Eczema herpeticum in two elderly patients

Introduction

Eczema herpeticum or Kaposi′s varicelliform eruption refers to a widespread cutaneous infection of herpes simplex virus in a patient with pre - existing skin disease. It is commonly seen between second to third decade of life[1] complicating diseases like atopic dermatitis,[2] Darier′s disease[3] pemphigus foliaceous,[4] ichthyosis vulgaris.[5]

Case 1

A 53 - year -old woman presented with blisters and erosions all over the body of two weeks duration. The lesions were painful but non itchy. There were normal lesions or constitutional symptoms. There was no previous history of herpes infection. The Nikolsky′s sign was positive. Haematological parameters and liver function tests were normal. Urine showed the presence of white blood cells, granular casts and bacteria. Acantholytic cells were seen in the Tzanck smear. Skin biopsy showed a cleft in the stratum granulosum and Direct immunofloresence was positive to IgG. [Figure - 1], [Figure - 2]

A diagnosis of pemphigus foliaceous was made and the patient was started on antibiotics, cyclophoshamide and steroids (50 mg daily). Within two weeks the lesions started healing. At the end of the second week fresh vesicles, which were larger and centrally umbilicated appeared on the face and the lesions eczematized and later spread to the rest of the body. These lesions appeared on the dermatitis involved skin. Repeat Tzanck smear from these lesions revealed multinucleated giant cells along with the acantholytic cells. Eczema herpeticum was thought of and acyclovir 200 mg 5 times a day was started. The lesions however continued to worsen. The dose of acyclovir was increased to 800mg 5 times a day and at the end of 7 days there was compete clearence of the lesions.

Case 2

A 56 year old woman, a known case of air borne contact dermatitis due to parthenium presented with multiple vesicular eruptions on the chin, peri - oral region, forehead and rest of the face of one week duration.The lesions on the chin were larger. There was associated scaling and hyperpigmentation over the dorsa of both hands. The rest of the body was spared. There were no constitutional symptoms. Atzanck smear was done from the vesicles and multinucleated giant cells were seen. She was on topical clobetasol propionate for her dermatitis. A diagnosis of eczema herpeticum was made and acyclovir 200mg 5 times a day was started. The lesions cleared within a week.

Discussion

Eczema herpeb ticum appear as vesicles which are umbilicated. These are confined to eczematized skin. Costitutional symptoms like fever, malaise which may become severe are seen and there is associated lymphadenopathy. The vesicles rapidly become pustular, later erorions from and which can get secondarily infected. New crops may continue to appear for 7 to 10 day S: the fever however subsides in 4 to 5 days. The face when involved may become odematous. The pustules crust and heal slowly leaving little scarring. In non responding persistent eczematous lesions we should suspect eczema herpeticum and investigate. Vesicles should be sought for and a simple tzanck smear would be helpful. The punched out appearance of the erosions is diagnostic′ and presence of multinucleated giant cells in the tzanck smear confirmatory. Milder infections are usually self limiting. Most patients respond well to oral acyclovir[7] whereas the severly ill may need intravenous acyclovir.[8]