Deep Herpes

Abstract

Herpes viruses are known for infecting epithelial cells and manifesting as vesicles. However, herpes viruses can also infect stromal cells. While established in the ocular setting, cutaneous stromal herpes (deep herpes) is previously unreported and may evade clinical and microscopic detection. We searched for skin biopsies with herpes stromal disease. Clinical information was retrieved via electronic medical records and pathology records system. Hematoxylin and eosin slides, immunohistochemical staining, and polymerase chain reaction detection of viral DNA was performed. We identified 12 specimens from 10 patients with cutaneous stromal herpes simplex virus 1/2 (n=7) or varicella-zoster virus infection (n=5). The most common site involved was the buttocks/perianal region (n=6). Ulceration was a frequent dermatologic finding (n=8). Pyoderma gangrenosum was clinically suspected in 6 specimens (50%). Eight patients (80%) were immunosuppressed. Biopsies frequently demonstrated a dense dermal mixed inflammatory infiltrate with subcutaneous extension and enlarged cells with viral cytopathic changes confirmed by herpes simplex virus 1/2 or varicella-zoster virus immunohistochemistry (n=10) or polymerase chain reaction (n=2). Most specimens (67%) lacked evidence of characteristic epidermal keratinocyte infection. This study presents the first known report of the ability of herpes virus to infect deep stromal cells of the dermis. We raise awareness of cutaneous stromal herpes in patients presenting with atypical clinical lesions, particularly while immunocompromised. Establishing the correct diagnosis is critical for initiating therapy.

Herpes zoster: A Review of Clinical Manifestations and Management

“…However, internal organs such as the gastrointestinal system may also be involved [34]. The major risk factor for deep HZ is immunosuppression [35].…”

Recurrent papulonodular herpes zoster, with syringitis, folliculitis, and vasculitis as clues to the diagnosis

“…6 Herpes viruses are reported to cause deep dermal involvement without evidence of epidermal infection, especially in atypical lesions in immunosuppressed patients. 7 Our case had painless papulonodular lesions in which epidermal involvement was absent but syringitis, folliculitis, and vasculitis were evident. We believe that the pain is associated with the presence of epidermal involvement, which can stimulate the nociceptors of the epidermis.…”

“…Histopathologically, the epidermis was involved with blisters with degenerated keratinocytes and multinucleated giant cells 6 . Herpes viruses are reported to cause deep dermal involvement without evidence of epidermal infection, especially in atypical lesions in immunosuppressed patients 7 …”

Herpes Zoster no adulto e na criança: impacto, diagnóstico e tratamento nas esferas neurológicas, dermatológicas e oftalmológicas

“…No entanto, órgãos internos, como o sistema gastrointestinal, também podem ser afetados. A imunossupressão é o principal fator de risco para o desenvolvimento de HZ profundo(Krystel-Whittemore et al, 2021).…”