A 69-year-old man, with a background of recurrent outbreaks of herpes labialis approximately once every 2 years and childhood varicella, noticed vesicles on the lower lips. Five days later, a skin eruption developed on the right side of his face. Although he had no history of atopic dermatitis, Kaposi varicelliform eruption with secondary bacterial infection was suspected at another hospital, so he was treated with oral acyclovir and levofloxacin for 2 days. The patient subsequently presented to our outpatient clinic for consultation after the lack of symptomatic improvement.
On examination, erythema and small vesicles were present on the right side of the face in the dermatome innervated by the maxillary branch of the trigeminal nerve; the dorsum nasi, philtrum and upper lip were also affected. Crusting of these lesions was observed, and the right eyelids were red and swollen. Small vesicles were also noted at the bottom of the lower lip (fig. 1). Vesicles with red halos were scattered on the trunk and extremities. Laboratory investigations revealed an elevated level of C-reactive protein of 2.4 mg/dl, suggesting a mild inflammatory reaction; however, other blood tests, including immunoglobulin levels and HIV antibody results, were either normal or negative. No evidence of immunological dysfunction was seen. A small number of coagulase-negative staphylococci were identified on bacterial culture of a swab taken from a skin lesion.
The differential diagnosis included disseminated herpes zoster, varicella, herpes simplex and impetigo. We performed the LAMP assay (Eiken Chemical, Tokyo, Japan) using swab samples taken from the following areas: an erosion on the right cheek, vesicles on the upper and lower lips (fig. 1; arrows 1, 2 and 3) and a vesicle with a red halo on the right thigh. HSV-1 and VZV were detected by LAMP in samples taken from all 3 sites on the face, and VZV was detected in the sample taken from the vesicle on the right thigh. LAMP results were confirmed by real-time PCR (table 1). Serologically, HSV-1- and VZV-specific IgG were positive. Based on these findings, the patient was diagnosed with facial herpes simplex and disseminated herpes zoster.
The patient was treated with acyclovir at 750 mg/day for 7 days and cefcapene pivoxil at 300 mg/day due to the possibility of secondary bacterial infection. After 7 days of treatment, the facial swelling improved and all facial vesicles had crusted. The eruption on the trunk and extremities also became crusted. Postherpetic neuralgia or ocular lesions did not complicate disease resolution.