patient was treated with oral aciclovir at a dose of 800 mg, five times a day for 10 days. He had dramatic improvement this time with complete resolution of the ulcers without any recurrence at the 1-month follow-up. VZV is implicated in causing varicella and herpes zoster, and is rarely associated with Kaposi varicelliform eruption. Multiplex PCR (for HSV, CMV and VZV) helped in establishing the diagnosis. Complete resolution was obtained with a higher dose of aciclovir appropriate for VZV infection. The resolution without recurrence further validated our diagnosis. This case was interesting because VZV as an aetiological agent for persistent genital ulcers has not previously been reported to the best of our knowledge. Clinical consideration of such a unique presentation of VZV is important for timely diagnosis and appropriate management, especially in immunocompromised individuals, to avoid possible complication of repeated treatment for HSV infection.