A Collection of Herpes Manifestations and Herpes-Associated Syndromes
Herpes Zoster
Dee Wee Lim, MD
A 50-year-old woman had visited several healthcare providers seeking relief from lower back pain. The patient likened the pain to an electric shock that started at the left side of the lower back and radiated to the front of the left leg. The area was also numb. X-ray films had revealed no abnormalities.
History. Low back pain with sciatica and disk disease was previously diagnosed, and she had been prescribed hydrocodone bitartrate, acetaminophen tablets, and methylprednisolone. Despite medical therapy, the patient’s pain did not abate. Eight weeks after the onset of pain, she again sought medical attention.
Physical examination. After close examining the unclothed patient under good lighting, a healing, deep-seated cluster of tiny blisters was observed on the left side of her lower back (Figure 1). Additional groups of healing blisters were seen on the left leg along dermatomes L1 to L5 (Figure 2). Herpes zoster was diagnosed.
Discussion. Herpes zoster on the lower back can be easily missed if the skin is not searched thoroughly; it is unusual for this disease to affect more than 1 dermatome.
Outcome of the case. Oral acyclovir was prescribed. Antiviral agents are most effective when given in the early stages of disease; however, the therapy appeared to hasten the patient’s recovery. The blisters healed, and the pain subsided.
Koebner Phenomenon
Adam A. Martin, MD, Julia K. Padgett, MD, and Kira B. Mayo, BS
A 29-year-old male prisoner with a history of plaque psoriasis complained of herpes zoster (shingles) of 2 months’ duration. He had experienced a sudden onset of right-sided chest and back pain that evolved into a red rash with blisters. The pain resolved, but the rash persisted (Figures 1 and 2).
Laboratory tests. A review of systems was otherwise negative.
The patient had indeed suffered an initial episode of herpes zoster, though it is uncommon for its cutaneous manifestations to last more than 2 to 3 weeks in nonelderly, immunocompetent patients. The lesions that persisted were psoriasis indicative of Koebner phenomenon.
Discussion. Psoriasis vulgaris has a broad range of clinical morphologies. The most common is chronic plaque psoriasis, characterized by well-defined, erythematous papules and plaques that develop an overlying whitish scale. Prevalence is estimated at 2% to 4.6% in the United States; the incidence peaks at age 20 to 30 years and again at 50 to 60 years.1
First documented in 1872, Koebner phenomenon (the isomorphic response) describes the appearance of trauma-induced psoriatic lesions on previously uninvolved skin. The pathogenesis of this response remains unknown.
One theory suggests that trauma to the dermis exposes keratinocyte receptors to activated T lymphocytes and inflammatory cytokines, including tumor necrosis factor-alpha, basic fibroblast growth factor, and substance P.2,3 This exposure may then trigger an inflammatory cascade that results in keratinocyte proliferation and subsequent psoriatic lesions at the site of injury. Reports of psoriatic lesions developing in patients at the site of herpes zoster and primary varicella are not uncommon.4
Treatment. Koebner phenomenon occurs in up to 25% of patients with psoriasis.2 Treatment options for psoriasis that arises as a Koebner phenomenon are the same as for other psoriatic lesions. Topical therapy with corticosteroids, vitamin D3 analogs, and/or retinoids should be attempted before phototherapy or systemic treatments.
Outcome of the case. At the time, the patient’s psoriasis involved approximately 30% of his body surface area and was demonstrating little response to topical therapy. Based on that indication, as well as the patient’s incarceration, he was treated with systemic methotrexate therapy.
References:
- van de Kerkhof PC, Schalkwijk J. Psoriasis. In: Bolognia JL, Jorizzo JL, Rapini RP, et al, eds. Dermatology. 2nd ed. Philadelphia, PA: Mosby Elsevier; 2008:115-116.
- Weiss G, Shemer A, Trau H. The Koebner phenomenon: review of the literature.
- J Eur Acad Dermatol Venereol. 2002;16(3):241-248.
- Farber EM, Rein G, Lanigan SW. Stress and psoriasis. Psychoneuroimmunogenic mechanisms. Int J Dermatol. 1991;30(1):8-12.
- Veraldi S, Rizzitelli G. Varicella, Koebner phenomenon, and psoriasis. Int J Dermatol. 1994;33(9):673-674.
Herpes Zoster That Resembles Athlete’s Foot
Mark Popkin, MD
When vesicles developed on a 35-year-old man’s right sole, he thought he was having a recurrence of athlete’s foot.
Physical examination. However, pain and tenderness in the area suggested herpes zoster. Further, the vesicles and erosions shown were mainly in the S1 dermatome.
The diagnosis of herpes was confirmed by the presence of multinucleated giant cells in a Tzanck smear taken from the floor of a vesicle.
Laboratory tests. Cytology cannot distinguish between herpes simplex and herpes zoster; however, viral culture of vesicle fluid can make this determination.
Discussion. Zoster is most commonly seen in elderly persons. If it appears in a young person, evaluation for possible causes of immunosuppression is indicated; zoster can be the first sign of HIV infection.
Outcome of the case. No underlying immunosuppressive disease was found in this patient. The pain and rash disappeared promptly following oral acyclovir therapy.
Herpes Simplex
Steven R. Bruhl, MD, MS, Hollis W. Merrick, MD, and Basil E. Akpunonu, MD
These painful eczematous lesions at the angle of the mouth and the base of the nostrils had been present in a 52-year-old woman for 3 days (Figure 1).
