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

Ibrahim Aliyu

doi:10.4103/ejdv.ejdv_23_18

CASE REPORT

Year : 2019 | Volume : 39 | Issue : 1 | Page : 46-48

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

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

Date of Submission	07-Jun-2018
Date of Acceptance	01-Jan-2019
Date of Web Publication	28-Jan-2019

Correspondence Address:
Ibrahim Aliyu
Department of Paediatrics, Aminu Kano Teaching Hospital/Bayero University, Kano, 700001
Nigeria

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ejdv.ejdv_23_18

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 2023 Mar 31];39:46-8. Available from: http://www.ejdv.eg.net/text.asp?2019/39/1/46/250815

Introduction

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.

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Discussion

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

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.

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