1. A severe case of eczema herpeticum and septicemia in a patient with atopic dermatitis
Le Hoa Nguyen, Dang Thu Huong, Nguyen Quynh huong, Nguyet Minh Vu, Thi Phuong Hoang, Huy Luong Vu, Ha Giang Quach, Huu Sau Nguyen.
National Institute of Dermatology and venereology - VietNam
Introduction : Eczema herpeticum or Kaposi’s varicelliform eruption is referred to a widespread skin infection with a virus in a patient with pre-existing skin diseases (1). The great majority of cases are infections with HSV (herpes simplex virus). The mortality rates up to 10% and is usually caused by bacterial superinfections or septicemia.
Fig2: After 5 days of treatment with antibiotics and antivirus, the umbilicated vesicles of eczema herpcticum were gradually dissapeared. His temperature became normal and he was discharged from the hospital after 14 days of treatment. However, Skin eruption of atopic dermatitis was still persistent.
Case presentation:
A 5 years-old-male has atopic dermatitis treated by topical corticosteroids creams. One week before having vesicles around his eyes, nose, mouth, he had high fever, headache. The vesicles rapidly became pustular erupt in massive crops on all over the face, neck and quickly disseminated to other parts of the body such as elbows, knees and dorsal of the hands and feet (Fig1). His face was grossly edematous. Lymph nodes at the neck were enlarged. His temperature was 39°c. He was very tired. No abnormal symptoms were found on others organs.
Fig1: vesicles rapidly became pustular erupt in massive crops on the face and quickly disseminated to other parts of the body such as elbows, knees and dorsal of the hands and feet. The patient was very tired with high fever.
Discussion:
Eczema herpeticum results from a widespread of cutaneous infection with a virus in a patient with pre-existing cutaneous pathologies. Atopic dermatitis is the commonest predisposing condition. The great majority of patients are infections with HSV, for which the term eczema herpeticum is widely used.
Having a history of atopic dermatitis, our patient presence typical skin lesions of eczema herpeticum with umbilicated vesicles becoming rapidly pustular erupt. The diagnosis of eczema herpeticum was confirmed by finding the Tzanck cell with giant multinuclear in vesicles. Further more HSV-1 was identified by PCR in the vesicle fluid.
The most herpes simplex infections in patients with atopic dermatitis are usually severe or widespread. Topical corticosteroids for long-time may be a favorable factor for the dissemination of herpetic infections. Tacrolimus is recently considerated as an increased risk for eczema herpeticum (2). Our patient was a severe case with septicemia. The pustular erupt in massive crops were quickly disseminated on all over his body and the constitutional symptoms were severe. His atopic dermatitis is a predisposed condition for HSV infections.
Bacterial superinfections and septicemia are the most severe complications which are the main causes of mortality. It supposes that hemoculture should be done in every patient with eczema herperticum generalized and high fever. The common pathogens include Staphylococcus aureus, Streptococcus and pseudomonas. The presence of Klebsiella pneumonia in the blood of patient confirmed by hemoculture identified the diagnosis of septicemia in this patient.
The patient responded well to oral acyclovir 400mg per day and intravenous Ceftazidim 2gr/day during 7 days. It is advised that antivirus as well as antibiotics should be indicated as early as possible to prevent the complications. Corticosteroids creams are avoided until eczema herpeticum finished. Local antiseptics, emollients creams are helful for treatment. A c 1 2 1 2 2 B D
Haemoculture: Presence of Klebsiella pneumonia.
PCR of vesicle fluid: HSV-1(+) and HSV-2 (-).
Tzanck smear: Tzanck cell with giant multinuclear.
The diagnosis of septicemia and eczema herpeticum in a patient with atopic dermatitis was identified.
The patient was treated by Ceftazidim 2gr/day/ 7days, Acyclovir 200mg every 12 hours during 7 days and topical application of acyclovir as well as moisture cream.
After 5 days of treatment, his temperature became normal. Blood culture was negative. The pustules were crusted and gradually disappeared. The patient was discharged from hospital after 14 days of treatment.
Conclusions: Eczema herpesticum is not a common disease. It mostly happens in a patient with history of Atopic Dermatitis. In some cases, it is very severe if the patients have the infectious complications such as septicemia. Early treatment with antibiotics and anti-virus can save the patient.
References
1- Wollenberg A,Zoch C, Wetzel S, Plewig G, Przvbilla B. Predisposing factors and clinical features of eczema herpeticum: a retrospective analysis of 100 cases;
J Am Acad Dermatol Aug;49(2):
2- Lubbe J, Pournaras CC, SauratJH Eczema herpeticum during treatment of atopic dermatitis with 0.1% tacrolimus ointment. Dermatology. 2000;201(3):249-51