Disseminated mucocutaneous herpes simplex in an atopic individual

A 30-year-old Caucasian man was referred to eye casualty by his general practitioner (GP) with a two-day history of a widespread, rapidly progressing, blistering rash with ulceration, along with red painful eyes. It started with a ‘flu-like’ illness with symptoms of malaise and arthralgia for which the patient self-medicated with ibuprofen. After one day the rash began on the shaft of the penis and groin with painful vesicles that caused gross oedema. He had no genital mucosal involvement and denied dysuria or purulent discharge. Within several hours widespread painful, punched-out ulcers developed over his face and anterior thoracic wall. The individual was known to suffer from asthma and eczema. Past ophthalmic history revealed previous penetrating keratoplasty in the right eye and left cataract surgery without any lens implant in the left eye. On examination he had an acute gingivostomatitis with blistering around the mouth and ulcerating lesions of the buccal mucosa, tongue and lips. Unaided visual acuities were 6/9 in both eyes. A punched-out rash was distributed over his sternum and he had a marked eczematous blepharitis with a papillary conjunctivitis (Figure 1). No symblephara formation was noted. Corneal punctate epithelial erosions were noted but anterior chamber examination did not reveal any abnormality. The intraocular pressures were normal. Fundoscopy was unremarkable. The individual had unprotected sexual intercourse with a new partner one week prior to the development of the rash. He denied any previous episodes of herpes simplex viral infection and had no previous high-risk behaviours such as intravenous drug use. Subsequent HIV testing was negative. Blood tests, including liver function tests, were normal. Polymerase chain reaction on a conjunctival swab was positive for herpes simplex virus (HSV) type 1. The provisional diagnosis of Stevens-Johnson syndrome was made. He was treated initially with chloramphenicol ointment four times a day, hourly celluvisc 0.5% and two-hourly dexamethasone 0.1% eye drops. The patient was admitted under the medical team and subsequently reviewed by dermatology and the genitourinary medicine team the following day who clinically diagnosed disseminated mucocutaneous herpes simplex infection, also known as eczema herpeticum or Kaposi’s varicelliform eruption. His eye drops were subsequently changed to 3% aciclovir ointment five times a day, having received the above treatment for one day. He was treated with intravenous aciclovir 5 mg/kg three times a day for two days. Following a good response to the treatment he was discharged home with oral valaciclovir 1g PO for 10 days.