SAEM Clinical Images Series: When in Doubt, Swab It Out

eczema

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.

Additional Images

Physical Exam

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.

Laboratory Data

CBC: WBC 10.7; PLT 244

Lactate: 1.31

CSF: Colorless, clear; WBC 1; RBC<1; Protein 23; Glucose 55, Gram Stain Negative

Case Question: What is the most likely diagnosis?

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).

Case Question: What are the potentially concerning complications and disposition for this patient?

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.

Case Discussion

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.

References

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.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2025 SAEM Annual Meeting | Copyrighted by SAEM 2025 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.