Viral culture is the least desirable, as it is often laborious and requires several days to obtain a result. Antibody testing against HSV-1 or HSV-2 has very little utility in the diagnosis of most HSV infections and should be avoided. In this patient, the diagnosis of HSV-1 infection was confirmed by an immunohistochemistry method using a mouse anti-human monoclonal antibody directed against HSV-1 (Cell Marque Corporation, Rocklin, California; concentration 0.15 µg/mL) on paraffin-embedded tissue sections.
For the management of HSV infection, high doses of acyclovir, famciclovir, or valacyclovir are good choices. Although acyclovir is more cost-effective than the other two options, it is the least desirable because of more frequent dosing and less bioavailability.
In conclusion, HSV infection should be included in the differential diagnosis of rectal masses in persons with HIV infection and even in those who are HIV-negative. The patient in this case had CD4 T-cell counts > 200 cells/µL; thus, it is difficult to say that immune suppression was the main factor contributing to his unusual presentation. Early diagnosis and treatment can prevent some of the potential complications that may follow HSV proctitis. We can rightfully conclude that not all fungating and infiltrative rectal masses are cancers.
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