Stage One

A 43-year old male accountant, married for 15 years and living in England, had complained of general malaise and weight loss for 18 months. For the last year he had had increasingly severe chronic ulceration and excoriation in the anal area, needing to wear sanitary pads.

He was managed mainly by colorectal surgeons who were searching for bowel cancer. Sigmoidoscopy, colonoscopy and barium enema had been very painful, but showed no sign of disease.

He became progressively weaker and his haemoglobin fell to 7.9g/dl.

Chronic perianal ulceration (Colm O'Mahony)

Perioral crusting lesions (Colm O'Mahony)

Phimosis with preputial ulceration (Colm O'Mahony)

Stage two

Throughout this time, he also had chronic crusting perioral labial lesions, and longstanding painless ulceration around the prepuce, causing phimosis.

The dermatologist had considered various causes of orogenital apthous ulceration: Topical steroids failed to improve the situation.

What would YOU do next?

Stage three

In desperation, his Italian wife took him home to her family doctor, who immediately did an HIV test which was positive.

On return to the UK, he saw a venereology and HIV specialist.

  • CD4 count was 69 cells/ml3.
  • HIV viral load was >105 copies/ml.
  • Syphilis serology was negative.

Swabs for herpes were positive for HSV-1 at the mouth and HSV-2 ano-genitally.

Herpes simplex viruses 1 and 2

Perianal ulceration at presentation (Colm O'Mahony)

Healing perianal ulceration (Colm O'Mahony)

Healing perianal ulceration (Colm O'Mahony)

Healing perianal ulceration (Colm O'Mahony)

Stage four

As well as antiretroviral therapy for HIV, treatment for herpes commenced with Valaciclovir 1g twice daily for two weeks followed by long term suppression with Aciclovir 400mg twice daily.

Within one week on Valaciclovir the anal lesion was much better.  It gradually healed over the next eight weeks to give complete resolution.

Stage five

The oral lesions healed within two weeks.

Chronic orolabial crusted herpes (Colm O'Mahony)

Healing orolabial herpes (Colm O'Mahony)

Chronic penile herpes (Colm O'Mahony)

Healed preputial herpes with complete phimosis (Colm O'Mahony)

Successful circumcision after complete phimosi (Colm O'Mahony)

Stage 5 continued

The penile ulceration healed gradually over one month, leaving a complete phimosis. A few months later he had a circumcision.

After 15 years on antiretroviral therapy his immune system has recovered such that he no longer needs suppressive Aciclovir, and he remains well.

He is heterosexual and travelled widely as a student. His wife is HIV negative.

Lessons

  1. With any atypical ulcerative lesion – think herpes.
  2. With any atypical or chronic herpes – think HIV.
  3. People may live with undiagnosed HIV for several years. If there are clinical indications, you should consider HIV even if there seems to be no current risk behaviour.
  4. Female partners in long term relationships with HIV-positive heterosexual men will not necessarily have HIV themselves.

If there are clinical indications, you should consider HIV!