A 30-year-old male with a long-standing history of living with HIV on appropriate antiretroviral therapy presented to the hospital emergency department for evaluation of worsening generalized itchy and painful erythematous rash involving entire face (including around ears), neck, arms, hands, feet and trunk that had developed over a month (Fig. 1). He also complained of soreness in the throat with right ear drainage and purulent eruptions. His past medical history included a skin biopsy for his recalcitrant eczema which showed spongiotic dermatitis. This rash was extensively evaluated in the past with negative PAS stain for fungus, immunofluorescence study, ANA test, anti-mitochondrial antibody, ANCA, celiac antibody test, stool for Entamoeba histolytica/other enteric pathogens (including cryptosporidium and giardiasis), strongyloides antibody serology, urinary Chlamydia and Neisseria gonorrhea testing. The patient had a history of positive CMV antibodies, eosinophilia and elevated IgE levels. The patient was treated with steroids for a prolonged time, eventually stopped due to concern for long-term side effects.
The patient had a febrile course. Physical examination was notable for diffuse areas of erythema with monomorphic confluent erosions with yellow crusting, dryness and cracking on the face, neck, palms of the hands, trunk, lower back region and left foot. The patient did not have any lymphadenopathy, conjunctivitis, or neck rigidity. Patient's laboratory workup is presented in the Table 1.
WBC-white blood cells, HSV-Herpes Simplex Virus, PCR-polymerase chain reaction.
The patient had normal liver and kidney function tests, iron panel, folic acid, and B1/B6 levels. The patient's blood culture did not show any growth. The patient had negative nasal MRSA screen, perirectal VRE, QuantiFERON TB, RPR, Strongyloides antibody IgG, syphilis IgG antibody, hepatitis B surface antigen/antibody, hepatitis B core total antibody, hepatitis C antibody test, hepatitis C quantitative RNA. CT of face and neck on day 5 of the presentation was notable for prominent lymph nodes, most located at left of the midline in the sublingual region, pathological enlarged submental lymph node to left, and borderline enlarged right-sided level 2 cervical lymph node throughout cervical chains.
The patient was admitted with a provisional diagnosis of possible atopic dermatitis with cellulitis of face and neck and started on weight-based intravenous vancomycin but left against medical advice. He was readmitted the next day with ongoing symptoms. He declined another skin biopsy as the previous biopsy did not clarify an entity beyond his original eczema. A dermatologist at a different facility assessed his images and suggested collecting Herpes viral PCR samples from any drainage locations. Given the findings, the patient was placed on intravenous acyclovir due to the high likelihood of EH. His drainage from the right external auditory ear canal was positive for both HSV 1 and 2 by PCR DNA. Intravenous antibiotic coverage for superinfection was also continued until the patient course stabilized. The patient's symptoms and rash improved significantly after being started on intravenous acyclovir. The patient was eventually transitioned to oral valacyclovir and clindamycin at discharge time. Patient was maintained on oral valacyclovir for prophylaxis. For the past 2 years, a consultant dermatologist has prescribed dupilumab with success to treat his eczema. Most recently, the patient has been placed back on valacyclovir treatment and then prophylaxis because of relapsing herpes infection. The patient has been followed up for 6 years.