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Clinical Summary

Infection with herpes simplex virus (HSV) is extremely common in HIV-infected patients and may present with oral, genital, anal, esophageal, or ophthalmologic involvement. The hallmark for most clinical presentations of HSV outbreaks is an inflammatory cutaneous eruption, with or without vesicles, and pain. HSV esophagitis is seen in immunocompromised HIV-infected patients and presents as dysphagia and odynophagia with or without oral lesions. Idiopathic aphthous ulcerations in HIV-infected patients are indistinguishable from HSV lesions. Perirectal lesions are often erythematous, ulcerative, and extremely tender, with a predilection for the gluteal cleft. Perirectal HSV may also be associated with proctitis and anal fissures.

Ocular HSV may be demonstrated by observing dendritic lesions after fluorescein staining. HSV is associated with a syndrome of acute retinal necrosis characterized by pain, keratitis, and iritis that may lead to retinal detachment. The diagnosis is usually made clinically but can be confirmed by a Tzanck test, biopsy, or culture.

Management and Disposition

Multiple oral treatment regimens are available to treat HSV. Duration of treatment is usually increased for immunocompromised patients. Ocular HSV requires prompt ophthalmology consultation.


  1. Anticipate involvement of multiple sites in HIV patients; presentations of HSV may be atypical compared to HSV in immunocompetent individuals.

  2. Suspect HSV in any HIV patient with a chronic painful ulcerative lesion.

  3. Perirectal HSV outbreaks may be missed on a superficial history and physical examination. Ask if it is painful to wipe after stool and examine the perianal area. Do not assume hemorrhoids in HIV-infected patients at risk for HSV.

FIGURE 20.32

Herpes Simplex Virus in an HIV Patient. Severe, recurrent perirectal HSV lesions in an HIV patient. (Photo contributor: Briana Hill, MD.)

FIGURE 20.33

Severe HSV on Genitalia. Severe ulcerative HSV lesions on the penis and scrotum of an HIV patient. (Photo contributor: John O’Mara, MD.)

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