Skip to main content

Extensive eczema herpeticum in a previously well child

A Correction to this article was published on 01 June 2022

This article has been updated

Abstract

Background

Eczema herpeticum, also known as Kaposi varicelliform eruption, is a potentially life-threatening disseminated cutaneous viral infection. In the majority of cases, this condition develops as a complication in patients with atopic dermatitis. However, it may arise in a wide spectrum of pre-existing skin conditions, including psoriasis, seborrheic dermatitis, contact dermatitis, cutaneous T cell lymphoma, pemphigus vulgaris, and others.

Case presentation

We present the case of a 2-year-old boy who was brought to the emergency department because of a high-grade fever and rash. The fever started 2 days before his presentation, and its maximum measurement was 39.6°C. The following day, the patient developed numerous painful, pruritic vesiculopustular eruptions, and oozing involving the lips, rendering the patient unable to tolerate oral feeding. The patient was seen by the dermatology team who diagnosed the child as having eczema herpeticum. The patient was commenced on antiviral and empirical antibiotic therapy in the form of intravenous acyclovir and cephalexin along with topical fusidic acid and panthenol. The patient showed clinical improvement with resolution of the fever and partial involution of the rash 2 days following the administration of the antimicrobial therapy.

Conclusion

Eczema herpeticum is a rare clinical entity that can result in significant morbidity. The case highlights the importance of considering the diagnosis of eczema herpeticum in the appropriate clinical settings, even in patients who were not known to have any prior skin disorder.

Background

Eczema herpeticum, also known as Kaposi varicelliform eruption, is a potentially life-threatening disseminated cutaneous viral infection. It is typically caused by the herpes simplex virus, but it can develop by coxsackie, vaccinia, and smallpox viruses. In the majority of cases, this condition develops as a complication in patients with atopic dermatitis [1]. However, it may arise in a wide spectrum of pre-existing skin conditions, including psoriasis, seborrheic dermatitis, contact dermatitis, cutaneous T cell lymphoma, pemphigus vulgaris, and others [2]. Here, we present the case of a previously healthy boy with extensive eczema herpeticum.

Case presentation

We present the case of a 2-year-old boy who was brought to the emergency department by his parents because of a high-grade fever and rash. The fever started 2 days before his presentation, and its maximum measurement was 39.6°C. The parents reported partial resolution of the fever with paracetamol. The following day, the patient developed numerous painful, pruritic vesiculopustular eruptions and oozing involving the lips, rendering the patient unable to tolerate oral feeding. On the same day, the rash spread sequentially spread to involve the face, neck, and upper trunk. The genitalia was spared. There was no history of upper respiratory tract symptoms, abdominal pain, or change in urinary or bowel habits. The patient had no sick contact and was fully up to date with his vaccination schedule. The patient was previously healthy with unremarkable past medical history.

Upon examination, the child appeared sick with severely cracked oozing lips (Fig. 1). Further, disseminated non-blanching maculopapular rash involving the face and trunk was observed (Fig. 2). His vital signs were as follows: a pulse rate of 118 bpm, a blood pressure of 124/80 mmHg, a respiratory rate of 24 bpm, and a temperature of 39°C. Head and neck examination showed erythematous congested pharynx with palpable cervical lymph nodes. Cardiorespiratory and abdominal examinations revealed normal findings. Initial laboratory investigation revealed a hemoglobin level of12.1 g/dL, leukocyte count of 8000/μL, a platelet count of 455,000/μL, and C-reactive protein of 37.8 nmol/L. A swab culture of the lesions revealed no bacterial growth. Chest radiograph demonstrated clear lung fields with no airspace opacity.

Fig. 1
figure 1

Photograph of the child showing severely cracked oozing lips

Fig. 2
figure 2

Photograph of the child showing the disseminated non-blanching maculopapular rash involving the back

Given the inability to tolerate oral feeding, the patient was admitted for further evaluation and management. The patient was seen by the dermatology team who diagnosed the child as having eczema herpeticum. The patient was commenced on antiviral and empirical antibiotic therapy in the form of intravenous acyclovir and cephalexin along with topical fusidic acid and panthenol. The patient showed clinical improvement with resolution of the fever and partial involution of the rash 2 days following the administration of the antimicrobial therapy. The patient started to tolerate oral feeding. The patient was discharged after 6 days of admission and was prescribed symptomatic treatment. In the follow-up visit after 2 weeks, the patient had complete resolution of the rash with no active complaints.

Discussion

We presented a rare case of eczema herpeticum in a child who was not known to have any dermatological conditions. This condition was first described by Moriz Kaposi in 1887 [3]. The exact pathogenesis of eczema herpeticum remains unclear. It is suggested that a complex interplay of epidermal barrier breakdown with impairment in the cell-mediated and humoral immunity [4]. In the present case, however, the patient did not have any history suggesting immunodeficiency or previous skin disorders. While eczema herpeticum can affect both genders, a prior study found that male patients experience a more severe course of the disease [5].

The diagnosis of eczema herpeticum is made mainly by the clinical findings of disseminated vesiculopustular rash, which can evolve into hemorrhagic vesicles. Systemic symptoms, including fever, may occur in over 50% of patients [5]. Tzank smear can be performed which can demonstrate multinucleated giant cells on the Wright-Giemsa stain. Direct fluorescent antibody staining, polymerase chain reaction, and viral cultures can determine the causative viral agent [6]. Such investigations were not performed in the present case and the diagnosis of eczema herpeticum was made solely on the clinical grounds that supported the rapid clinical improvement following the administration of acyclovir.

