Relapsing herpes simplex‐2 folliculitis in the beard area

ARTICLE

Auteur(s) : Caterina FOTI¹, Raffaele FILOTICO¹, Agata CALVARIO², Anna CONSERVA¹, Annarita ANTELMI¹, Giovanni ANGELINI¹

¹ Department of Internal Medicine, Immunology and Infectious Diseases, Unit of Dermatology 
² Virology Laboratory, Hygiene, Epidemiology and Public Health II Unit 
University of Bari, Policlinico, Piazza Giulio Cesare 11, 70124 Bari, Italy

Article accepted on 21/5/2004

Α 52-year-old man with a history of cholelithiasis, hiatal hernia and herniated disks in the cervical zone was referred to us for evaluation of recurrent folliculitis on the left cheek associated with intense pain. The patient developed the first eruption seven years prior to presentation, with relapses occurring about twice a year. Repeated cultures taken from the follicular lesions were positive for Staphylococcus aureus (coagulase-negative), Streptococcus species and diphtheroid species. Treatment with topical and systemic antibiotics had led to transient improvement and minocyclin-resistance. Micological cultures were negative. In the last years recurrences had increased in frequency with four episodes in one year. 

In July 2003 the patient was admitted to our clinic with a five days history of follicular eruption on the left cheek associated with intense pain and mild lymphadenopathy of the left submandibular region. Physical examination was remarkable for many follicular lesions without evidence of vesicles (Figure 1). Bacteriological, mycological and Tzanck tests from the lesions were negative. Histopathological study showed mild acanthosis of the epidermis and a dense perivascular and perifollicular inflammatory infiltrate in the dermis, lying beside areas in suppurating evolution. Direct immunofluorescence for immunoglobulin and complement was negative. 

Virological differential tests for HSV/1, HSV/2 and VZV by nested PCR technique (nPCR), carried out on swabs and paraffin-embedded tissue sections from the face lesions, detected HSV/2 genoma in both samples. 

Skin swabs from other healthy areas of the face, the serum and the peripheral blood leukocytes (PBL) were negative in nPCR for targeted herpes viruses.
Immunological evaluation including peripheral blood immunophenotyping seric immunoglobulin levels, HC50, neutrophyl phagocytotic and respiratory burst activity resulted normal. Anti-HIV antibodies were absent. 
One month later, on the occasion of a further relapse of the dermatitis, nPCR results on follicular lesion swabs confirmed HSV/2 infection. 
The patient reported recurrent episodes of herpes labialis during adolescence but denied herpetic infections of the genital area in him or his family members.
Systemic treatment with Valacyclovir chlorhydrate (500 mg/die) was advised and after six months follow-up the patient had no recurrence of the dermatitis.

Materials and methods nPCR test for HSV/1, HSV/2,VZV

Serum, PBL, skin swabs and histological sections were performed by nested PCR technique (nPCR). DNA extraction from the cellular samples (PBL, histological sections) was carried out at 95 °C by alkaline thermolysis, followed by chelating resin treatment to exclude the presence of inhibitors and then acid neutralization (EXTRACell Kit^® – Amplimedical – Divisione Bioline Diagnostici).
For acellular samples (serum and swabs) DNA extraction was performed by heat denaturation at 80 °C with guanidine and alcohol precipitation. Ten microliters of positive extraction internal control (CPE containing DNA Beta-globin^®, Amplimedical – Divisione Bioline Diagnostici) were added to 250 μl of sample in a monotest tube containing the lysis solution from the commercial extraction Kit (EXTRAgen^® – Amplimedical – Divisione Bioline Diagnostici).
The extracts obtained were used for HSV/1, HSV/2, VZV genome amplification analyses (HSV/1:gpD; HSV/2:gpG; VZV: major DNA binding protein), using a commercial assay following manufacturer’s guidelines (Amplimedical- Divisione Bioline Diagnostici); 5 μl of the extract were added to a monotest tube, specific for targeted viruses, containing a 40 μl mixture of external primers, buffer, dNTPs and 2U/μl DNA polymerase, suitably diluted with DECK (DNA Easy Check^® Amplimedical-Divisione Bioline Diagnostici). The use of DECK, a solution containing specific human β-globin primers, makes it possible to check that the samples are suitable for use in amplification reactions. A negative control, with sterile distilled water, and a positive control, containing the specific genomic region of the virus being searched for, were performed in parallel. At the end of the first amplification phase, 1 μl of amplified product and 5 μl of enzyme were added to 40 μl of a mixture of internal primers, buffer, dNTPs for the second amplification cycle. The manufacturer guarantees the sensitivity of the commercial kit to be 10 viral copies/reaction.
Amplicons were analysed by electrophoresis in a 4% agarose gel. A different amplificated size product identified each targeted herpes virus, being of 160 bp for type HSV/1, 81 bp for type HSV/2, 208 bp for VZV, respectively. The 600 bp amplicon relative to DECK indicated correct amplification.

Discussion

Viral folliculitis is an infrequently reported entity that can be caused by herpes and molluscum contagiosum viruses [1].
Herpes folliculitis of the face, first described by Izumi et al. as “herpetic sycosis”, must be differentiated from bacterial and mycotic sycosis [2].
Our 52-year-old immunocompetent patient presented with a history of recurrent follicular lesions on the left cheek associated with intense pain. The clinical picture was similar to that described by Izumi and other authors, but unlike previous reports, the Tzanck smear and histological examination did not show typical signs of viral infection.
Both for immunocompetent and immunocompromised patients differential herpetic diagnosis of atypical lesions is problematic since it is not always possible from a purely clinical perspective [3].
Therefore for more than ten years the opportunity to carry out differential viral diagnosis has been stressed as a rapid and sensitive means of detection of herpes simplex virus and varicella zoster virus from skin lesions which is important for the prompt initiation of antiviral therapy and appropriate patient management [4, 5].
The PCR protocol used in this study is more sensitive and faster than the traditional viral isolation followed by type – specific monoclonal antibodies [6-10]; furthermore it provides for the use of internal control to exclude PCR inhibitors in the samples [11]. This technique enabled us to make a differential diagnosis of recurrent herpetic folliculitis by HSV/2, an agent that has never been reported before as a cause of folliculitis.
In previous studies concerning herpetic folliculitis [1, 2] the authors did not identify the “HSV type” responsible for the eruption so HSV-2 involvement cannot be excluded.
The case we observed offers some interesting points for reflection, as it shows that even in immunocompetent patients HSV/2 lesions can feature atypical clinical aspects which may lead them to be misdiagnosed as bacterial or fungal infections. Therefore, in the presence of acute and painful recurrent folliculitis, the PCR technique seems to be a valuable diagnostic tool, also when the histological and clinical features of the eruption are not suggestive for a viral infection. n

References 

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