Herpes Simplex Neuralgia

History: A 48-year-old woman was seen because of her concern about a lesion on the left buttock.  She is worried that she had gotten a spider bite six months prior.  It healed but she has had two similar episodes since then.  

The patient is in her usual state of health.  Her only medication is sertraline.  She says she is not under any stress but I know that she has a 20-year-old daughter with psychiatric disease who is a great concern for her.   She has one sexual partner who is asymptomatic.   

O/E:  On examination, the patient has a cluster of resolving vesicular lesions on the left buttock. 

Images: (Photos taken by patient and two weeks after acyclovir)

Further history reveals that she has seen a neurologist for sciatic symptoms down the left leg extending to the foot and has been diagnosed with sciatica, meralgia paresthetica and small fiber neuropathy.  She was prescribed gabapentin for this (which she discontinued).

IMPRESSION:  I believe she has recurrent sacral herpes simplex.  This has also called been called "herpes buttockalis" in Iraq, and "herpes okolealis" in Hawaii. Some of these patients have secodary neurological symptoms.

I discussed this with her and prescribed acyclovir 400 mg t.i.d. which she will take for a month or so and then the dose will be lowered depending on symptoms.

Discussion: This patient interested me, because I saw a similar case in the mid 1980s and researched the topic at that time.  He was in his 60s and had a history of recurrent sciatica and urinary obstruction.  He’d been worked up by neurology, orthopedics and urology.  One day, he came in with sacral HSV and anamnesis revealed that this had been going on a few times a years and seemed to be related to his recurrent HSV. I found the article by a Layzer and Conant¹.  When they wrote it, acyclovir was not on the market, but it was in 1985².  I placed that patient on the then new acyclovir and his chronic neuropathy and urinary symptoms improved.  I have always remembered this man.

 

This recent patient is similar.  I did a Pubmed search on "Sciatica Herpes simplex" and found only 8 hits.  Most old.

I suspect this may be an under-reported entity that is worth discussing.  This woman likely underwent an unnecessary neurological work-up and now is labeled now with "small fiber neuropathy."  It was recently reported in the Online Journal of Community and Patient-Centered Dermatology and Our Dermatology Online.

 

References:

1. R B Layzer, M A Conant. Neuralgia in recurrent herpes simplex. Arch Neurol. 1974 Oct;31(4):233-7.

2. Oral form of acyclovir approved. FDA Drug Bull. 1985 Apr;15(1):3-4.

3. Herpes Okolealis.  OJCPCD August 2015

4.  Sharquie K. et. al. Herpes simplex (Buttockalis) of the buttock is a variant of herpes simplex genitalis Khalifa E. Our Dermatology Online 2020;11(e):e170.1-e170.5.