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Nodular herpes simplex virus-1-positive oral lesions as a manifestation of immune reconstitution inflammatory syndrome
A Briggs and G R Kinghorn Int J STD AIDS 2010 21: 377 DOI: 10.1258/ijsa.2010.010002 The online version of this article can be found at: http://std.sagepub.com/content/21/5/377

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CASE REPORT

Nodular herpes simplex virus-1-positive oral lesions as a manifestation of immune reconstitution inammatory syndrome
A Briggs
MRCP DipGUM

and G R Kinghorn

MD FRCP

Department of Genitourinary Medicine, Royal Hallamshire Hospital, Glossop Road, Shefeld S10 2JF, UK

Summary: We describe a case of nodular oral herpes simplex virus-1-positive lesions consistent with immune reconstitution inammatory syndrome in a patient recently commenced on treatment for tuberculosis and HIV co-infection. Keywords: HAART, HIV, herpes simplex virus, AIDS

INTRODUCTION
Immune reconstitution inammatory syndrome (IRIS) is well described following the initiation of antiretroviral medication in the setting of HIV with an opportunistic co-infection. Oral manifestations that have been reported are candidiasis, hairy leukoplakia, parotid enlargement and recurrent non-herpetic ulcers.1,2 Genital ulceration as a result of herpes simplex virus (HSV) is a common presentation of IRIS.3,4 To the best of our knowledge, nodular oral lesions as a result of HSV-1 in this setting have not been described.

CASE REPORT
A 26-year-old woman, originally from Zimbabwe, was diagnosed HIV positive. She presented with a one-month history of fevers, night sweats and 6.5 kg weight loss. She reported an ongoing cough productive of clear sputum, shortness of breath and fatigue. In addition, she had been passing blood per rectum for several weeks, experiencing intermittent loose stools and had experienced recurrent painful ulcers in the mouth and on her tongue. On examination she was cachectic with shotty bilateral cervical lymphadenopathy and oral hairy leukoplakia. No oral ulcers were present on admission. She had a resting sinus tachycardia of 124 beats/min and low-grade pyrexia. Her O2 saturations were normal with no desaturation on exercise. She was noted to be anaemic with a haemoglobin of 8.7 g/dL. Her CD4 count on admission was 33 cells/mL and her HIV viral load was 700,000. Her bronchoalveolar lavage (BAL) was positive for Pneumocystis jiroveci (PCP) on polymerase chain reaction and bright on PCP immunouorescence, but no denite cysts were seen. Mild P. jiroveci pneumonia was initially diagnosed.
Correspondence to: A Briggs Email: aparnabriggs@yahoo.co.uk

Subsequently, Mycobacterium tuberculosis was isolated from induced sputum, a BAL sample and a computed tomography (CT)-guided retroperitoneal lymph node biopsy. An abdominal CT with contrast showed an abnormal, thickened terminal ileum. She was diagnosed with fully sensitive lymph node, pulmonary and probable gastrointestinal tuberculosis. Her vitamin D level was 21.6 nmol/L, consistent with probable vitamin D insufciency and she received calcium and ergocalciferol as replacement. The patient was initially treated with high-dose cotrimoxazole intravenously for three days and then switched to oral therapy for a total of 21 days treatment. She commenced antiretroviral medication with tenofovir/emtricitabine and efavirenz and started antituberculous therapy six days later. Sixteen days after the initiation of antiretroviral medication, she developed fevers, rigors and had raised inammatory markers. Full septic screening did not yield a source of infection and a repeat CD4 count was 159 cells/mL and repeat HIV viral load was

Figure 1

Nodular lesion on tongue

DOI: 10.1258/ijsa.2010.010002. International Journal of STD & AIDS 2010; 21: 377 378
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378

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International Journal of STD & AIDS

Volume 21

May 2010

tract as a result of HSV-2 in an HIV-positive man and cites ve other similar cases, three of which were in conrmed HIV-positive individuals. The patient in that report had been on antiretroviral medication for six years with limited immune reconstitution. The appearance of the oral nodules in our patient was consistent with being an IRIS phenomenon: she had no oral lesions on admission and the nodules appeared synchronously with other features of IRIS, a rise in CD4 cell count . 100 cells/ mL and a substantial drop in viral load 16 days after commencing antiretroviral therapy. Genital herpes is a common presentation of IRIS in the literature. We now suggest that atypical oral herpes could also be included in IRIS manifestations.

Figure 2 Nodular lesion on gum

REFERENCES rez-Amador VA, Espinosa E, Gonza lez-Ram rez I, Anaya-Saavedra G, 1 Ram n G. Identication of oral candidosis, hairy leukoplakia Ormsby CE, Reyes-Tera and recurrent oral ulcers as distinct cases of immune reconstitution inammatory syndrome. Int J STD AIDS 2009;20:259 61 n-Cepeda LA, Magalha es MG. Oral 2 Ortega KL, Ceballos-Salobren a A, Gaita manifestations after immune reconstitution in HIV patients on HAART. Int J STD AIDS 2008;19:305 8 3 Ratnam I, Chiu C, Kandala NB, Easterbrook PJ. Incidence and risk factors for immune reconstitution inammatory syndrome in an ethnically diverse HIV type 1-infected cohort. Clin Infect Dis 2006;42:418 27 4 Reddy V, Luzzi GA. Chronic vulval ulceration another immune reconstitution inammatory syndrome? Int J STD AIDS 2005;16:454 5 5 Plowman GM, Watson MW, DSouza H, Thomas MG. Obstructive endo-bronchial pseudotumour due to herpes simplex type 2 infection in an HIV-infected man. Int J STD AIDS 2009;20:737 8 (Accepted 22 March 2010)

1429. In view of these results the symptoms were ascribed to an IRIS. No specic treatment was given. Three days later she developed painful nodular lesions on the tongue (Figure 1), gums (Figure 2) and palate, and ulceration of the lips. They raised sufcient interest for an oral surgical opinion to suggest biopsy. The suggested diagnosis was tuberculosis granulomata. However, the lesions resolved after treatment with acyclovir and a viral swab identied HSV-1. Of note, her baseline HSV immunoglobulin G was positive.

DISCUSSION
Hypertrophic presentations of HSV have been described. A recent case report5 describes a pseudotumour in the respiratory

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