Chronic non-healing perianal ulcer as presenting sign of acquired immunodeficiency syndrome

A male in his forties presented with painful, persistent, nonhealing ulcers in the buttocks for two months with history of inadvertent weight loss and loss of appetite. History of highrisk sexual behavior including anal intercourse was present. On examination, the patient appeared cachexic with a body mass index of 15kg/m2. A shallow, tender, non-indurated, perianal ulcer of size around 10 x 7cm, with irregular margins, unhealthy granulation tissue and slough was noted. Multiple, skin-colored, umbillicated papules were also noted in bilateral buttocks (Figure 1). Multiple, non-tender, non-matted, inguinal lymph nodes were present bilaterally. A provisional diagnosis of chronic non-healing ulcer secondary to Herpes Simplex Virus with Molluscum contagiosum was considered. During workup, ELISA revealed antibodies to HIV-1 and was confirmed by Western blot test. His CD4 counts were 6.4% with absolute CD4 count of 113/µL. Blood culture revealed methicillin resistant coagulase negative staphylococci and pus culture reported growth of Enterobacter. His routine baseline investigations were normal. Rapid plasma reagin (RPR) test for syphilis and serology for hepatitis B and C virus were negative. The patient was started on tablet acyclovir 400mg thrice daily for 7 days and tablet linezolid 600 mg twice daily for 14 days along with topical antibiotic cream. The patient was then referred to the antiretroviral therapy (ART) centre. At 2 weeks’ follow-up, the ulcer showed complete re-epithelialization