A 22-year-old man with asthma and atopic dermatitis presented with a pustular rash on his face and neck. The rash began the day of presentation and was not painful or pruritic. Lesions spread to the right eyelid, which caused swelling but no visual disturbance. His eczema symptoms were more severe during the preceding two weeks, but the acute rash was distinct in appearance and location and the patient was not on eczema therapy. He otherwise felt well, and denied travel and topical or infectious exposures. He was afebrile and normotensive. On exam, the patient had yellow pustules on an erythematous base across the forehead, right upper eyelid, bilateral cheeks, and neck. Some of the lesions were eroded and crusted. There were no vesicles. The right eyelid was edematous and the conjunctiva was injected. Lichenified xerotic plaques were present on the neck, trunk, and extremities. He had no leukocytosis and was HIV negative. He was started on IV acyclovir for possible disseminated zoster. HSV-1 IgG was positive, while HSV-1 IgM, HSV-2 IgM, HSV-2 IgG, RPR, and varicella zoster serum PCR were negative. A biopsy obtained from the right ear showed keratinocyte nuclei with chromatin rimming and molding supporting the diagnosis of impetiginized herpetic infection. Direct florescence antibody stain (DFA) was positive for HSV-1 and negative for HSV-2. Bacterial cultures were positive for Staphylococcus aureus. The patient was transitioned to oral valacyclovir and mupirocin for treatment of eczema herpeticum with superimposed impetigo.
Discussion:
Eczema herpeticum is an uncommon manifestation of HSV-1 infection seen with comorbid dermatologic conditions, often atopic dermatitis. The lesions are usually itchy or painful vesicles which may crust over and cause erosions; however, it was described to be pustular or vesiculopustular in rare cases. Our case demonstrates that neither vesicles nor pain are ubiquitous features of this infection.
Conclusions: Physicians must maintain a high index of suspicion for eczema herpeticum in patients with atopic dermatitis as it may present atypically with predominantly pustular lesions due to bacterial superinfection.