Unusual, rapidly growing ulcerative genital mass due to herpes simplex virus in a human immunodeficiency virus-infected woman

Sir, Herpes simplex virus (HSV) type 2 infection is common in human immunodeficiency virus (HIV) type 1‐infected subjects, and generally causes classical vesicular herpetic genital lesions1 with several recurrent episodes,2 sometimes severe and associated with extensive genital ulcerations and prolonged viral shedding.3 Bacterial or fungal superinfections may occur.3 We report an HIV‐infected woman with a history of recurrent genital HSV 2 infection who developed a rapidly growing ulcerative genital mass while on highly active antiretroviral therapy (HAART). A 39‐year‐old HIV+ woman with a previous history of severe immune depression [CD4 cell count 7 mm−3 in 1996, when she had cytomegalovirus (CMV) retinitis] presented to us in June 2000 with a 10‐day history of a painful, nonulcerative mass of the left labium majus extending to the perianal region. The left inguinal lymph nodes were swollen and ultrasound showed multiple enlarged hypoechogenic lymph nodes. For the previous 14 months she had been on a triple antiretroviral regimen consisting of stavudine, lamivudine and nevirapine. Her CD4 cell count was 880 mm−3 (22·7% of total lymphocytes), and HIV RNA was < 50 copies mL−1 (Chiron Quantiplex 3.0 assay; Chiron, Emeryville, CA, U.S.A.). The patient had had a primary genital herpetic infection in 1990 and, due to periodic episodes of recurrence, had been on prophylaxis with oral aciclovir 800 mg daily since 1997. On the presumptive diagnosis of a bacterial superinfection presenting as a genital mass, the patient was treated empirically with amoxicillin/clavulanate for 15 days without any improvement. One month later a biopsy of the mass was performed: tissue cultures for viruses (HSV 1 and 2, CMV and varicella‐zoster virus), fungi, bacteria and mycobacteria (Mycobacterium tuberculosis and atypical mycobacteria) were negative, as were serological tests for syphilis and Cryptococcus neoformans.