SAEM Clinical Images Series: When in Doubt, Swab It Out
A 26-year-old female with a history of atopic dermatitis presents with one week of rash that began on her lower lip but spread over her face, eyelids, and neck, plus one day of fevers and headache. She was seen at an urgent care and referred to the emergency department for evaluation and management of “impetigo.” On presentation, she endorsed nausea, headache, and mild neck pain.
Vitals: Temp 100.7° F; BP 134/85; HR 121; SpO2: 100%
General: Uncomfortable appearing.
Cardiovascular: Tachycardia
Neurological: AOx3. CN II-XII grossly intact. Moves all extremities equally and spontaneously.
Skin: Upper cutaneous lip – eroded plaque with yellow crust. Bilateral jaw line, cheek, neck, eyelids – eroded papules. Lichenified patches in antecubital fossa bilaterally.
CBC: WBC 10.7; PLT 244
Lactate: 1.31
CSF: Colorless, clear; WBC 1; RBC<1; Protein 23; Glucose 55, Gram Stain Negative
Given the patient’s history of atopic dermatitis and evidence of crusted over papules/pustules on exam, this patient’s presentation was most consistent with diagnosis of eczema herpeticum (EH).
Swabs of the upper lip lesion were positive for HSV1 DNA, which confirmed the diagnosis. Early identification and treatment of EH is critical to preventing dangerous complications including ocular involvement, viremia, meningoencephalitis, hepatitis, or secondary infection with S. aureus resulting in bacteremia. Patients with EH involving the face, periocular areas, or systemic symptoms should be admitted for intravenous antiviral therapy and supportive care.
Take-Home Points
- The diagnosis of EH is primarily based on history and physical, but the presence of HSV in skin lesions can be confirmed by PCR.
- Delayed treatment is associated with increased risk of complications and prolonged hospitalization.
1.Wollenberg A, Wetzel S, Burgdorf WH, Haas J. Viral infections in atopic dermatitis: pathogenic aspects and clinical management. J Allergy Clin Immunol. 2003 Oct;112(4):667-74. PMID: 14564342.
2.Aronson PL, Yan AC, Mittal MK, Mohamad Z, Shah SS. Delayed acyclovir and outcomes of children hospitalized with eczema herpeticum. Pediatrics. 2011 Dec;128(6):1161-7. PMID: 22084327.