Herpes is everywhere

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AAD meeting, San Francisco – Human herpes viruses are ubiquitous pathogens among humans that can establish latent infections in their host and reactivate to produce recurrent disease. This scenario is particularly true in immunocompromised patients. Each virus is associated with a set of typical clinical signs and symptoms; however, atypical presentations are common and recognizing the atypical presentations of these viruses is key to arriving at a timely diagnosis and appropriate therapy in affected patients.

“Most of us can become infected at some point with any of the human herpes viruses throughout our lifetime. They can manifest in different ways, depending on the clinical circumstance and, especially, on the degree of immunosuppression one may have. It’s the atypical presentations of these herpes infections that we have to keep in the forefront and be wary of in our patients,” says Warren R. Heymann, M.D., Professor of Medicine and Pediatrics and Head of the Division of Dermatology at the Cooper Medical School of Rowan University, Camden, N.J.

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Atypical presentations

Of the over 100 herpes viruses that exist, humans are most commonly affected by the human herpes viruses 1 to 8. The typical clinical presentations of these viruses are readily recognized by experienced clinicians and well documented in the literature, but the atypical presentations that these viruses may cause, particularly in the immunocompromised host, can sometimes be challenging to quickly recognize and accurately diagnose in the clinical setting.

“Atypical presentations are something that we need to acutely keep in mind when contemplating diagnosis and appropriate therapy and management of affected individuals. The astute clinician must be wary of these atypical presentations, such as an unusual ulcer recalcitrant to standard therapy,” Dr. Heymann says.

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Sometimes atypical presentations of herpes simplex can look verrucous or can be chronic, according to Dr. Heymann, making them suspicious of another disease process or infection, such as HPV infection. The keys to clinical diagnosis in those circumstances might be to look carefully at the border to see if the lesion is scalloped or not. Dr. Heymann says that atypical presentations have to be at the forefront of lesions that are not healing in immune compromised hosts, which can be seen in HSV-1 infections, as well as in cytomegalovirus infections in terms of peri-anal ulcerative lesions. Epstein-Barr virus infection is seen acutely in mononucleosis but it is also being increasingly implicated in the association with Lipschütz ulcers. Furthermore, the virus is also increasingly being linked to many different disorders including several lymphomas (other than Burkitt’s lymphoma) such as hydroa vacciniforme-type associated lymphomas as well as lymphomas linked to hypersensitivity from mosquito bites. Dr. Heymann emphasizes that clinicians need to thoroughly follow up on any unusual lump or bump that might be an atypical presentation of an associated lymphoproliferative malignancy in either a post-transplant patient or other immune compromised host.

“It is sometimes easy not to think of HHV infections in these scenarios because of the atypical presentations. No one is going to miss grouped vesicles on an erythematous base. However, it would be easy to miss a non-healing chronic ulcer and not think about HHV infection. Similarly, it’s easy to not think about the potential role of the Epstein-Barr virus if you have an atypical nodule that may be a lymphoma in the elderly. It is important that we get into the habit and mindset of thinking about these viruses when they are atypical and in the right context,” says Dr. Heymann.

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Evolving therapies

New and evolving therapies are slowly making headway in the management of HHV infections, Dr. Heymann says, witnessed by the drop in frequency of varicella zoster virus infections. According to Dr. Heymann, the ongoing research for potential vaccines for the Epstein-Barr virus would be especially important going forward in immunosuppressed patients to potentially prevent the subsequent lymphomas that can occur. Most recently, the roseola virus is increasingly being associated with its potential role in DRESS syndrome, a drug reaction in part characterized by eosinophilia and systemic symptoms or drug-induced hypersensitivity.

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“There is a lot going on in terms of the recognition of atypical presentations of these viruses in immune-compromised patients, their disease associations as well as potential therapeutic measures. We have to be aware of these changes on the horizon that may alter our approach to patients who are at risk of complications, especially lymphoproliferative complications,” Dr. Heymann says.

Dr. Heymann advises that clinicians should consider performing appropriate laboratory tests in these settings, which could include biopsy as well as viral culture and serologies because there may be certain circumstances when treating the viral infection may be of immediate benefit to the patient.

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Dr. Heymann has no relevant disclosures