Saturday, August 01, 2015

Sacral Herpes Simplex


The patient is a 77-year-old woman who presents for evaluation of a recurrent localized blistering eruption on the right buttock.  This has happened off and on for 2-3 years.  Before this, she noticed a pain in the right buttock to hip that was attributed to some form of trauma and has had physical therapy for the pain.

EXAMINATION:  The examination shows grouped vesicles on an erythematous base on the right buttock. 

Clinical Picture:

Lab: Tzanck smear was positive for multinucleated giant cells. 

IMPRESSION:  Sacral herpes simplex.  Her buttock and hip pain may be related.  

PLAN:  Acyclovir 400 mg three times a day for seven to ten days.  If her hip pain improves, I would continue the acyclovir for a few months at 400 mg twice to three times a day to see if that impacts the chronic hip pain for which she has had physical therapy without much relief.

Discussion:  Sacral herpes simplex is seen with some regularity, although it has not been well-studied.  In 1974, Lenzer and Conant mentioned sciatica with sacral herpes simplex. I have seen a few memorable cases over the years.  One, in particular was a 70 yo man with sciatica and urinary symptoms that resolved completely when his recurrent sacral HSV was treated with acyclovir and he was maintained on suppressive therapy.

Patient reports:  I completed the full ten day regimen of acyclovir with apparent success - healing of the lesion and elimination  of the ache in my buttock which I had thought was a lingering result of the fall that I had almost two years ago. I am wondering if I should continue with prophylactic use of the acyclovir.

References:
1. Neuralgia in Recurrent Herpes Simplex
Robert B. Layzer, MD; Marcus A. Conant, MD
Arch Neurol. 1974;31(4):233-237.
ABSTRACT: Five patients with recurrent herpes simplex of the skin had unusual neuralgic pains preceding the eruptions by 24 hours or more. Although prodromal neuralgia is an uncommon feature of recurrent herpes, about 15 similar cases have been reported previously. The pain is often diffuse and aching in character and, in contrast with herpes zoster, leaves no sensory or motor deficit. Stereotyped cycles of pain and herpes simplex may occur repeatedly for as long as 20 years. The fact that pain precedes the eruption supports the theory that a persistent latent infection of sensory ganglia is activated during recurrences of herpes simplex.

2. [Recurrent herpes with neuralgia and zones of cutaneous hypoesthesia].
[Article in French]
de la Sayette V, er. Al
Abstract: A 52-year old man presented with recurrent Herpes simplex of the thigh and buttock of 30 years duration. The skin eruption was preceded by pain and sciatica. Surgical excision of the skin area involved modified the site of recurrence. During an attack, the patient developed severe pain and hypoaesthesia in the left half of his chest. The skin lesions were unmodified, and a type 2 Herpes simplex virus was isolated from a vesicle. A clinical examination performed 5 weeks later showed reduced sensitivity to pin prick in the previously painful D5 to D12 territory. Three points are of interest in this case: the site of recurrence moved after surgical excision, pain extended over a wide area and, most of all, persistent hypoaesthesia occurred during a recurrence.

3. Although this review (below) does not mentione HSV neuropathy, I suppose it belongs in this group.

Infectious neuropathies.
Sindic CJ1. Curr Opin Neurol. 2013 Oct;26(5):510-5
Abstract
PURPOSE OF REVIEW: Infectious neuropathies are heterogeneous neuropathies with multiple causes. They still represent an important world health burden and some of them have no current available therapy.
RECENT FINDINGS: Leprosy incidence has decreased by 50% during the last years, but leprosy-related neuropathies still cause severe disability. The pure neuritic leprosy is a diagnostic challenge that may require nerve biopsy or nerve aspiration cytology. The treatment itself may lead to a 'reversal reaction', which further causes injuries to the nerve. HCV-related neuropathies may be related or not to the presence of cryoglobulins. The absence of vasculitis, the most frequent form is a peripheral sensory neuropathy involving small nerve fibers, and more accurately diagnosed by pain-related evoked potentials. HIV-related neuropathy has become the major neurological complication of HIV infection. Both HIV-induced neuropathy and antiretroviral toxic neuropathy are clinically indistinguishable. The existence of an isolated chronic polyneuropathy due to Borrelia burgdorferi remains highly controversial. Lastly, an active infectious ganglioneuritis caused by varicella zoster virus, producing shingles, is the most frequent infectious neuropathy in the world and may cause various neurological complications. Zoster sine herpete remains frequently undiagnosed.
SUMMARY: Recent data have improved our knowledge and diagnostic tools of infectious neuropathies. Treatment of the injured nerves is not yet available, and prevention and rapid diagnosis remain the main priorities for the clinician.

2 comments:

  1. Khalifa Sharquie from Baghdad wrote: "This is a very interesting case as I see a few cases every year in my busy private clinic especially among middle age females. And I am always asking about anal intercourse, but all patients denied that. Most recently I have seen a young male patient with penile and sacral herpes at the same time who also gave no history of anal sex. Hence, I believe that genital herpes could be seen as recurrent sacral rash with associated prodromal symptoms like malaise, sacral pain, and sciatica-like complaints. This important message that should be sent to rheumatologists as most of them are unaware about this condition since the literature is poor about this clinical entity."

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