| Author | Affiliation |
|---|---|
| Leyan Shalabi, DO | University of Illinois at Chicago, College of Medicine, Department of Emergency Medicine, Chicago, Illinois |
| Wesley Eilbert, MD | University of Illinois at Chicago, College of Medicine, Department of Emergency Medicine, Chicago, Illinois |
ABSTRACT
Case presentation
A 21-year-old woman with a history of eczema presented to the emergency department with a painful rash over the previous three days spreading from her left axilla to her left arm, left chest and left abdominal wall. The rash consisted of clusters of small, erythematous vesicles on hyperpigmented patches of skin. The patient was treated empirically with intravenous acyclovir for eczema herpeticum with improvement. Polymerase chain reaction testing of the fluid obtained from the rash vesicles later confirmed the presence of herpes simplex virus-1.
Discussion
Eczema herpeticum is a cutaneous superinfection with herpes simplex virus on pre-existing sites of eczema. Left untreated, it can have a mortality rate over 50%. Early identification and treatment of this high morbidity condition with antiviral agents is key to improving outcome.
CASE PRESENTATION
A 21-year-old woman with a history of eczema presented to the emergency department complaining of a painful rash present for three days. Over the previous week, she had been experiencing worsening eczema symptoms for which she had been applying two corticosteroid creams. The painful rash consisted of grouped clusters of small erythematous vesicles overlying hyperpigmented patches. The rash had started in her left axilla and spread to her left arm, chest, and abdomen (Images 1, 2 and 3). With the rash, she reported associated chills and intermittent emesis.
Due to the extensive skin involvement and associated systemic symptoms, the patient was treated empirically with intravenous acyclovir and admitted to the hospital. Fluid collected from the vesicles of the rash was positive for herpes simplex virus (HSV) -1 deoxyribonucleic acid (DNA) on polymerase chain reaction (PCR) testing. She had significant improvement of the rash and was discharged on hospital day three to complete a 10-day course of valacyclovir.
DISCUSSION
Atopic dermatitis, or eczema, is the most common inflammatory skin disease, affecting up to 18% of children and 7% of adults.1 Eczema herpeticum (EH) is a cutaneous superinfection with HSV, most commonly HSV-1, on pre-existing sites of eczema.2,3 Up to 3% of patients with eczema will experience an episode of EH, and at least 20% of all patients with EH will have a history of recurrent herpes infections.1,4 An initially local disease, EH may progress to a potentially life-threatening systemic infection.3
Eczema herpeticum typically presents as a sudden eruption of monomorphic, dome-shaped, grouped, 2–3 millimeter vesicles on an erythematous base, superimposed on areas of pre-existing sites of eczema, most commonly the face, neck and upper chest.5 The rash is pruritic and painful and may spread to involve areas of normal skin.5 The rash is often accompanied by systemic symptoms such as fever, malaise, headache, and lymphadenopathy.4 The vesicles rupture and form crusts over underlying erosions after one to two weeks.3
The diagnosis of EH is made on clinical grounds and confirmed by the detection of HSV DNA in vesicle fluid by PCR.5 The sensitivity of PCR testing is between 80–100%.3 If PCR is not available, direct fluorescent antibody testing, a Tzank smear, or viral cultures may be used.5
The mortality rate of EH in the era before antiviral therapy was frequently over 50%.6 Given its potential high morbidity, treatment of EH should begin when it is suspected, without waiting for confirmatory tests.1,3 Acyclovir is the antiviral agent of choice for the treatment of EH.3,4 Mild cases can be treated with oral acyclovir on an outpatient basis.5 Patients with signs of systemic illness, extensive skin involvement, and those less than one year of age should be hospitalized and treated with IV acyclovir.1,5 Up to 30% of patients hospitalized for EH will have bacterial superinfection with Staphylococcus aureus, and some authors recommend empiric treatment with antistaphylococcal antibiotics for cases with extensive skin involvement.7,8
CPC-EM Capsule
What do we already know about this clinical entity?
Eczema herpeticum is a cutaneous superinfection with herpes simplex virus. Left untreated, eczema herpeticum can have a mortality rate over 50%.
What is the major impact of the image(s)?
The images show the characteristic rash of eczema herpeticum: grouped clusters of small erythematous vesicles overlying hyperpigmented patches of skin.
How might this improve emergency medicine practice?
Rapid identification and treatment is necessary to prevent associated mortality.
Footnotes
Section Editor: Anna McFarlin, MD
Full text available through open access at http://escholarship.org/uc/uciem_cpcem
The authors attest that their institution requires neither Institutional Review Board approval, nor patient consent for publication of this case report. Documentation on file.
Address for Correspondence: Wesley Eilbert, MD, University of Illinois at Chicago, College of Medicine, Department of Emergency Medicine, Room 469 CME, 1819 W Polk St. Chicago, IL 60612. Email: weilbert@uic.edu. 9:107 – 108
Submission history: Revision received March 4, 2024; Submitted September 11, 2024; Accepted September 7, 2024
Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.
REFERENCES
1. Wang V, Boguniewicz J, Boguniewicz M, et al. The infectious complications of atopic dermatitis. Ann Allergy Asthma Immunol. 2021;126(1):3-12.
2. Micali G, Lacarrubba F. Eczema herpeticum. N Engl J Med. 2017;377(7):e9.
3. Damour A, Garcia M, Seneschal J, et al. Eczema herpeticum: clinical and pathophysiological aspects. Clin Rev Allergy Imunol. 2020;59(1):1-18.
4. Traidl S, Roesner L, Zeitvogel J, et al. Eczema herpeticum in atopic dermatitis. Allergy. 2021;76(10):3017-27.
5. Xiao A, Tsuchiya A. Eczema herpeticum. StatPearls [Internet]. 2024. Available at: http://www.ncbi.nlm.nih.gov/books/NBK560781/. Accessed March 26, 2024.
6. Wheeler CE, Abele DC. Eczema herpeticum, primary and recurrent. Arch Dermatol. 1966;93(2):162-73.
7. Aronson PL, Yan AC, Mittal MK, et al. Delayed acyclovir and outcomes of children hospitalized with eczema herpeticum. Pediatrics. 2011;128(6):1161-7.
8. Almoalem M, AlAlharith I, Alomer H, et al. Extensive eczema herpeticum in a previously healthy child. Int J Emerg Med. 2022;15(1):21.
