Case presentation eczema herpeticum

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Case presentation eczema herpeticum

  1. 1. CASE PRESENTATIONBenedictus Widaja FY1Awesomemedicalnotes.wordpress.com
  2. 2. HISTORY 11 year old boy Known eczema since age of 3 Presented with 1 day history of:  Sudden onset tender vesicular lesions on right side of face and neck. Burning sensation on face  Redness on the right eye with some discharge  Headache and vomiting 3-4x 1/7 ago but not on the day of admission  No fever or vomiting PMH:?infected eczema in the past. Discharged from clinic in April. DH: epiderm BD & eumovate TDS
  3. 3. EXAMINATION
  4. 4. EXAMINATION Obs stable (T: 37.1, P 101) Alert, well-hydrated, not in distress Eczematous rash on face, neck, elbows, hands and left ankle Pustular, vesicular eruption in clusters over right side of face, neck and behind left ear. No lesion in the ear Right eye – swollen lid margins, red conjunctive, purulent discharge. No pain, normal eye movements and reactive to light Otherwise normal
  5. 5. DIAGNOSIS Eczema herpeticum with secondary impetigo Right conjunctivitis Impetigo
  6. 6. MANAGEMENT Admitted to ward Start IV aciclovir, Benzylpenicillin and Flucloxacillin Routine bloods + Herpes PCR Skin swab and eye swab for bacteriology and virology Chloramphenicol eye ointment (d/w opthal reg) Referral to opthalmology and dermatology
  7. 7. DERMATOLOGY REVIEW Continue IV treatment for 1 week Doublebase emollient Paste bandages (viscopaste) Betnovate QC ointment to limb under viscopaste bandages Chloramphenicol cream to face Vioform HC to face – not available, hydrocortisone 0.5% cream prescribed
  8. 8. RESULTS Swabs – staphylococcus aureus Blood culture –ve Routine bloods normal PCR – HSV DNA type 1/2 not detected
  9. 9. DISCHARGE Discharge with dermatology follow up in one week Oral aciclovir five times/day (total 10 days) Oral flucloxacillin 1g QDS (total 7 day) Phenoxymethylpenicillin 500mg QDS (total 7 days) Chloramphenicol eye drops QDS for 1 week Doublebase gel Hydrocortisone 1% cream BD Betamethasone valerate 0.1% ointment under viscopaste bandages in the morning
  10. 10. ECZEMA HERPETICUM Acute disseminated herpes simplex infection, often associated with systemic symptoms, in patients with atopic dermatitis Commonly involve HSV type 1 or type 2 Rarely vaccinia virus and Coxsackie A16 virus Infection may be from auto-innoculation or from infected contact
  11. 11. CLINICAL PRESENTATION Multiple clusters of vesicles in areas of pre-existing atopic dermatitis Spreading (to normal skin), haemorrhagic and crusted Painful punched out erosions, which may coalesce to form larger areas of erosions and crusting Majority of patients have fever and malaise Subclinical herpetic infection is quite common
  12. 12. PICTURES
  13. 13. PICTURES
  14. 14. PICTURES
  15. 15. IMPETIGO VS ECZEMA HERPETICUM Features that favour impetigo  Honey-coloured crust  Slower evolution  Fewer systemic symptoms Features that favour eczema  Punched out erosions
  16. 16. INVESTIGATION Swab for virology (PCR) and bacteriology from fresh vesicle Other investigations:  Bloods: FBC, biochem (CRP & albumin) Other tests to diagnose viral infection:  Tzanck preparation  Direct fluorescent antibody testing
  17. 17. MANAGEMENT Consider advising patient to discard previously used emmolient (esp if it is stored in tubs) or creams if contamination is suspected Initiate treatment on the same day (delay may increase length of hospital stay)  IV or oral aciclovir  IV or oral antibiotics (flucloxacillin & benzylpenicillin) for secondary bacterial infection  Topical antibiotics cream if no evidence of bacterial infection (rarely used in UK due to bacterial resistance)  Topical opthalmic antiviral may be added if there is evidence of periocular involvement (keratitis prophylaxis)  Dermatology referral Opthalmology referral for periocular lesions
  18. 18. MANAGEMENT OF ECZEMASteroids from least to most potent:Hydrocortisone, eumovate (clobetasone), betnovate (betamethasone),dermovate (clobetasol)Topical calcineurin inhibitor (tacrolimus) may be used on face ifhydrocortisone is not sufficient. The use of stronger steroids is notrecommended on faceSide effect of steroids: skin thinning, telangiectasia, adrenal suppression
  19. 19. PROGNOSIS Very low mortality with the availability of effective antivirals Average duration of illness is 16 days, cases lasting as long as 6 weeks have been reported. Recurrent episodes tend to be milder and are not associated with systemic symptoms. Complications if untreated:  Herpes hepatitis  DIC  Herpes keratitis, conjunctivitis  In disseminated infection can involve brain, lung, GI and adrenal
  20. 20. CONCLUSION Although potentially life threatening, if eczema herpeticum is recognized early it is easily and effectively treated. Any patient with history of atopic dermatitis and acute "blistering" should be examined for eczema herpeticum.
  21. 21. REFERENCES Royal college of paediatrics and child health allergy care pathways for children eczema Aronson PL, Yan AC, Mittal MK, Mohamad Z, Shah SS Delayed acyclovir and outcomes of children hospitalized with eczema herpeticum. [Journal Article, Multicenter Study, Research Support, N.I.H., Extramural, Research Support, Non-U.S. Govt] Pediatrics 2011 Dec; 128(6):1161-7. Brook, I., Frazier, E.H., & Yeager, J.K. (1998). Microbiology of infected eczema herpeticum. Journal of the Academy of Dermatology, 38, 627-629. Sais, G., Jucgla, A., Curco, N., & Peyri, J. (1994). Kaposis varicelliform eruption with ocular involvement. Archives of Dermatology, 130, 1209-1210 CG57 Atopic eczema in children: NICE guideline Mooney MA, Janniger CK, Schwartz RA. Kaposis varicelliform eruption. Cutis. 1994;53:243-245.

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