WHODUNIT: framed, guilty or an accessory after the act?
Description of the case: A 46 year-old man with long-standing HIV (human immunodeficiency virus), who was immunosuppressed with a CD4 count of 23/µL and a viral load of 81,000copies/mL, recently re-commenced on anti-retroviral therapy, presented with a single ulcer on the glans penis. The ulcer was initially painless but became painful as it progressed and was associated with inguinal lymphadenopathy.
He was previously known to have Herpes Simplex Virus Type 2(HSV2) affecting the perianal region, with frequent recurrences and associated superimposed bacterial infections that had previously required hospitalisation. Nucleic acid amplification technique (NAAT ) testing at the site was positive for HSV2 and T.pallidum. H.parainfluenzae, with reduced susceptibility to cefotaxime, was also isolated at the site. Serological testing was negative for T.pallidum. Testing did reveal vitamin B12 deficiency. Initial treatment with benzathine penicillin, valaciclovir and ciprofloxacin did not improve the ulcer after three weeks. He was referred to a tertiary centre with presumed acyclovir-resistant HSV2 for consideration of treatment with foscarnet.
Questions for Discussion: This case addresses the challenging problem of recurrent genital ulceration in an immunosuppressed individual, with multiple potential etiologies. It also raises the issue of the development of resistance to commonly used antimicrobials in those with a long history of immunosuppression and the management of resistant organisms.
Literature review: The literature review will examine common causes of genital ulceration in HIV, the sensitivity and specificity of NAAT-based testing and the management of acyclovir- resistant HSV.
