Page 237 - AIDSBK23C

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HERPESVIRUSES.—Genital and anorectal herpes simplex virus (HSV) produces
localized vesicles and ulcers that are chronic but cyclical in appearance and severity. They often
respond to acyclovir therapy and may disappear following treatment. Grossly, most lesions
appear as vesicles that contain fluid, but may rupture to produce shallow ulcerations.
A less common appearance, though one more likely to occur in immunocompromised
persons, is hypertrophic herpes simplex genitalis (HHSG) and most often described in
association with HIV-1 infection. The lesions appear as painful ulcerated nodular lesions of the
vulva and perianal area that can measure up to several centimeters in diameter. Macroscopically,
the lesions may appear as high-grade vulvar intraepithelial neoplasia Grade 3 (VIN 3) and
invasive squamous cell carcinoma. The nodularity is produced by massive inflammatory
infiltrates containing numerous plasma cells that extend into the subcutis. Multinucleated herpes
simplex virus 1 and herpes simplex virus 2-positive epithelial cells with glassy intranuclear
inclusions can be identified. The lesions can be resected can recur.[971]
Varicella zoster virus (VZV) infections in association with HIV infection may resemble
those typical of other immunocompromised patients. Children infected with HIV may have a
severe primary VZV infection that can be fatal from internal organ involvement including
pneumonitis, pancreatitis, and encephalitis. Adults with HIV infection have more extracutaneous
organ involvement and risk for death from primary VZV infection. Development of dermatomal
zoster is frequent in children with HIV and usually occurs in a few years. Dermatomal zoster is
marked by painful vesicular eruptions, most commonly from the thoracic or cervical dorsal root
ganglia or from the ophthalmic branch of the trigeminal ganglion. Less common presentations
include follicular zoster and ecthymatous, crusted, or punched-out ulcerations. Chronic
verrucous or ecthymatous VZV, resembling a wart caused by papillomavirus, may persist for
weeks to months [466,972,973]

MOLLUSCUM CONTAGIOSUM.-- This double-stranded DNA virus of the poxvirus
family may produce a self-limited cutaneous infection. It can appear in a widely disseminated
form over the skin surfaces in persons with HIV infection. There can be cases with dozens of 0.2
to 0.6 cm firm tan to pink dome-shaped nodules or papules, or cases with fewer nodules but a
wider size range up to 1 cm, or cases in which giant nodules >1 cm are found. The more florid
verrucous form or cases of "giant" molluscum contagiosum with very large nodules can occur at
a late stage of AIDS when the CD4 lymphocyte count is <50/µL and the plasma HIV-1 RNA
level is >100,000 copies/mL.[974,975]
The nodules or papules may have central umbilication and can appear widely scattered or
in clusters. HIV-infected patients with molluscum contagiosum are more likely to have head and
neck involvement, typically the face, unlike immunocompetent patients in which lesions are
most common on lower abdomen, genitalia, and thighs. Lesions may also appear less frequently
on the trunk and extremities. Almost all cases occur in males.
The diagnosis can be confirmed by biopsy. The lesions of this poxvirus have the typical
microscopic appearance with hematoxylin-eosin staining, with large prominent pink
intracytoplasmic inclusions forming in lower epidermis and extending into a central cavity.
Molluscum contagiosum infections associated with HIV-infection do not typically resolve
spontaneously and tend to have a chronic relapsing course. The lesions tend to be more
extensive when the degree of immunosuppression is greater, as indicated by a lower CD4 count
or increased HIV-1 RNA level.[972]