Two cases of recurrent lumbosacral herpes simplex without concomitant genital lesions are reported. Both patients presented with vesicular lesions on the middle of the lower back and on the left thigh, respectively, and had positive serum antibody to herpes simplex virus type 2 and negative antibody to HIV. The lesions healed completely within 1 week by oral administration of acyclovir.
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Herpes simplex virus type 2 (HSV-2) is one of the most prevalent sexually transmitted infections worldwide. The overall age-adjusted HSV-2 seroprevalence was 17.0% in 1999–2004 in the USA.1 Herpetic skin lesions can occur virtually anywhere on the body in association with genital herpes.2 Recurrent cutaneous herpetic lesions on the lower back and buttocks can occur in the absence of actual genital lesions3 so the diagnosis is sometimes difficult. We describe here two cases of recurrent lumbosacral herpes simplex without concomitant genital lesions.
A 29-year-old man presented with three episodes of crops of identical vesicular lesions on the lower back as well as mild backache over about 1 year. He recalled unprotected vaginal sex with several female partners 1 year ago and no onset of genital lesions. The lesions were commonly triggered by fatigue, stress, over drinking and so on. Physical examination showed small clustered vesicles and erosions on the erythematous base on the middle of the lower back (see fig S1 of the supplementary material). There was positive serum antibody to HSV-2 and negative antibody to HIV by ELISA. The patient was treated with oral acyclovir 0.4 g three times daily for 5 days and the lesions healed completely within 7 days.
A 35-year-old man had more than 10 outbreaks of thigh herpes with mild sciatic pain over about 3 years. He reported unprotected intercourse with a casual female partner 3 years ago. There was no record of genital lesions and the triggering factors were similar to those in case 1. On examination, there were small grouped vesicles on the erythematous base and hyperpigmented macules on the upper part of left thigh (fig 1). Serum HSV-2 antibody was positive and HIV antibody was negative. Treatment with oral acyclovir 0.4 g three times daily was started and healing was completed within 5 days.
The development of extragenital lesions during the course of infection is a common complication of first episode primary genital herpes and is seen more commonly in women than men. Extragenital lesions are most frequently located in the buttocks, groin or thigh area. Among patients with primary HSV-2 and non-primary HSV-2, 9% and 2% developed extragenital lesions, respectively, most commonly on the buttocks.4 Corey et al reported that extragenital mucocutaneous lesions developed in 26% of women and 10% of men with primary HSV-2 infection, and in 5% of women and 3% of men with recurrent genital herpes.5 Genital and extragenital recurrences occurred with similar frequency.2
The lumbosacral eruptions may occur with or without concomitant genital involvement.6 The recurrence is ordinarily triggered by stress, fatigue or the menses. The main feature is the prodrome of localised burning, pruritus or deep pelvic ache occurring 1–3 days before the appearance of the vesicles.3 6 Here, case 1 had lower backache and case 2 had sacral radiculopathy symptoms. The lesions occur on the middle of the lower back or the left thigh (S2 dermatome) and heal with hyperpigmentation and little scarring, but neither of them had experienced any other external genital sign of herpes. The diagnosis of lumbosacral herpes simplex should be differentiated from lower back strain, herniated lumbosacral disk, herpes zoster and sciatica. The recurrent onset, pre-existence of hyperpigmented patches and, possibly, concomitant genital lesions are the clues to the diagnosis of lumbosacral herpes simplex.
Lumbosacral herpes simplex without concomitant genital involvement is rare.
Recurrent onset, pre-existence of hyperpigmented patches and, possibly, concomitant genital lesions are the clues to the diagnosis of lumbosacral herpes simplex.
Differential diagnosis of lumbosacral herpes simplex includes lower back strain, herniated lumbosacral disk, herpes zoster and sciatica.
Competing interests: None.
Patient consent: Obtained.
Contributors: Y-MF wrote and revised the manuscript. Y-MF, Y-PY and WL collected the clinical data.