Department of Dermatology, SUNY Downstate Health Sciences University, Brooklyn, New York, USA.
J Cutan Pathol. 2023 Oct;50(10):878-883. doi: 10.1111/cup.14490. Epub 2023 Jul 9.
We report a case of a 42-year-old immunocompromised (human immunodeficiency virus [HIV], CD4 count 86 cells/μL) Black male who presented with fever, oropharyngeal candidiasis, and phimosis, followed by eruption of umbilicated papulovesicles most concentrated on the face. The patient was diagnosed with Mpox (MPXV, formerly monkeypox), herpes simplex virus 1 (HSV1), varicella-zoster virus (VZV), and late latent syphilis. Tzanck smear of a Mpox lesion proved a useful and rapidly obtained pertinent negative test, lacking the typical changes of HSV/VZV (multinucleation, margination, and molding). A biopsy specimen showed viral changes consistent with both Mpox (ballooning degeneration and multinucleated keratinocytes) and herpesvirus (multinucleated epithelial giant cell within a zone of follicular necrosis). Lesion PCR was positive for HSV1 and MPXV, and negative for HSV2 and VZV. Immunohistochemistry was positive for VZV and orthopoxvirus. Empiric treatment for HSV/VZV in patients with suspected or confirmed Mpox should be considered for patients with HIV or other immunocompromised patients. It is important to recognize that MPXV, HSV, and VZV may all be present and difficult to distinguish clinically. More than one test modality (PCR, H&E, immunohistochemistry, and Tzanck) and multiple lesion samples may be required to thoroughly evaluate widespread papulovesicular eruptions, especially in immunocompromised patients.
我们报告了一例 42 岁免疫功能低下（人类免疫缺陷病毒 [HIV]，CD4 计数 86 个/μL）的黑人男性，他表现为发热、口腔念珠菌病和包茎，随后出现脐状丘疹水疱，主要集中在面部。患者被诊断为猴痘（MPXV，以前称为猴痘）、单纯疱疹病毒 1（HSV1）、水痘-带状疱疹病毒（VZV）和晚期潜伏梅毒。Mpox 病变的 Tzanck 涂片证明是一种有用且快速获得的相关阴性检测，缺乏 HSV/VZV 的典型变化（多核、边缘化和成型）。活检标本显示病毒变化符合猴痘（气球样变性和多核角蛋白细胞）和疱疹病毒（滤泡坏死区的多核上皮巨细胞）。病变 PCR 对 HSV1 和 MPXV 呈阳性，对 HSV2 和 VZV 呈阴性。免疫组化对 VZV 和正痘病毒呈阳性。疑似或确诊猴痘的 HIV 或其他免疫功能低下患者应考虑针对 HSV/VZV 的经验性治疗。重要的是要认识到，MPXV、HSV 和 VZV 可能同时存在且难以在临床上区分。为了彻底评估广泛的丘疹水疱性皮疹，特别是在免疫功能低下的患者中，可能需要多种检测方式（PCR、H&E、免疫组化和 Tzanck）和多个病变样本。
