Cutaneous HSV-2 infection with serial recurrences at multiple sites

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A 60-year-old white male presented to the dermatology clinic in early 1997 complaining of painful, recurrent lesions on his arms, legs, and hands for several months. At presentation, he was noted to have a cluster of erythematous pustules on his right thigh and left palm (Fig. 1). He had no systemic complaints, fever, chills or adenopathy. His past medical history included a seizure disorder, type 2 diabetes, coronary artery disease, benign prostatic hypertrophy, diverticulosis, and a history of bowel surgery. He reported he was in a monogamous relationship with a partner after the death of his wife of many years. He reported no history of similar lesions in the past. Biopsy of a lesion was performed, which was consistent with herpes virus infection. Basic screening labs at the time were all within normal limits. The lesions resolved within 10 days.The following month, new lesions appeared on his right ankle and right medial calf. Within the second and third month after presentation, new lesions appeared on his left neck and right thigh, respectively. Biopsy of lesions from both time points again demonstrated pathology consistent with herpes virus infection.Within the next several weeks, the patient subsequently developed pustulovesicular lesions on his lower back with dermatomal pain. Serologies using ELISA for HSV-1 and HSV-2 were both positive for IgG; but both were IgM negative. He was started on famciclovir 500 mg po three times daily for 2 weeks, but continued to develop lesions on his right buttock and right hand (May 1998) (Fig. 2). Four viral cultures of lesions returned positive for HSV-2.Valacyclovir 1 gram po three times daily was prescribed to suppress outbreaks and for 2 months, the patient had no new lesions. Serum protein electrophoresis was normal; and CD4 count done at this time was 1081. T-helper to suppressor ratio and absolute numbers were within normal limits. The patient was seen in infectious disease clinic in the interim, and twice tested negative for HIV. Valacyclovir was decreased to 500 mg twice daily then to 500 mg daily over the next 5 months. On the lower dosage however, new lesions developed on his left leg and both hands, and the dose was increased to valacyclovir 1 gram po three times daily.For 3 months, the patient also complained of left facial swelling and pain. CT scan of the parotid glands showed enlargement bilaterally of the superficial lobes which was consistent with viral infection or synulosis. When the patient has stopped taking valacyclovir, new lesions developed on his posterior scalp, left shoulder, right posterior auricular scalp and right buttock (July 1999).As of the fall of 1999, the patient continued to have intermittent outbreaks clinically consistent with his previous HSV outbreaks.

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