A 24-year-old African-American female with perinatally acquired HIV and AIDS (CD4 = 27, VL 16, 164) with nonadherence to highly active antiretroviral therapy (HAART), presented to her primary HIV provider with sore throat, fever, and weakness for two weeks, and URI symptoms for one week. She reported difficulty with swallowing solids and liquids including all HAART pills due to throat pain. Three days prior to presentation, she was seen at an outside emergency department and had a positive rapid streptococcal antigen test for which she was prescribed amoxicillinclavulanic acid for strep pharyngitis; she did not fill the prescription. On exam, there was a 6-kilogram weight loss since two months prior to presentation. She was febrile and was noted to have a muffled voice. There were thick white plaques on the left tonsil, tonsillar pillar, and tongue mucosa that did not scrape off. Due to the degree of discomfort and persistent fevers up to 102 degrees Fahrenheit, there was concern for a severe infection of the parapharyngeal or retropharyngeal spaces (i.e., Lemierre's syndrome, abscess), and a CT scan of the neck was obtained. It revealed bilateral palatine tonsillitis with evidence of a possible early abscess in the left glossopalatine recess, but no obvious areas of fluid collections. Clindamycin was added to the antibiotic regimen at that time.
Her past medical history was significant for a CD4 nadir of 14
, recurrent skin infections and abscesses, chronic purulent otitis media requiring tympanostomy tubes, trichomonas, and Grade 1 cervical intraepithelial neoplasia. She was notably nonadherent to her HAART regimen of daily atazanavir, lamivudine, abacavir, and ritonavir. She was also on monthly aerosolized pentamidine for pneumocystis prophylaxis, but was not taking prophylaxis for mycobacterium avium intracellulare.
Three days later, the throat pain had worsened with extension to the right side. The patient remained febrile and was unable to take any solids or liquids orally due to pain. She also reported the development of a painful genital ulcer during the past week. She had vaginal intercourse with an asymptomatic male partner one week prior to the onset of symptoms and reported intermittent condom use. She denied any new sexual partners for the last 2 months and adamantly denied orogenital sexual contact.
The patient denied headaches, visual changes, vomiting, seizures, or other focal neurologic symptoms on review of systems.
Physical exam at this time revealed an ill-appearing young woman who was alert, and oriented with new enlargement of the right tonsil with erythema, new white plaques on the posterior pharynx without improvement of the left tonsil or the left side of the tongue. The patient demonstrated pain when opening her mouth for exam. On the genitourinary exam, there was labial swelling and a 1
cm large open ulcer with cream-colored discharge centrally over the ulcer. There was also a creamy film covering the vaginal introitus. She was unable to tolerate a speculum and one-finger manual exam due to significant swelling and pain.
The patient was admitted to the hospital for worsening tonsillitis and pharyngitis not responding to dual oral antibiotic coverage, dehydration, and persistent fevers. She was started on intravenous ampicillin sulbactam, fluconazole, and acyclovir. Subsequent viral cultures from the throat, mouth, and genital ulcer became positive for HSV-2 at two days. Two years prior to the current presentation, qualitative determination of antibody status for specific IgG to both HSV-1 and HSV-2 using indirect chemiluminescence immunoassays was negative during the patient's pregnancy. Repeated evaluation using the same method for specific IgG to both HSV-1 and HSV-2 remained negative with the current illness at approximately two and a half weeks from onset of symptoms. Antibody status of HSV IgM was also negative. She was known to have had appropriate antibody responses to Hepatitis A and B vaccines. Other admission labs included a white blood cell count of 8600 per cubic millimeter with an absolute neutrophil count of 7040 per cubic millimeter, and normal complete metabolic panel with normal liver function markers.
The patient's condition improved with treatment and once she was able to tolerate oral intake, she was discharged on hospital day 5 on oral valacyclovir 1000
mg twice daily, fluconazole 200
mg daily, and amoxicillin clavulanic acid extended-release 1 gram twice daily.