Title : Acute HIV infection presenting as eczema herpeticum and herpes simplex keratitis: A case report
Abstract:
Introduction: Eczema herpeticum (EH), also known as Kaposi’s varicelliform eruption, is an unusual, severe manifestation of herpes simplex infection. It usually presents in pediatric patients with history of atopic dermatitis. It can be a life-threatening disease with mortality risk due to complications of systemic infection. Herpes simplex keratitis is a potentially blinding disease due to infection and inflammation of the cornea. Persons with immune deficiencies and Human Immunodeficiency Virus (HIV) infection are at increased risk for herpes keratitis. We present a case of eczema herpeticum and herpes keratitis in a Colombian patient with acute HIV infection.
Case Presentation: A 30 year-old Colombian male with past medical history of atopic dermatitis presented to the emergency room with complaints of three days of a facial rash and eye pain. He initially had pruritus, edema and palpebral erythema of the right eye. On the third day of symptoms, he presented fever and noted a painful erythematous rash on his right frontal region, right periorbital region and dorsum of the nose, with multiple umbilicated papules and vesicles, and some superficial ulcers. Additionally, he experienced severe pain in the right eye, with blurry vision and epiphora.
On physical examination, erythema, multiple vesicles, papules and “punched-out” erosions were noted on the nose, right upper eyelid, right frontal and cigomatic region, and the scalp. Cervical lymphadenopaties were noted. Conjunctival injection, chemosis, and decreased corneal sensation were noted on eye examination. Oral examination was unremarkable.
Polymerase chain reaction (PCR) for Herpes Simplex Virus-1 (HSV-1) was positive. Intravenous and ophthalmic acyclovir were started. Laboratory studies revealed white blood cells (WBC) count of 4970/uL, neutrophils were 3830/uL, lymphocytes were 480/uL; platelet count was 127000/uL. Human Immunodeficiency Virus (HIV) testing was positive. Viral load was 26712 copies/mL. CD4 count was 228 cells/mm^3. Highly active antiretroviral therapy (HAART) was started.
Discussion: Eczema herpeticum is an unusual superinfection caused by herpes simplex virus. It usually affects patients with atopic dermatitis, but it has also been described to affect patients with Hailey-Hailey disease, pemphigus, mycosis fungoides, and Sezary syndrome. The most commonly compromised regions include the face, neck, and thorax. EH is characterized by painful, vesicles, pustules, ulcers and umbilicated papules. Risk factors include younger age, nonwhite ethnicity and psoriasis. Disruption of the epithelial barrier and immunosuppression allow a widespread infection. Around 10% of EH patients have eye involvement. Herpes keratitis is the leading infectious causes of corneal ulcers and blindness in the world. Primary infection occurs after inoculation of mucosal or skin surface. Clinical manifestations include conjunctivitis, chemosis, blurry vision, reduced corneal sensation and corneal ulcers. Herpes keratitis can be clinically diagnosed, although PCR and viral culture may be performed for diagnostic confirmation. Treatment with antivirals reduces viral replication, severity of the lesions and prevents complications.
Conclusion: Eczema herpeticum is a severe infection of the skin that affects persons with underlying skin disorders. It may be life-threatening, particularly in immunocompromised patients. Herpetic keratitis is a potentially blinding disease caused by HSV. Both conditions should be considered in HIV patients. Early antiviral treatment is of paramount importance to prevent associated morbidity and mortality.
