CASE REPORT

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

and G R Kinghorn

MD FRCP

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

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

INTRODUCTION
Immune reconstitution inflammatory 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 immunofluorescence, but no definite 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 insufficiency 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 inflammatory 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

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. Identification of oral candidosis.19:305 –8 3 Ratnam I..... the lesions resolved after treatment with acyclovir and a viral swab identified HSV-1. Obstructive endo-bronchial pseudotumour due to herpes simplex type 2 infection in an HIV-infected man........ Of note..20:259 –61 ´ n-Cepeda LA... gums (Figure 2) and palate. In view of these results the symptoms were ascribed to an IRIS. three of which were in confirmed HIV-positive individuals......... hairy leukoplakia Ormsby CE... Gonza ´lez-Ramı ´rez I. DISCUSSION Hypertrophic presentations of HSV have been described...... 1 Ramı ´ n G. Three days later she developed painful nodular lesions on the tongue (Figure 1). Kandala NB. a rise in CD4 cell count ..20:737– 8 (Accepted 22 March 2010) 1429. and ulceration of the lips.....16:454 –5 5 Plowman GM........42:418– 27 4 Reddy V.... However... Watson MW. her baseline HSV immunoglobulin G was positive.. Figure 2 Nodular lesion on gum REFERENCES ´rez-Amador VA........... Reyes-Tera and recurrent oral ulcers as distinct cases of immune reconstitution inflammatory syndrome....... They raised sufficient interest for an oral surgical opinion to suggest biopsy. A recent case report5 describes a pseudotumour in the respiratory .... Int J STD AIDS 2009....... Gaita manifestations after immune reconstitution in HIV patients on HAART...378 ............ The suggested diagnosis was tuberculosis granulomata... Thomas MG...... Chronic vulval ulceration – another immune reconstitution inflammatory syndrome? Int J STD AIDS 2005. The patient in that report had been on antiretroviral medication for six years with limited immune reconstitution. Espinosa E........ Ceballos-Salobren ˜ a A. Chiu C...... Clin Infect Dis 2006.. Genital herpes is a common presentation of IRIS in the literature.. International Journal of STD & AIDS Volume 21 May 2010 tract as a result of HSV-2 in an HIV-positive man and cites five other similar cases...... No specific treatment was given.... Anaya-Saavedra G.... Incidence and risk factors for immune reconstitution inflammatory syndrome in an ethnically diverse HIV type 1-infected cohort.... We now suggest that atypical oral herpes could also be included in IRIS manifestations... Luzzi GA........ Magalha ˜ es MG... 100 cells/ mL and a substantial drop in viral load 16 days after commencing antiretroviral therapy.. D’Souza H.... Int J STD AIDS 2009.. Easterbrook PJ... Int J STD AIDS 2008...... Oral 2 Ortega KL.

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