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July 2004

Perianal Ulcer in a Patient With AIDS—Quiz Case

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Arch Dermatol. 2004;140(7):877-882. doi:10.1001/archderm.140.7.877-e

A 52-year-old white man with AIDS and a CD4 cell count of 5/µL developed a solitary, tender 2-cm punched-out, deep perianal ulcer with anerythematous scalloped border (Figure 1). The ulcer was initially attributed to herpes simplex virus (HSV) infection,as the patient had a history of perianal HSV 1 infection. He was treated for more than 1 year with high-dose oral acyclovir therapy and wound care, withoutimprovement. His general health was complicated by pulmonary and cutaneous Kaposi sarcoma, Pneumocystis carinii pneumonia, esophagealcandidiasis, duodenitis, lumbar plexopathy secondary to HSV, cytomegalovirus (CMV) retinitis, hypertension, and gastroesophageal reflux disease. His medicationsat presentation included zidovudine, lamivudine, indinavir sulfate, acyclovir, sulfamethoxazole-trimethoprim (double-strength), fluconazole, lisinopril,propranolol hydrochloride, omeprazole, and doxepin hydrochloride. The differential diagnosis included lymphoma, Kaposi sarcoma, squamous cell carcinoma, andinfection with atypical mycobacteria, deep fungi, or virus. Viral cultures and direct fluorescent antibody tests were negative for HSV-1 and -2, andtissue cultures were negative for fungi and bacteria. Urine cultures were positive for CMV, but blood cultures were nega tive for CMV. A skin biopsyspecimen was obtained from the border of the perianal ulcer (Figure 2).

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