Photo Quiz

An Acute Vesiculobullous Rash on the Face

 


FREE PREVIEW. AAFP members and paid subscribers: Log in to get free access. All others: Purchase online access.


FREE PREVIEW. Purchase online access to read the full version of this article.

Am Fam Physician. 2014 Mar 15;89(6):473-475.

An 18-year-old man presented with a three-week history of a painful, nonpruritic, diffuse eruption involving the face. He had a history of atopic eczema and intermittent asthma flare-ups. There was no family history of atopy. He was not taking any medication. Treatment with oral prednisone one week earlier seemed to aggravate the condition.

Physical examination revealed a confluent, erythematous, edematous, hyperpigmented rash on the face. The eruption was composed of coalescent vesicles with honey-colored crusting (Figure 1). There were fissuring on the forehead and cheeks and open ulcerations in the nasomesial folds. There were no lesions elsewhere on the body.


Figure 1.

Question

Which one of the following is a common complication of the primary disorder presented here?

A. Arthritis.

B. Epididymitis.

C. Glomerulonephritis.

D. Keratitis.

E. Meningitis.

Discussion

The answer is D: keratitis. The sudden onset of a widespread blistering facial rash in a patient with atopic eczema is suggestive of eczema herpeticum (Kaposi varicelliform eruption). This condition is commonly caused by herpes simplex viruses 1 and 2.1 A disrupted skin barrier from atopic or irritant dermatitis or Darier-White disease, coupled with local immune dysfunction, facilitates the spread of the virus.2 Other predisposing factors include a history of elevated immunoglobulin E levels and treatment with corticosteroids.3 Eczema herpeticum should be considered in patients with sudden onset of a widespread, blistering rash. Tzanck testing showing multinucleated giant cells (Figure 2) is confirmatory. Viral culture, polymerase chain reaction testing, direct immunofluorescence, and histologic examination can also be used to confirm the diagnosis.4

View/Print Figure

Figure 2.

Tzanck test showing multinucleated giant cells.


Figure 2.

Tzanck test showing multinucleated giant cells.

Herpetic keratitis is a major ophthalmologic complication of eczema herpeticum. Ophthalmologic consultation is recommended when the patient has red or irritated eyes.2 Vesicles with purulent drainage may occur on the eyelids. Ocular pain, photophobia, foreign object sensation, and tearing are common.5 Recurrent herpetic keratitis is a primary cause of acquired blindness in the industrialized world.6

Arthritis that is migratory or transient is a common early symptom of systemic lupus erythematosus.5 The acute cutaneous manifestation of lupus is the butterfly facial erythema, an eruption that begins in the malar area and the bridge of the nose, sparing nasolabial folds. Bullous lesions occur as grouped vesicles, usually on sun-exposed areas (e.g., head, neck, arms). Vesicles are not typically seen on the corneal surface.

Epididymitis is a common scrotal inflammatory condition and can be a complication of Chlamydia trachomatis or Neisseria gonorrhoeae infection.5 Typical symptoms include testicular pain, scrotal nodules, urethral discharge, and dysuria, although some cases are asymptomatic. Pathogens such as varicella and herpes simplex virus cause orchitis as a result of disseminated disease in severely immunocompromised persons.5

Group A beta-hemolytic streptococcal skin infections are complicated by poststreptococcal glomerulonephritis in about 2% to 5% of patients.5 Impetigo typically occurs in children younger than six years and is characterized by discrete, sharply demarcated vesicles with rapid progression to honey-colored crusting.5

Meningitis can occur in patients with primary genital herpes simplex virus 2 infection. Overall, herpes simplex virus 2 is responsible for less than 1% to 3% of all cases of aseptic meningitis.7 Herpes simplex virus 1 infection is rarely associated with aseptic meningitis. Patients with meningitis present with signs of meningeal irritation, including nuchal rigidity, headache, and stiffness. Anorexia, vomiting, and a nonspecific rash sometimes occur.

