Eczema Herpeticum in a Young Boy

Dear Editor, Eczema herpeticum (EH) is a disseminated cutaneous infection caused by herpes simplex virus (HSV) that develops in individuals with atopic dermatitis (AD).[1] This type of HSV infection can also occur in patients with other forms of dermatitis that compromise the skin barrier, known as Kaposi varicelliform eruption.[2] It typically manifests as a sudden eruption of monomorphic vesicles and “punched-out” erosions with hemorrhagic crusts over the eczematous areas. Patients may have systemic symptoms such as fever, lymphadenopathy, or malaise.[3] A 9-year-old boy presented with blisters and punched-out erosions with hemorrhagic crusts mostly on the face, neck, upper limbs, and lower limbs for 1 week [Figure 1]. The lesions were pruritic and painful. Prior to the appearance of lesions, he had high-grade fever. There was no previous or family history of HSV infection. The patient had a recent history of AD. Blood test showed platelet count of 596,000/mm3, an increased number of monocytes (15%), a C-reactive protein level of 52.21 mg/L, and a slightly elevated serum glutamate pyruvate transaminase level (39.9 IU/L). Pus culture was negative. Other hematological parameters, liver function test, and renal function test were normal. Direct immunoassay was positive for immunoglobulin G (IgG; 1.304) against HSV-1. History of AD, characteristic appearance of punched-out lesions, distribution and rapid progression of disease, and IgG reactivity against HSV-1 led to the diagnosis of EH. The patient was admitted in a multispeciality hospital for comprehensive care involving a pediatrician, physician, and ophthalmologist. The treatment included intravenous acyclovir (250 mg three times daily), antibiotics, and fluid-electrolyte maintenance. The lesions resolved within a week without scarring with excellent improvement in overall condition [Figure 2]. The patient was then switched to oral acyclovir. Due to unmasking of AD on the face and upper limbs, oral cyclosporine was initiated, to which the patient responded very well.Figure 1: Multiple punched-out erosions with hemorrhagic crustsFigure 2: Erythema with mild scalingEH affects < 3% of patients with AD, predominantly infants and children rather than adults.[4] The pathophysiology of EH involves a compromised epidermal barrier and dysfunctional immune responses inherent to AD, which make the skin vulnerable to HSV entry and proliferation.[5] The impaired skin barrier, along with dysregulated T-cell responses and reduced production of antimicrobial peptides, limits the host’s ability to control viral replication. This results in widespread vesiculopustular eruptions, often accompanied by systemic symptoms such as fever and malaise.[6] Most patients respond well to oral acyclovir, whereas those who are severely ill may require intravenous acyclovir.[7,8] Declaration of patient consent The authors certify that they have obtained all appropriate consent forms, duly signed by the parent(s)/guardian(s) of the patient. In the form, the parent(s)/guardian(s) has/have given his/her/their consent for the images and other clinical information of their child to be reported in the journal. The parents understand that the names and initials of their child/children will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.