Pemphigus Vulgaris with Acyclovir-Resistant Herpes Simplex Virus Superinfection: A Case Report

Summary: We present the case of a 27-year-old woman initially presenting with acute pemphigus vulgaris (PV) whose hospital stay was complicated by development of acyclovir-resistant herpes simplex virus (HSV) following treatment with high-dose steroids and rituximab. This case exhibits a complex clinical predicament whereby necessary immunosuppressive treatment of PV lead to the development of acyclovir-resistant HSV during the patient’s admission. Treatment with both steroids and rituximab in PV patients leads to impaired cellular immunity and makes them more susceptible to developing acyclovir-resistant infections compared with immunocompetent individuals. In the case of this patient, after HSV culture sensitivities confirmed acyclovir resistance, acyclovir was discontinued and seven days of foscarnet treatment lead to the resolution of HSV lesions PV patients are at an increased risk for developing complex superinfection due to their medication-induced immunosuppressed status. In the case of genital lesions, providers should have a low suspicion for acyclovir-resistant HSV and should initiate proper treatment immediately.