A 56-year-old male, HIV-positive, presented with a 3-day history of painful lesions on his right gluteus. He denied a prior diagnosis of genital herpes. The patient had been on antiviral medication since diagnosis and his viral load was undetectable with a CD4 cell count of 942 cells/µL. He denied any systemic symptoms. During the physical examination, multiple indurated erythematous nodules with superficial and well-defined erosions were noted (Fig. 1). Skin biopsy was performed for histopathological studies and microbiological cultures. Blood analysis was within normal values. Biopsy of one of the lesions showed ballooning-necrotic keratinocytes and acantholysis with inflammation extending to subcutaneous tissue (Fig. 2). A diagnosis of nodular cutaneous and herpes simplex infection was made. Cultures supported the diagnosis as they were positive for Herpes simplex 2 and negative for bacteria mycobacteria and fungi. Valacyclovir was initiated and followed by complete resolution within 7-days.

Figure 1.

Multiple indurated, erythematous nodules with superficial erosions with irregular, geographic borders.

(0.11MB).

Figure 2.

Keratinocytes with ballooned nuclei, compacted, marginalized chromatin into the nuclear periphery, with a ground-glass appearance and giant multinucleated keratinocytes (Hematoxylin & eosin, ×100).

(0.17MB).

Genital herpes simplex infection recurrences may not be limited to the anterior part of the genitalia and clinical presentation in the lumbar area or gluteus must be differentiated from a varicella-zoster virus infection.1 HSV polymerase chain reaction-based testing and cell culture of the lesion can be helpful to determine the causative virus.1,2 Tumor-like presentation is a very rare manifestation of HSV cutaneous infection.3 It is important to take this morphological variant into consideration not to delay the diagnosis of a viral infection, especially in an immunosuppressed patient.4 Nodular genital herpes simplex is a very rare form of clinical presentation; only one case has been reported in the literature.3,5 The authors describe a case of cutaneous HSV (herpes simplex virus) infection in an HIV patient that clinically presented with a nodular configuration, mimicking a tumor, supported by histopathology and microbiological cultures.