• Users Online: 792
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 39  |  Issue : 1  |  Page : 46-48

Eczema herpeticum in a child: management challenges in a resource-constraint setting


Consultant Paediatrician, Fellow of the National Postgraduate College of, Nigeria

Date of Submission07-Jun-2018
Date of Acceptance01-Jan-2019
Date of Web Publication28-Jan-2019

Correspondence Address:
Ibrahim Aliyu
Department of Paediatrics, Aminu Kano Teaching Hospital/Bayero University, Kano, 700001
Nigeria
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejdv.ejdv_23_18

Rights and Permissions
  Abstract 


Eczema, which is also known as atopic dermatitis (AD), is a chronic relapsing inflammatory disorder of the skin. It has immunologic basis, and those with asthma and hay fever have a 30–50% risk of developing AD. It occurs worldwide with a varying prevalence, depending on the area of study. AD destroys the protective function of the skin, predisposing to skin infections. This results from alteration of the physical barrier function of the stratum corneum, therefore disrupting its innate immune function; it also alters the skin microbiome. Among other infections is the risk of disseminated herpes simplex type 1 called eczema herpeticum; this is a dermatologic emergency, which if not diagnosed early and promptly treated may result in severe complications. Therefore, the case of a 3-year-old boy with background AD who developed superimposed herpes simplex infection is reported.

Keywords: atopic dermatitis, eczema herpeticum, herpes simplex, staphylococcal infection


How to cite this article:
Aliyu I. Eczema herpeticum in a child: management challenges in a resource-constraint setting. Egypt J Dermatol Venerol 2019;39:46-8

How to cite this URL:
Aliyu I. Eczema herpeticum in a child: management challenges in a resource-constraint setting. Egypt J Dermatol Venerol [serial online] 2019 [cited 2019 Aug 18];39:46-8. Available from: http://www.ejdv.eg.net/text.asp?2019/39/1/46/250815




  Introduction Top


Eczema is an atopic dermatitis (AD) [1]. It is a chronic relapsing immunologic disorder of the skin [2]. It occurs worldwide. Nnoruka [3] reported a prevalence of 8.5% in Enugu, Eastern Nigeria, whereas George [4] reported a prevalence of 6.1% in Ibadan, Western Nigeria. Studies in the USA documented a higher prevalence of 10–20% [5], whereas those in China and Iran recorded a lower prevalence of 2% [6].

AD destroys the physical barrier function of the stratum corneum, and its innate immune function; it also disrupts the skin flora. A common infection associated with AD includes impetigo. Increased colonization and infection with Staphylococcus aureus has been reported in AD in approximately 46–80% of cases; this results in flare-ups of AD and also extensive cutaneous dissemination of infection. However, the case of a 1-year-old African child who presented with AD complicated with herpes simplex (HS) infection, which is uncommon, is reported.

Case report

A 3-year-old boy presented with recurrent body rashes which was associated with itching since the age of 3 months, for which he was treated for AD. However, 5 days to presentation, he developed fever with vesicular skin rashes without central umbilication; some of which had ruptured and crusted, involving the face trunk and extremities. This was associated with body pain; however, no history of vomiting or diarrhea was present. Moreover, there was no cough or difficulty in breathing. On examination, there were vesicular skin rashes; some had ruptured with crusted lesions and punched-out ulcers. The parents had applied gentian violet painting in some areas of the skin; there were no oral ulcers. The perianal and skin folds were also involved with areas of hyperemia ([Figure 1]). He had skin swabs taken for culture which yielded no growth, whereas Tzanck smear showed multinucleated acantholytic cells. However, no viral culture or direct fluorescent antibody test was done owing to nonavailability of these tests in our facility. The diagnosis of eczema herpeticum was made, and he had treatment with oral acyclovir 25 mg/kg/day for 10 days while he continued on intravenous ampicillin/cloxacillin, and topical desonide cream was prescribed. He made significant improvement within 7 days. He had ophthalmologist consult, which ruled out herpetic keratitis. Consent was obtained from the caregiver of the patient for use of patient medical information and pictures.
Figure 1 Extensive dermatitis with crusted lesions and ulcers affecting the face, trunk, and extremities.

Click here to view



  Discussion Top


AD affects all age groups and presents in early infancy with pruritus and eczematous skin rashes often involving the face, forehead, neck, axillary, extensor surfaces of the limbs, and wrist, as was witnessed in the index case. In older age patients, the lesions may be limited to the skin folds such as the antecubital fossa, popliteal fossa, and axillary folds. It is often aggravated by skin dehydration and irritants such as wooly clothing.

