Treatment of Acyclovir-Resistant Herpetic Ulceration with Topical Foscarnet and Antiviral Sensitivity Analysis

Abstract

Background: Herpes simplex virus (HSV) can produce persistent mucocutaneous disease in patients with the acquired immunodeficiency syndrome (AIDS). In this case report, we evaluate the efficacy, safety and viral resistance after topical foscarnet in severe genital ulceration due to acyclovir-resistant HSV-2. Case Report: A 45-year-old African woman was known for an HIV infection with severe immunosuppression (CD4 <100/mm3). She had received a long-term prophylaxis with acyclovir (400 mg b.i.d.) for a recurrent genital herpes. Few weeks after stopping this prophylaxis, she developed large genital ulcerations progressing despite valacyclovir treatment (1,000 mg t.i.d.). Cultures were positive for HSV-2, resistance to acyclovir was shown by the plaque reduction assay and topical foscarnet was tried. Treatment consisted of a 20-min application of topical foscarnet 2.4% twice a day. Dramatic improvement was observed with rapid antalgia, and cicatrization of the genital ulcerations was observed after 50 days. HSV could not be detected on the mucosal surface. Initially, HSV-2 was resistant to acyclovir but sensitive to foscarnet. After 1 month of topical treatment, HSV-2 became sensitive to acyclovir and was still sensitive to foscarnet. Finally, after 6 weeks of treatment, no virus could be detected by culture. Conclusion: Topical foscarnet (2.4%) is a convenient treatment for chronic genital herpes. Resistance to acyclovir disappears few weeks after stopping this drug and sensitivity to foscarnet persists during the 50 days of treatment.

Exophytic Ulcerated Tumors in HIV Patients: Diagnostic and Therapeutic Problems

“…Therefore imiquimod is considered as a topical adjuvant to make HSV more susceptible to systemic antiviral treatment. Other substances as topical cidofovir compounded into a 1–2% gel or cream daily for 5 consecutive days [31] or topical foscarnet 2.4% 20 min twice a day until clearing of the skin lesions [32] have also been described as effective topical adjuvants. Even excision of the tumor can be helpful in combination with systemic antiviral treatment [16].…”

Chronic mucocutaneous herpes simplex virus and varicella zoster virus infections

“…29 Perianal involvement (see Fig 4) usually manifests itself as multiple lesions, 65 ranging from small ulcers to ulcerations of up to 50 cm 2 . 30,38 Verrucous lesions may reach 4 to 5 cm in diameter (Figs 5 and 6). CHSV is likely to recur, 34,37,58,59 whereas CVZV generally occurs as an isolated event.…”

“…48,59 In general, genital CHSV presents as a single lesion, but several large ulcerations are sometimes seen (see Fig 4). 38 Orolabial CHSV typically presents as several small ulcerations. 29 Perianal involvement (see Fig 4) usually manifests itself as multiple lesions, 65 ranging from small ulcers to ulcerations of up to 50 cm 2 .…”

Antiviral Drug Resistance in Herpesviruses

“…Topical formulations of FOS, including a 1 % cream (Javaly et al 1999) and a 2.4 % solution (Pechere et al 1998), were effective in the treatment of mucocutaneous HSV infections unresponsive to ACV. Topical formulations of CDV have been also used successfully for the treatment of drug-resistant mucocutaneous HSV infections (Lalezari et al 1997;Sacks et al 1998;Sims et al 2007;Evans et al 2011).…”