An atypical presentation of HSV-1 cutaneous lesions in a patient with non-hodgkin T cell lymphoma: A case report

Cutaneous T-cell lymphomas (CTCL) are rare extranodal non-Hodgkin lymphomas characterized by malignant proliferation of skin-homing T lymphocytes. Immunosuppressed patients are prone to opportunistic viral infections such as Herpes simplex virus (HSV), which may present atypically and mimic disease progression or transformation. We describe a 67-year-old woman with T-cell non-Hodgkin lymphoma on chemotherapy who presented with pneumonia and neutropenia. During hospitalization, she developed a widespread erythematous, papulovesicular rash involving the extremities, trunk, and palms. Skin biopsies revealed dermal lymphomatous infiltrates with minimal epidermotropism, while polymerase chain reaction (PCR) confirmed HSV-1 infection. The patient improved clinically following intravenous acyclovir therapy and supportive care. However, follow-up positron emission tomography demonstrated new cutaneous and subcutaneous nodules consistent with cutaneous T-cell lymphoma progression. This case illustrates a rare coexistence of disseminated HSV-1 infection and CTCL in an immunocompromised host. Viral infections, including HSV, may exploit skin barrier disruption caused by lymphoma infiltration or chemotherapy, potentially exacerbating disease activity through chronic antigenic stimulation. The presentation resembled Kaposi varicelliform eruption, a disseminated HSV infection classically described in patients with underlying dermatoses. Clinicians should maintain a high index of suspicion for viral co-infections in lymphoma patients presenting with new or atypical skin lesions. Early antiviral therapy is crucial to prevent systemic complications. This report underscores the diagnostic challenges and possible pathogenetic interplay between HSV infection and CTCL in immunocompromised individuals.