Reactions 1680, p15 - 2 Dec 2017
Development of resistance to aciclovir and
foscarnet during the treatment for recurrent herpes
simplex virus 2 infection: case report
A 49-year-old man developed acquired resistance to
aciclovir and foscarnet during the treatment for herpes simplex
virus 2 anogenital infection [dosage, duration of treatment to
reaction onset not stated].
The man was admitted with a recurrent painful ulcerative
left inguinal lesion. His history was significant of AIDS since
14 years (CDC Stage 3 disease). Eight years ago, he was
diagnosed with ulcerative herpes simplex virus infection of the
left groin. He was initially treated with oral aciclovir following
which his lesion resolved. Due to multiple recurrences, he was
transitioned to oral valacyclovir without any significant
response. Two years later, a skin biopsy of the ulcerative lesion
revealed HSV-2. Further testing revealed that the strain was
sensitive to aciclovir. He was treated with IV aciclovir.
Resolution occurred 14 day after treatment with IV aciclovir.
Thereafter, he was transitioned to oral valacyclovir. Over the
next few years, he had multiple recurrences despite of
suppressive therapy. He had a varied responses to IV aciclovir.
Resistance to aciclovir occurred eventually. Thereafter, he was
treated with IV foscarnet. Initial clinical improvement was
observed with foscarnet. However, ten months later, the
lesion progressed to an approximately size of 5cm
erythematous, ulcerated nodule with prominent granulation
tissue. A skin biopsy revealed epidermal ulceration with focal
viral changes most consistent with herpes simplex virus
infection. Further, drug sensitivity testing confirmed resistance
to foscarnet. aciclovir sensitivity was noted. Despite of six
week course of IV aciclovir, the lesion progressed to a large
hypertrophic papillomatous mass with significant erosions.
The IV aciclovir was continued for another six weeks with
minimal improvement. A positron emission tomography scan
revealed 2-deoxy-2-[18F] fluoro-d-glucose uptake in the left
groin, left pelvic and left inguinal lymph nodes.
The man was then admitted for wide local excision of the
ulcer and excisional biopsy of a left inguinal lymph node. He
was then discharged on oral valaciclovir. He did well after the
surgery. Four months later, his wound was completely healed.
His treatment with oral valaciclovir was continued for
preventive therapy. There were no recurrences of the left
Author comment: "We present a case of a 49-year old
man with HIV who had an 8-year history of recurrent left
inguinal herpes simplex virus type 2 ulcerations. He initially
responded to oral acyclovir, but developed resistance to
acyclovir and eventually foscarnet." "Acyclovir-resistant strains
have been documented in 5% of HIV-positive patients"
Arinze F, et al. Surgical excision for recurrent herpes simplex virus 2 (HSV-2)
anogenital infection in a patient with human immunodeficiency virus (HIV).
Infection 45: 705-707, No. 5, Oct 2017. Available from: URL: http://
doi.org/10.1007/s15010-017-1027-y - USA
Reactions 2 Dec 2017 No. 16800114-9954/17/1680-0001/$14.95 Adis © 2017 Springer International Publishing AG. All rights reserved