View/Print Table

Summary Table

ConditionCharacteristics

Arthritis

Migratory or transient arthritis is a common early sign of systemic lupus erythematosus

Butterfly facial erythema; bullous lesions of systemic lupus erythematosus occur as grouped vesicles, usually on sun-exposed areas (e.g., head, neck, arms)

Epididymitis

Can be a complication of Chlamydia trachomatis or Neisseria gonorrhoeae infection

Testicular pain, scrotal nodules, urethral discharge, and dysuria, although some cases are asymptomatic

Glomerulonephritis

Can be a complication of group A beta-hemolytic streptococcal skin infections; typically occurs in children younger than six years

Impetigo typically occurs in children younger than six years and is characterized by discrete, sharply demarcated vesicles with rapid progression to honey-colored crusting

Keratitis

Major morbidity associated with eczema herpeticum

Ocular pain, photophobia, foreign object sensation, and tearing; sudden onset of a widespread, blistering facial rash in persons with atopic eczema

Meningitis

Primary genital herpes simplex virus 2 infection can lead to aseptic meningitis

Meningeal irritation, including nuchal rigidity and headache; anorexia, vomiting, and nonspecific rash sometimes occur

Summary Table

ConditionCharacteristics

Arthritis

Migratory or transient arthritis is a common early sign of systemic lupus erythematosus

Butterfly facial erythema; bullous lesions of systemic lupus erythematosus occur as grouped vesicles, usually on sun-exposed areas (e.g., head, neck, arms)

Epididymitis

Can be a complication of Chlamydia trachomatis or Neisseria gonorrhoeae infection

Testicular pain, scrotal nodules, urethral discharge, and dysuria, although some cases are asymptomatic

Glomerulonephritis

Can be a complication of group A beta-hemolytic streptococcal skin infections; typically occurs in children younger than six years

Impetigo typically occurs in children younger than six years and is characterized by discrete, sharply demarcated vesicles with rapid progression to honey-colored crusting

Keratitis

Major morbidity associated with eczema herpeticum

Ocular pain, photophobia, foreign object sensation, and tearing; sudden onset of a widespread, blistering facial rash in persons with atopic eczema

Meningitis

Primary genital herpes simplex virus 2 infection can lead to aseptic meningitis

Meningeal irritation, including nuchal rigidity and headache; anorexia, vomiting, and nonspecific rash sometimes occur

Author disclosure: No relevant financial affiliations.

Address correspondence to Robert T. Brodell, MD, at rbrodell@umc.edu. Reprints are not available from the authors.

REFERENCES

show all references

1. Brook I, Frazier EH, Yeager JK. Microbiology of infected eczema herpeticum. J Am Acad Dermatol. 1998;38(4):627–629....

2. Olson J, Robles DT, Kirby P, Colven R. Kaposi varicelliform eruption (eczema herpeticum). Dermatol Online J. 2008;14(2):18.

3. Wollenberg A, Zoch C, Wetzel S, Plewig G, Przybilla B. Predisposing factors and clinical features of eczema herpeticum: a retrospective analysis of 100 cases. J Am Acad Dermatol. 2003;49(2):198–205.

4. Frisch S, Siegfried EC. The clinical spectrum and therapeutic challenge of eczema herpeticum. Pediatr Dermatol. 2011;28(1):46–52.

5. James WD, Berger T, Elston D. Andrews' Diseases of the Skin: Clinical Dermatology. 10th ed. Philadelphia, Pa.: Saunders; 2006.

6. Ostler HB. Herpes simplex: the primary infection. Surv Ophthalmol. 1976;21(2):91–99.

7. Rotbart HA. Viral meningitis. Semin Neurol. 2000;20(3):277–292.

Contributing editor for Photo Quiz is John E. Delzell, Jr., MD, MSPH.

A collection of Photo Quizzes published in AFP is available at http://www.aafp.org/afp/photoquiz.

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at http://www.aafp.org/afp/photoquizinfo. To be considered for publication, submissions must meet these guidelines. E-mail submissions to afpphoto@aafp.org.



 

Copyright © 2014 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Dec 1, 2016

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article