Herpes Vegetans: An Atypical Presentation of Herpes Simplex Virus (HSV) in AIDS

Herpes vegetans (HV) is an atypical presentation of herpes simplex virus (HSV) that occurs in immunocompromised patients, specifically those with human immunodeficiency virus (HIV) infection or individuals diagnosed with acquired immunodeficiency syndrome (AIDS). Lesions typically appear as verrucous, hypertrophic masses in the inguinal and anogenital region. We present a case of a male patient with AIDS and a history of noncompliance to anti-retroviral therapy who developed large, verrucous HV lesions on both the penis and inguinal regions. Following imaging and work-up to rule out a suspected malignancy, a biopsy was performed, confirming HSV etiology. Subsequent medical therapy with valacyclovir 1000 mg daily for two months resulted in complete resolution of all lesions. Due to the atypical appearance of HV lesions, diagnostic workup for malignancy without HSV testing is often prompted, which effectively delays the timeline from lesion onset to therapy induction. This delay can result in increased morbidity for patients, highlighting the necessity for increased awareness regarding HV in immunocompromised patients. Although cases of valacyclovir resistance have been reported, it still remains the first-line therapy. Although HV is rare and its appearance can often mimic malignancy, a prompt biopsy with HSV staining is warranted in new atypical lesions in an immunocompromised patient. A timely diagnosis can increase the chance of full resolution, without the need for more invasive therapeutic approaches.