AD alters the relationship of the skin microbiome such as viruses and fungi, tilting the balance toward harmful organisms. Among these is cutaneous HS infection called Eczema herpeticum; this is also known as ‘Kaposi varicelliform eruption’. This is a dermatologic emergency [7], resulting in disseminated cutaneous and visceral infection, presenting with fever, prominent lymph nodes, and extensive skin vesicles these may rupture, forming monomorphic punch-out ulcers [8] as was witnessed in the index case. However, if it is not diagnosed early and properly managed, it may result in death [9],[10]. It is a rare disease and can be easily confused with common cutaneous diseases such as impetigo as was experienced in the index case. However, a thorough description of the lesions such as presence of vesicles (which are nonpurulent) and crusted and punched-out ulcers and absence of umbilicated lesions and absent history of smallpox vaccination (which has been eradicated) make other viral infections such as varicella and eczema vaccinatum, unlikely in the index case.

Skin colonization and infection is a major determinant of disease severity [11], and superimposed infection with Staphylococcus aureus is a major player. This results in increasing risk of mortality. In addition to the loss of physical cutaneous barrier, patients with AD have deficiencies in microbial defense mechanism of the skin. Deficiencies of factors such as lysozyme and cathelicidin have been reported in patients with AD with Staphylococcus aureus infection [12]; however, the skin swab cultures in the index case was negative for Staphylococcus aureus but the Tzanck smear was positive for multinucleated acantholytic cells which made HS the most likely cause. Neither viral culture nor direct fluorescent antibody test was done owing to nonavailability of these tests in our facility. This may be considered a limitation in this communication. However, the index case responded remarkably to acyclovir.


  Conclusion Top


AD distorts the cutaneous microbiome, predisposing affected individuals to different forms of infections including viruses, such as was witnessed in the index case. Disseminated HS infection is a dermatologic emergency and response to oral acyclovir was remarkable in the index case.

Declaration of patient consent

The author certify that appropriate permission was obtained from patient’s caregiver; he consented to the use of the images and other clinical information reported in this journal.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Turner JD, Schwartz RA. Atopic dermatitis. A clinical challenge. Acta Dermatovenerol Alp Panonica Adriat 2006; 15:59–68.  Back to cited text no. 1
    
2.
Schwartz RA. Pediatric atopic dermatitis. Available at: http://emedicine.medscape.com/article/ 911574-overview#a6. [Assessed 12 January 2017].  Back to cited text no. 2
    
3.
Nnoruka EN. Current epidemiology of atopic dermatitis in south-eastern Nigeria. Int J Dermatol 2004; 43:739–744.  Back to cited text no. 3
    
4.
George AO. Atopic dermatitis in Nigeria. Int J Dermatol 1989; 28:237–239.  Back to cited text no. 4
    
5.
Ong PY, Leung DY. Immune dysregulation in atopic dermatitis. Curr Allergy Asthma Rep 2006; 6:384–389.  Back to cited text no. 5
    
6.
Williams H, Stewart A, von Mutius E, Cookson W, Anderson HR. Is eczema really on the increase worldwide? J Allergy Clin Immunol 2008; 121:947–954.  Back to cited text no. 6
    
7.
Shenoy MM, Suchitra U. Kaposi’s varicelliform eruption. Indian J Dermato Venereol Leprol 2007; 73:65.  Back to cited text no. 7
    
8.
Tang CS, Wang CC, Huang CF, Chen SJ, Tseng MH, Lo WT. Antimicrobial susceptibility of Staphylococcus aureus in children with atopic dermatitis. Pediatr Int 2011; 53:363–367.  Back to cited text no. 8
    
9.
Studdiford JS, Valko GP, Belin LJ, Stonehouse AR. Eczema herpeticum: making the diagnosis in the emergency department. J Emerg Med 2011; 40:167–169.  Back to cited text no. 9
    
10.
Ganz J, Rosso R. Eczema herpaticum: an uncommon complication of atopic dermatitis. Consultant 360 for pediatricians 2005; 4. Available at: http://www.pediatricsconsultant360.com. [Assessed 1 December 2006].  Back to cited text no. 10
    
11.
Matiz C, Tom WL, Eichenfield LF, Pong A, Friedlander SF. Children with atopic dermatitis appear less likely to be infected with community acquired methicillin-resistant Staphylococcus aureus: the San Diego experience. Pediatr Dermatol 2010; 28:6–11.  Back to cited text no. 11
    
12.
Schröder JM. Antimicrobial peptides in healthy skin and atopic dermatitis. Allergol Int 2011; 60:17–24.  Back to cited text no. 12
    


    Figures

  [Figure 1]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed438    
    Printed44    
    Emailed0    
    PDF Downloaded62    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]