Herpes genitalis is the most common sexually transmitted disease worldwide. Its incidence has been increasing, especially among positive human immunodeficiency virus patients.[1] The typical presentations of cutaneous herpes simplex virus are well known and rarely cause diagnostic difficulty. However, in patients with advanced human immunodeficiency virus infection, unusual and severe manifestations of herpes simplex virus infection are common and are included among the opportunistic processes that define the acquired immunodeficiency syndrome.[2] The unusual clinical presentations increasingly observed in clinical practice have led to the use of new treatment modalities such as immunomodulatory agents, in particular topical imiquimod cream as an adjunctive therapy to the first-line drug acyclovir with satisfactory results.[1] Our case report describes a human immunodeficiency virus-infected man with a herpetic infection that was refractory to acyclovir but not to imiquimod, followed by literature review of similar cases.

A 54-year-old human immunodeficiency virus-infected man presented with a 5-month history of painful penile erosions. Physical examination revealed extensive herpetiform erosions involving the penis [Figure 1a]. His CD4 cell count was 299/µL and his viral load was undetectable. He had been receiving antiretroviral therapy and had no previous history of genital herpes infection. He had already been treated in a primary health-care unit with acyclovir (4 g daily), penicillin and azithromycin with no improvement. Results of blood tests were positive for syphilis (venereal disease research laboratory 1: 32; fluorescent treponemal antibody-absorption positive) and herpes simplex virus (immunoglobulin M negative; immunoglobulin G positive), cytomegalovirus (immunoglobulin M negative; immunoglobulin G positive) and chlamydia (immunoglobulin M negative; immunoglobulin G positive). Skin biopsy was inconclusive. The patient was hospitalized and began empiric treatment with crystalline penicillin and intravenous acyclovir (800 mg three times daily) for 15 days due to oral acyclovir refractory herpes simplex. He was discharged with partially improved but still unhealed genital ulcers.