Physical examination. Some of the vesicles had ulcerated and left a crust over the region. The patient said she had similar attacks in the past. The diagnosis of recurrent herpes simplex virus 1 (HSV-1) infection was made.
Discussion. The painful vesicles of HSV-1 infection appear most commonly on the lip and rarely on other regions of the face, as in this patient. It is frequently difficult to distinguish primary HSV infection from a recurrent attack, because the presentation can be similar. Unless the history suggests otherwise, assume that an HSV infection is primary and treat the patient accordingly.
Outcome of the case. The patient was treated with acyclovir for 1 week, and all the lesions disappeared.
In a second atypical case, numerous small pustules with surrounding erythema were seen on the thumb of a 5-year-old girl who was a thumb-sucker (Figure 2).
Physical examination. She also had recurrent tiny ulcerations on one side of her tongue. The thumb lesions had developed 2 days earlier as clear vesicles and became pustular overnight. She now had a low-grade fever and decreased appetite. One lesion was deroofed with a fine scalpel and the fluid was cultured.
Outcome of the case. The culture grew HSV-1. After treatment with mupirocin ointment, 3 times daily, the thumb lesions resolved rapidly.
Initially Asymptomatic Herpes Zoster
Joe Monroe, PA-C
A 65-year-old woman sought evaluation of a unilateral, asymptomatic rash that involved the oral mucosa and lips.
Physical examination. The rash consisted of ulcerations and vesicles. The suspected diagnosis of herpes zoster was confirmed 4 days later when the patient experienced lancinating pain throughout the affected area and into her scalp and neck.
Discussion. The rash of herpes zoster is typically preceded by tingling sensations, pruritis, and often pain (the so-called premonitory symptoms). In the patient, the complete absence of any of those symptoms was unusual. Although the diagnosis was made clinically in this case, a viral culture or immunofluorescence studies could distinguish a herpes zoster eruption from the similar lesions of herpes simplex.
Outcome of the case. Oral valacyclovir, 1 g tid for 1 week, and a tapered dose of prednisone, 60 mg for 2 weeks, alleviated the patient’s symptoms.
Kaposi Varicelliform Eruption
John Cole, MD, Kat HY Kobraei, MD, and Lauren N. Elliot, MD
A 46-year-old man with HIV infection was hospitalized for evaluation of a nonhealing, tender wound on the right lower extremity.
History. The lesion had been present for 2 months following a minor injury to the leg, but it flared the week before admission. A month before hospitalization, the patient was given trimethoprim/sulfamethoxazole and minocycline for treatment of the wound, with no improvement. The patient denied fevers, chills, and night sweats. Laboratory studies obtained a month before admission included a bacterial culture that grew methicillin-resistant Staphylococcus aureus.
Physical examination. On admission, a cutaneous examination revealed multiple, discrete, 2 mm to 3 mm hemorrhagic punched-out crusted erosions, with several areas that coalesced into large, denuded patches (Figure 1). Edema was present and chronic underlying stasis changes were appreciated on his lower extremities, manifested by slightly scaly, brown patches. No other significant skin findings were present. The patient was afebrile, with stable vital signs. Dermatology was consulted given the lack of improvement with outpatient antibiotic treatment.
Laboratory tests. Blood cultures exhibited no growth. No leukocytosis was noted. Direct immunofluorescence of the erosion was positive for herpes simplex virus (HSV) and negative for varicella-zoster virus (VZV). A diagnosis of Kaposi varicelliform eruption (KVE) was made.
Treatment. Intravenous acyclovir was initiated, and the lesions began to involute. Marked improvement was noted by discharge 5 days later (Figure 2).
Discussion. KVE is a disseminated viral cutaneous infection, usually caused by viruses in the herpesvirus group, that occurs in areas of skin barrierdefect. Although HSV is the most common cause, VZV, Coxsackievirus, and vaccinia virus are other etiologic agents.
KVE may present as a primary or recurrent infection with HSV.1 Typically, the primary infection is more severe and patients are often febrile and have generalized lymphadenopathy. Recurrences are usually less severe, involve less body surface area, and resolve quickly (unlike a primary infection).
KVE has been reported to occur in various age-groups and in multiple skin conditions where there is disruption of the epidermal barrier, including atopic dermatitis, burns, autoimmune blistering disorders, and ichthyoses.2,3
In this immunocompromised patient, it is likely that stasis dermatitis and a recent leg injury provided the necessary factors for his infection. KVE is often either misdiagnosed as a bacterial infection or attributed to a flare of the underlying skin disease. Anaerobic and aerobic wound cultures should be performed. S aureus, group A streptococci, and Pseudomonas aeruginosa are common isolates; if these pathogens are present, antibiotic therapy should be initiated.4 However, viruses, such as HSV and VZV, should be considered, to prevent unnecessary antibiotic use or a delay in diagnosis.
Outcome of the case. The patient continued treatment with oral famciclovir for another 7 days.
REFERENCES:
Wheeler CE Jr, Abele DC. Eczema herpeticum, primary and recurrent. Arch Dermatol. 1966;93(2):162-173.
Kramer SC, Thomas CJ, Tyler WB, Elston DM. Kaposi’s varicelliform eruption: a case report and review of the literature. Cutis. 2004;
73(2):115-122.
Bork K, Bräuninger W. Increasing incidence of eczema herpeticum: analysis of seventy-five cases. J Am Acad Dermatol. 1988;19(6):
1024-1029.
Brook I, Frazier EH, Yeager JK. Microbiology of infected eczema herpeticum. J Am Acad Dermatol. 1998;38(4):627-629.