Acyclovir is the treatment of choice for eczema herpeticum. Considering the low bioavailability of oral acyclovir, its use should be limited to mild cases. The management should be started promptly as delayed acyclovir administration was found to prolong the need for hospital stay [7]. Empiric antibiotic therapy was not found to lower the hospital stay or the mortality rate [8]. We initiated the antibiotic therapy considering the extensive involvement of the skin while the result of the bacterial swab culture was not available. Notably, superinfection with Staphylococcus aureus in patients with eczema herpeticum may reach up to 30% [7].

Eczema herpeticum can be a cause of significant morbidity and mortality if its diagnosis and management were delayed. Prior to the use of acyclovir, the mortality rate from eczema herpeticum reaches 50% [9]. Further, the complications of eczema herpeticum can include meningoencephalitis, keratoconjunctivitis, and disseminated intravascular coagulation [10, 11].

Conclusion

Eczema herpeticum is a rare clinical entity that can result in significant morbidity. The case highlights the importance of considering the diagnosis of eczema herpeticum in the appropriate clinical settings, even in patients who were not known to have any prior skin disorder. Prompt administration of acyclovir is imperative to shorten the disease course and prevent its dissemination.

Availability of data and materials

Not applicable

Change history

References

  1. Wollenberg A, Zoch C, Wetzel S, et al. Predisposing factors and clinical features of eczema herpeticum: a retrospective analysis of 100 cases. J Am Acad Dermatol. 2003;49:198–205. https://doi.org/10.1067/s0190-9622(03)00896-x.

    Article  PubMed  Google Scholar 

  2. Santmyire-Rosenberger BR, Nigra TP. Psoriasis herpeticum: three cases of Kaposi's varicelliform eruption in psoriasis. J Am Acad Dermatol. 2005;53:52–6. https://doi.org/10.1016/j.jaad.2005.01.140.

    Article  PubMed  Google Scholar 

  3. Kaposi M. Pathologie und Therapie der Hautkrankheiten in Vorlesungen für praktische Ärzte und Studirende: Urban & Schwarzenberg; 1893.

    Google Scholar 

  4. Karray M, Souissi A. StatPearls; 2018.

    Google Scholar 

  5. Luca NJ, Lara-Corrales I, Pope E. Eczema herpeticum in children: clinical features and factors predictive of hospitalization. J Pediatr. 2012;161:671–5. https://doi.org/10.1016/j.jpeds.2012.03.057.

    Article  PubMed  Google Scholar 

  6. Ozcan A, Kahale K, Nguyen D. an 8-month-old girl with a vesicular rash. Global. Pediatr Health. 2019;6:2333794X19838526. https://doi.org/10.1177/2333794X19838526.

  7. Aronson PL, Yan AC, Mittal MK, et al. Delayed acyclovir and outcomes of children hospitalized with eczema herpeticum. Pediatrics. 2011;128:1161–7.

    Article  Google Scholar 

  8. Aronson PL, Yan AC, Mohamad Z, et al. Empiric antibiotics and outcomes of children hospitalized with eczema herpeticum. Pediatr Dermatol. 2013;30:207–14.

    Article  Google Scholar 

  9. Wheeler CE Jr, Abele DC. Eczema herpeticum, primary and recurrent. Arch Dermatol. 1966;93:162–73.

    Article  Google Scholar 

  10. Wollenberg A, Wetzel S, Burgdorf WH, et al. Viral infections in atopic dermatitis: pathogenic aspects and clinical management. J Allergy Clin Immunol. 2003;112:667–74. https://doi.org/10.1016/j.jaci.2003.07.001.

    Article  PubMed  Google Scholar 

  11. Zhuang K, Wu Q, Ran X, et al. Oral treatment with valacyclovir for HSV-2-associated eczema herpeticum in a 9-month-old infant: a case report. Medicine (Baltimore). 2016;95:e4284. https://doi.org/10.1097/md.0000000000004284.

    Article  Google Scholar 

Download references

Acknowledgements

Not applicable

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author information

Authors and Affiliations

Authors

Contributions

MA: drafted the manuscript; IA: reviewed the literature; HA: reviewed the literature; AA1: obtained the patient’s data; AA2: edited the manuscript; RH: obtained the patient’s data; OA: edited the manuscript; SA: responsible for the patient care and provided overall supervision. The authors read and approved the final manuscript.

Corresponding author

Correspondence to Manal Almoalem.

Ethics declarations

Ethics approval and consent to participate

Not applicable

Consent for publication

Informed consent was obtained from the patient’s next of kin for the publication of this paper and the accompanying images.

Competing interests

The authors declared that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The original version of this article was revised: Ibrahim AlAlhareth's name was misspelled in the original publication.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Almoalem, M., AlAlhareth, I., Alomer, H. et al. Extensive eczema herpeticum in a previously well child. Int J Emerg Med 15, 21 (2022). https://doi.org/10.1186/s12245-022-00425-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12245-022-00425-5

Keywords

  • Acyclovir
  • Eczema herpeticum
  • Herpes simplex virus
  • Rash
  • Case report