Recurring eczema herpeticum complicated by herpetic meningitis and staphylococcal bacteremia

Background

Eczema Herpeticum (EH) is a dermatological emergency that may progress to viral meningitis in patients not treated urgently. We present a case of recurrent EH in a young, immunocompetent patient complicated by progressing herpetic meningitis and staphylococcal bacteremia.

Case report

Our patient was a 20-year-old male intercollegiate athlete with a past medical history of atopic dermatitis (AD) who presented with photophobia, purulence in the medial left eye, and a painful rapidly worsening acute rash for two days. Polymerase chain reaction was performed on the cerebrospinal fluid and vesicular drainage. Both tested positive for herpes simplex virus type 1 (HSV-1), confirming the suspected diagnosis of EH. Blood culture returned positive for Staphylococcus aureus believed to be contracted through the breaks in his skin. He received intravenous normal saline, ceftriaxone, and acyclovir. He was hospitalized for 9 days before being discharged with oral acyclovir. Our patient returned to the emergency department one month later with a milder case of EH. Intravenous acyclovir was started, and the patient was discharged the next day with 1 g oral valacyclovir twice daily.

Why should an emergency physician be aware of this?

It is crucial to establish a previous history of HSV-1 infection and recognize cutaneous presentations of EH in order to initiate early empiric antiviral therapy. The emergency physician must be hypervigilant and aggressively pursue diagnosis and treatment of suspected HSV-1 and -2 infections when confronted with an inexplicably worsening vesicular rash in a patient with AD. Delay in treatment can significantly worsen prognosis and lead to mortality.