Everybody needs some sweet okole. Keola and Kopono Beamer

Abstract: Recurrent herpes simplex of the sacrum and buttocks is commonly seen by dermatologists but rarely described in the literature. These patients can be helped by timely administration of acyclovir (famcyclovir or valcyclovir). Since recurrent sacral and buttock herpes simplex virus (HSV) infections can be associated with neurologic symptoms (sciatica, urinary retention, low back pain) it is important to recognize for primary care physicians, orthopedists, physical therapists and urologists.

Case Report:

The patient is a 77-year-old woman who presented for evaluation of a recurrent localized blistering eruption on the right buttock. This has occurred off and on for two to three years. She has had a pain in the right buttock and hip for a number of years that was attributed to some form of trauma and she has had physical therapy without pain relief. Her general health is good.

The examination showed grouped vesicles on an erythematous base on the right buttock. A Tzanck smear was positive for multinucleated giant cells.
IMPRESSION: Sacral HSV infection. Her buttock and hip pain may be related.

The patient was treated with acyclovir 400 mg three times a day for seven to ten days. If her hip pain improves, we will recommend she continue acyclovir as suppressive therapy for a few months at 400 mg twice to three times a day to see if that has a salutary effect on her chronic pain.

Discussion: Sacral HSV is seen with regularity in dermatologic practice, although it has not been extensively studied or reported. In 1974, Layzer and Conant mentioned sciatica with sacral herpes simplex.¹ We have seen a few memorable cases over the years. One was a 70 yo man with a history of sciatica and episodes of urinary retention.   He presented with sacral herpes on the ipsilateral side and was treated with acyclovir.   His urinary symptoms and sciatica resolved when his recurrent sacral HSV was treated with acyclovir and he remained symptom free on suppressive therapy.

The sacral plexus, formed from the ventral rami of L4 – S3, innervates the buttocks, genitalia, thighs, calves and feet. Thus, latent HSV that is reactivated can manifest itself with cutaneous or neuralgic symptoms in any of these areas. Inoculation is most usually from genital or anal contact and it is not possible to determine, by examination, what the initial contact was. Most usually, the primary exposure is assumed to be sexual contact. History is not often forthcoming, however, and it is not useful to belabor the point with patients.

Both HSV and varicella-zoster virus can be associated with long-lasting neurological symptoms.^2,3,4,5,6 Sciatica, urinary retention and some chronic pain syndromes are related to subclinical infection with these viral infections. Zoster sine herpete is well-known but infrequently recognized, and herpes sine herpes undoubtedly occurs but has not been reported. These are presumably caused by subclinical viral replication in the nerve ganglia.

Professor Khalifa Sharquie from Baghdad comments: “This is an interesting case and I see a few similar patients every year in my busy private clinic. I always ask about anal intercourse but all of my patients deny this. Recently, I saw a young man with penile and sacral herpes at the same time who also gave no history of anal sex. It is my belief that genital herpes could be seen as recurrent sacral rash with associated prodromal symptoms like malaise, sacral pain, and sciatica-like complaints. This is an important message that should be sent to rheumatologists as most of them are unaware of this condition since the literature is poor about this clinical entity. I call herpes of sacrum “herpes simplex buttockalis” to distinguish it from herpes genitalis as the rash commonly involves the buttock rather than the actual sacrum. This term has become well known to Iraqi dermatologists.

Dr. Sharquie’s creative eponym “herpes simplex buttockalis” inspired us to title this report “herpes okolealis” since we will discuss this case in Hawaii.

References:

1. Neuralgia in Recurrent Herpes Simplex. Robert B. Layzer, MD; Marcus A. Conant, MD Arch Neurol. 1974;31(4):233-237.

2. de la Sayette V, et. al. [Recurrent herpes with neuralgia and zones of cutaneous hypoesthesia]. Presse Med. 1985 May 11;14(19):1081-3. French.

3. Infectious neuropathies. Sindic CJ. Curr Opin Neurol. 2013 Oct;26(5):510-5

4. Nagel MA, Gilden D. Neurological complications of varicella zoster virus reactivation. Curr Opin Neurol. 2014 Jun;27(3):356-60 Free Full Text.

5. Berger JR, Houff S. Neurological complications of herpes simplex virus type 2 infection. Arch Neurol. 2008 May;65(5):596-600.

6. Steiner I, Kennedy PG, Pachner AR. The neurotropic herpes viruses: herpes simplex and varicella-zoster. Lancet Neurol. 2007 Nov;6(11):1015-28.

Just for fun, you can listen to the Beamer sing “Sweet Okole.”