Genital Herpes in an HIV-Positive Patient Mimicking Donovanosis: A Case Report

Genital herpes is one of the most common sexually transmitted infections worldwide, primarily driven by herpes simplex virus type 2 (HSV-2). In immunocompetent individuals, the disease typically manifests as self-limiting vesicular lesions that progress to painful ulcerations. However, in patients living with human immunodeficiency virus (HIV), the clinical presentation can be remarkably atypical, chronic, and severe due to impaired cell-mediated immunity. In this specific population, hypertrophic or extensive vegetative ulcerations frequently mimic other infectious diseases and malignancy, creating a complex diagnostic dilemma for clinicians. This case report describes a 41-year-old woman who presented with persistent, chronic ulcerated vulvar lesions. Due to the aggressive and granulomatous clinical appearance of the lesions, the initial differential diagnoses focused heavily on donovanosis (granuloma inguinale) and vulvar malignancy. To establish an accurate diagnosis, an extensive clinical investigation was performed. Polymerase chain reaction (PCR) testing definitively confirmed HSV-2 infection. Upon initial evaluation, the patient was found to have a newly diagnosed HIV infection during the current admission; however, she later disclosed a prior diagnosis of HIV dating back to 2005, which she had not previously reported. The patient was managed with targeted intravenous acyclovir therapy, which resulted in significant and complete clinical improvement of the vulvar lesions. This case emphasizes the high variability of opportunist-associated cutaneous presentations in the context of advanced immunosuppression. It underscores the vital role of molecular diagnostics and tissue biopsies in distinguishing atypical herpes simplex virus presentations from other sexually transmitted infections and malignancies, ensuring timely antiviral intervention.