Herpes labialis and genitalis in a HIV positive patient. Is it not?

To the Editor,

I read with great interest the article "Herpes labialis and genitialis in a HIV positive patient" by Saoji and Salodkar published in the Indian Journal of Dermatology, Venereology and Leprology, 2001; 67:161. I would like to offer some comments over this case report. On the basis of clinical findings, they had made the diagnosis of herpes labialis and genitalis simultaneously occurring in a HIV positive patient. It is possible that they were not been able to undertake viral studies like viral culture, HSV DNA detection or HSV antigen detection in their case. But neither Tzanck test (a simple office tool investigation in a side laboratory in any medical college) nor biopsy study was done in the case to say at least this is of viral origin (by demonstrating giant multinucleated epithelial cells, ballooning and reticular degeneration). The type of oral findings stated in the case report (multiple small superficial erosions on the lips and a few on the buccal mucosa and tongue) suggest more towards aphthous ulceration than herpes labialis which presents as closely grouped vesicles and has unilateral focal occurance rather than widespread involvement.[1] These herpetic lesions heal in 7 to 10 days and commonly precipitated by trauma to the lips or by emotional stress, febrile illness, fatigue, menstruation or upper respiratory tract infections. On the other hand, aphthous ulcers tend to involute in two to three weeks and may be induced by various factors as stated for herpes labialis.[2] Thus response to oral acyclovir therapy within 7 days (and patient having oral ulcers of 10 days) also cannot be taken as evidence in favour of their diagnosis for oral lesions. As such, the clinical effect of acyclovir is considerable if therapy is initiated within 48 to 72 hours of onset of lesions. It is likely that patient had genital herps, since HIV patients have more frequent and prolonged episodes.[3]

Associated lymphadenopathy in the case may be due disease per se. In this regard, I would like to refer to our study of mucocutaneous disorders in 75 HIV patients with mucocutaneous lesions in which the common disorders noted were candidiasis (50 cases), dermatophytosis (26 cases), herpes simplex (18 cases), oral aphthae (12 cases), xerosis/ ichthyosis (11 cases), scabies (10 cases), human papilloma virus infection (10 cases), molluscum contagiosum (8 cases), and psoriasis (6 cases).′ As is apparent from our study that oral aphthae are quite common in HIV patients, their assumption in the case described (for oral erosions as herpes labialis) may be misleading and wrong in the absence of concrete evidence.