Case Presentation #2

Christoph Berger

Moritz, 20 months of age

History • Preterm boy (GA 34 weeks, birth weight 1900g) Neonatal respiratory distress syndrome

• Recurrent episodes of obstructive bronchitis, neurodermatitis

Current presentation • Pharyngitis 2 weeks ago • For 2 days increasing number of blisters and crusts on skin under the diaper. Such lesions now also on both legs and most of all on both hands.

Moritz, 20 months of age

Moritz, 20 months of age

Tentative Diagnosis ?

A Impetigo

B Chickenpox (varicella)

C Eczema herpeticum

D Scabies

Moritz, 20 months of age

Moritz, 20 months of age

Clinical Findings: • Reduced general condition, 10kg, scratching himself incessantly.

• Dry, scaling, in part lichenoid skin all over his body, most impressing on the flexor side of his knees and elbows.

• Serous or crusty vesicles (peri)genital, on both legs, both hands, behind his ears and some loose on the trunk. Mouth not affected.

Moritz, 20 months of age

Next steps?

A Swab from blisters, hospital admission

B Acyclovir iv, hospital admission

C Acyclovir peroral

D shaking mixture, intensify skin care

Moritz, 20 months of age

Information and advice ………. nevertheless, his mother decided for an outpatient treatment with peroral acyclovir.

At home ­ vomiting once after administration of acyclovir and ­ pronounced reaction on legs and in his face „as usual “ after application of tacrolimus ointment

→ back to the ER and hospital admission.

Moritz, 20 months of age

Treatment ­ Acyclovir iv 3x 10 mg/kg/day ­ Antihistaminica ­ Lipolotion

Moritz, 20 months of age

Further Treatment ?

A topical and or systemic antibiotic treatment

B no tacrolimus ointment

C prevent systemic steroid treatment prevent steroid­containing crèmes

D valacyclovir po

Moritz, 20 months of age

Exacerbated neurodermatitis Eczema herpeticum

Virus detection from vesicle: Herpes simplex type 1

Follow­up:

Acyclovir for 8 days Care of skin + Steroid crèmes + mupirocin ointment

After 1 month: ­ less skin inflammation ­ only rare scratch marks

Moritz, 20 months of age

Eczema herpeticum Primary or secondary HSV infection based on atopic eczema

Predisposing factors ü neurodermatitis: high IgE concentration ü early manifestation of the atopic eczema ­ steroids (topical or systemic) NOT SHOWN ­ topical tacrolimus/pimecrolimus UNCLEAR ü exacerbation of atopical eczema

Complications ­ secondary bacterial infections ­ viremia: organ manifestation, encephalitis, DIC

mortality without ACV: up to 75%

Wollenberg; J Am Acad Dermatol 2003; 49:198

Rerinck: H

autarzt 2006; 57:586

Thus, it is an EMERGENCY