November 2023 Case Study
Author: Alexis E. Carrington, MD
Reviewed by Karl Saardi, MD
A 30 year old female with a history of ulcerative colitis on ustekinumab and prednisone presents to the hospital with a sudden pustular eruption on the face, chest and arms. She also reports painful ulcers and sores on the tongue, lips and gums. Exam shows scattered pustules and tense vesicles with surrounding erythema on the face, upper trunk and arms (Image 1). There are also punched out ulcerations with a white-yellow base on the mucosal lip and gingiva. Labs are significant for ALT and AST elevated to 1847 units/L and 1163 units/L, respectively.
Which of the following next steps will help with diagnosis?
A.) Obtain an HSV/VZV PCR swab
B.) Obtain an enterovirus PCR swab
C.) Obtain a bacterial culture swab
D.) Obtain a fungal culture swab
This patient has disseminated herpesvirus infection complicated by fulminant hepatitis. This was ascertained by a negative HSV IgG 1 and 2 as well as positive HSV2 PCR from cutaneous swab and blood PCR. There was also a component of an acneiform eruption due to chronic steroid use, resulting in a pustular eruption. Her skin findings and hepatitis improved with initiation of IV acyclovir.
Disseminated HSV is a potentially fatal infection that can have visceral involvement. Organs that can be involved include the liver (HSV hepatitis), the central nervous system (meningoencephalitis), lungs (pneumonitis), bone marrow (neutropenia or thrombocytopenia) or the GI tract (necrotizing enterocolitis).1-3 Disseminated HSV is more common in immunocompromised patients, however can occur in immunocompetent patients. In fact, HSV hepatitis should be considered in the setting of acute fulminant liver failure of unknown etiology, as was the case in this patient.4
An HSV/VZV cutaneous swab for PCR (Answer A) is sensitive and specific for detecting herpesvirus infection, which classically presents as painful tense vesicles and punched out mucosal ulcerations and can cause fulminant hepatitis as a sequelae. Swabs for HSV culture are less sensitive but are needed if testing for acyclovir resistance is required. Coxsackievirus, bacterial and fungal etiologies are less likely to cause this cutaneous and systemic presentation (Answers B-D).
References:
- Bolognia, Jean L. Dermatology volume 2. Mosby, 2018.
- Srinivasan D, Kaul CM, Buttar AB, Nottingham FI, Greene JB. Disseminated Herpes Simplex Virus-2 (HSV-2) as a Cause of Viral Hepatitis in an Immunocompetent Host. Am J Case Rep. 2021 Aug 3;22:e932474. doi: 10.12659/AJCR.932474. PMID: 34341324; PMCID: PMC8349572.
- Fatahzadeh M, Schwartz RA. Human herpes simplex virus infections: epidemiology, pathogenesis, symptomatology, diagnosis, and management. J Am Acad Dermatol. 2007 Nov;57(5):737-63; quiz 764-6. PubMed ID: 17939933
- Wei E, Song P, Tan B, Burgin S, Prasad P. Disseminated herpes simplex virus in adult. In: Goldsmith LA, ed. VisualDx. Rochester, NY: VisualDx; 2023. URL:https://www.visualdx.com/visualdx/diagnosis/?moduleId=101&diagnosisId=52676. Accessed October 15, 2023.
