PERIANAL HERPES: ATYPICAL PRESENTATION – CASE REPORT

Case Presentation A 28-year-old male sought medical attention for a painful perianal ulcer with discharge, present for 6 months. On physical examination, there was extensive, circumferential perianal ulceration with a moderate amount of fibrin. An abdominal and pelvic CT scan showed diffuse densification of the adipose and subcutaneous tissue planes without evidence of fluid collection. Investigations for Crohn’s disease were initiated with a colonoscopy, revealing rectal enanthema associated with flat erosions covered by fibrin. The patient underwent a proctological examination under anesthesia, including a perianal biopsy, which showed chronic nonspecific inflammatory changes. Immunohistochemistry was requested, but before the patient could return for the results, he presented to the hospital with severe anemia and a deteriorating general condition. On examination, the patient had a perianal lesion and a 5x3 cm ulcerated lesion on the left hemithorax with signs of active infection, prompting consideration of Kaposi's sarcoma. HIV serologies were positive, and the case was transferred to internal medicine. The patient rapidly developed acute respiratory failure and cardiac arrest, with no response to resuscitation efforts. The diagnosis of perianal ulcer was confirmed as positive for Herpes simplex types 1 and 2, and CK5/6 in immunohistochemistry during the final hospitalization.

Discussion Genital herpes is a common sexually transmitted disease caused by the herpes simplex virus (HSV), characterized by periodic reactivation. Type 2 HSV is the most common cause of anal infection and is a risk factor for subsequent HIV infection. Both HSV types 1 and 2 can infect the anal region, causing vesicles that may appear individually or in clusters on the genitals, perineum, buttocks, upper thighs, or perianal areas, and they ulcerate before resolving. In cases of suspicion, other sexually transmitted diseases must be excluded, and pathogen detection should be performed via polymerase chain reaction (PCR). Treatment includes antiviral medication. The lack of a characteristic clinical picture, with atypical ulcers, often delays the diagnosis and treatment.

Conclusion Concomitant infection with HSV-2 and HIV increases the severity of HSV episodes and the likelihood of atypical presentations. This case reports a patient with an ulcer that lacked classic features, with a confirmed diagnosis for both types of herpes through polymerase chain reaction.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
25 April 2025