Further testing subsequently showed positive immunohistochemistry for herpes simplex virus 1 in the epithelial cells, with an impressive demonstration of a viral cytopathic effect (Figure 3). These findings supported the diagnosis of herpes simplex virus (HSV) infection.
Warthin-Starry staining was negative for spirochetes or "black elements," and immunostaining for adenovirus and cytomegalovirus (CMV) was also negative. Fungal stains, such as Gomori methenamine silver (GMS) and trichrome, did not show any fungal elements. Further workup for human herpes virus 8 (HHV-8) and human papillomavirus (HPV) infection was not pursued, as the histopathologic picture was not consistent with either of these conditions.
The RPR decline from 1:16 to 1:4 following previous syphilis treatment represents a fourfold titer decrease, which is consistent with a history of adequately treated syphilis. Gonorrhea would not be expected to cause a mass lesion, as it typically presents as mucositis. Furthermore, a recent polymerase chain reaction (PCR) analysis of urine and rectal mucosa samples did not support a diagnosis of gonorrhea.
Although LGV can cause both proctocolitis and a mass lesion in the rectum, especially in the secondary stage of LGV, the absence of Chlamydia on rectal nucleic acid amplification testing (NAAT) and the lack of histopathologic findings suggestive of LGV make this diagnosis less likely. Characteristic histopathologic findings of LGV in representative tissues include necrosis, especially within the lymph nodes, followed by abscess formation. Warthin-Starry staining of the lymph nodes often shows macrophages containing organisms that stain black.
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