Foscarnet is used to treat infections with herpes viruses, including drug-resistant cytomegalovirus
(CMV) and infections with herpes viruses 1 and 2 (HSV-1 and HSV-2). There are some reports of
intravenous foscarnet-induced penile and vulvar ulceration. The authors report a case of severe
penile ulcers after the initiation of intravenous foscarnet therap

Fernandes, I.

Sanches, M.

Selores, M.

Torres, T.

Acta Dermatovenerologica Alpina Pannonica et Adriatica

Repositório Científico do Centro Hospitalar do Porto

39Foscarnet-induced penile ulcerationActa Dermatoven APA Vol 20, 2011, No 1C a s e  r e p o r tFoscarnet-induced penile ulceration77RUUHV,)HUQDQGHV06DQFKHV06HORUHVK E YW O R D Sfoscarnet, penile ulcers, irritant dermatitis, side effectFoscarnet is used to treat infections with herpes viruses, including drug-resistant cytomegalovirus (CMV) and infections with herpes viruses 1 and 2 (HSV-1 and HSV-2). There are some reports of intravenous foscarnet-induced penile and vulvar ulceration. The authors report a case of severe penile ulcers after the initiation of intravenous foscarnet therapy.S U M M A R YFoscarnet is a pyrophosphate analogue that inhib-its viral DNA polymerases including reverse trancrip-WDVHRIKXPDQLPPQXQRGHÀFLHQF\YLUXVW\SH,WLVused to treat infections with herpes viruses, including drug-resistant cytomegalovirus (CMV), particularly LQ&09UHWLQLWLVDQGLQIHFWLRQVZLWKDQG+69DQG+697KHUH DUH VRPH UHSRUWV RI LQWUDYHQRXVfoscarnet-induced penile and vulvar ulcerations (1, 2).The authors report a case of a 32-year-old man with DFTXLUHGLPPXQHGHÀFLHQF\V\QGURPHZKRVWDUWHGLQ-travenous foscarnet (90 mg/kg/bid) for ganciclovir-resistant cytomegalovirus hepatitis. Ten days after initiating foscarnet, he developed multiple, painful penile ulcers (Fig. 1). Physical examination revealed an uncircumcised man with multiple irregular, tender, nonindurated ulcerations with serous exudate, located on the periurethral area, glans, and penile shaft. The surrounding skin was normal. Inguinal lymphade-nopathy was absent. Screening for syphilis (serology), fungi (potassium hydroxide preparation test), and vi-UXVHV7]DQFNSUHSDUDWLRQDQGSRO\PHUDVHFKDLQUHDF-tion test for herpes simplex virus) were all negative. A FXWDQHRXVELRSV\ZDV UHIXVHG3HQLOHFDWKHWHUL]DWLRQwas performed and foscarnet was discontinued after hepatic improvement. Improvement in the ulceration ZDVQRWHGDIWHURQHZHHN)LJDQGVLJQLÀFDQWKHDO-ing one month later.Foscarnet is used to treat herpes viruses, including drug-resistant cytomegalovirus (CMV), particularly &09 UHWLQLWLV DQG LQIHFWLRQVZLWK  DQG  +69DQG+69)RVFDUQHWFDQDOVREHXVHGWRWUHDW+,9patients as part of salvage therapy. Nephrotoxicity is a major side effect associated with foscarnet therapy. Additional adverse effects include hypocalcemia, ane-mia, thrombophlebitis of the peripheral veins, and mild elevation of liver function tests.There are some reports of intravenous foscarnet-induced penile and vulvar ulcerations (1, 2). The cause of the ulcerations is unknown. Although clinically the XOFHUVFDQUHVHPEOHDÀ[HGGUXJHUXSWLRQWKHELRSV\40Foscarnet-induced penile ulcerationActa Dermatoven APA Vol 20, 2011, No 1C a s e  r e p o r tÀQGLQJV GR QRW VXSSRUW WKLV GLDJQRVLV DQG WHQG WRsupport an acute dermatitis (3). Topical preparations RIIRVFDUQHWFUHDPKDYHEHHQIRXQGWRLQGXFHVH-vere irritant dermatitis, particularly in the subprepu-tial space in uncircumcised men, while topical prepa-UDWLRQVRIWRKDYHEHHQEHWWHUWROHUDWHG$SSUR[LPDWHO\RIWKHGUXJLVH[FUHWHGXQFKDQJHGin the urine and may be retained in the subpreputial space after urination. An irritant dermatitis second-ary to cutaneous contact with foscarnet in the urine seems plausible, mainly because all reports of ulcer-ation have occurred early on in treatment when high dose regimens are used. Moreover, because of foscar-net nephrotoxicity, good hydration during therapy is recommended, increasing the frequency of urination and thus increasing the chance of genital ulceration. Good personal hygiene, including washing the geni-tals after urination, is recommended to reduce the oc-currence of this side effect (5).Although the patient refused a biopsy, the devel-opment of the ulcers after starting foscarnet and the improvement with the cessation of the antiviral ther-apy allows us to assume that this is another case of foscarnet-induced genital ulcers.With the increasing number of patients with re-sistant herpes virus infections being treated with foscarnet, it is essential to be aware of this potential complication.Figure 1. Irregular, tender, nonindurated ulcer-ation, located on the periurethral area, gland, and penile shaft.Figure 2. Ulceration improvement after penile catheterization and discontinuation of foscarnet.R EFER ENCESA U T H O R S ’A D D R E S S E S1. (YDQV/0*URVVPDQ0()RVFDUQHWLQGXFHGSHQLOHXOFHU-$P$FDG'HUPDWRO± /DFH\+%1HVV$0DQGHO%.9XOYDOXOFHUDWLRQDVVRFLDWHGZLWKIRVFDUQHW*HQLWRXULQ0HG3. &RQQDOO\ *0 *D]]DUG 0$ +DZNLQV '$ )L[HG GUXJ HUXSWLRQ GXH WR IRVFDUQHW *HQLWRXULQ 0HG±4. 0R\OH*%DUWRQ6*D]]DUG%*3HQLOHXOFHUDWLRQZLWKIRVFDUQHWWKHUDS\$,'6±5. /HUQHVWHGW-2&KDQDV$&3HQLOHXOFHUDWLRQVZLWKIRVFDUQHW/DQFHWTiago Torres, MD, Department of Dermatology, Centro Hospitalar do Porto – Hospital de Santo António, Edifício das Consultas Externas do Hospital Geral Santo António, Ex. CICAP, Rua D. Manuel II, s/n, 4100 Porto, Portugal, E-mail: tiagotorres2002@hotmail.comIolanda Fernandes, MD, same address, E-mail: iolandacfernandes@iol.ptMadalena Sanches, MD, same address, E-mail: madalenavsanches@gmail.comManuela Selores, MD, same address, E-mail: dermat@sapo.pt

Foscarnet-induced penile ulceration

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Foscarnet-induced penile ulceration

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