Herpes-associated erythema multiforme worsened by a Siddha drug, Alpinia galanga, in an 18-year-old man.

To cite: Kumar M S, Kumar M H, Kumar VS, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2015212303 DESCRIPTION An 18-year-old man with fever and headache for 1 week was prescribed with capsules containing Alpinia galanga by a Siddha physician.Three days later, the patient developed extensive crustations on the lower lip. A provisional diagnosis of erythema multiforme was made with this drug history and, after further investigation, herpes-associated erythema multiforme (HAEM) was made. The patient was managed with a 1-week course of tablet acyclovir and prednisolone. This case details the role of A. galanga in exasperating HAEM and also describes its management approach. A. galanga belongs to Zingiberaceae (the ginger family). Its rhizome (rootstock) is commonly used in herbal medicine and as a spice in food. Its pharmacological actions are anti-inflammation, antioxidation, antiallergy, gastroprotection, hypoglycaemic effect and marked immunostimulation. An erythema multiforme-like reaction caused by A. galanga is due to the haptens present in it. The haptens in A. galanga are also strong allergens to T cells and provoke a T-cell-mediated immune response. Mechanisms of tissue damage include direct cytotoxicity against keratinocytes, mostly mediated by CD8+ T cells, and the T -cell release of cytokines that amplify the inflammatory response by targeting resident skin cells. Erythema multiforme is an acute and selflimiting mucocutaneous hypersensitivity reaction triggered by certain infections and medications. One of the most common predisposing factors for erythema multiforme is infection with herpes simplex virus (HSV). HAEM is an acute exudative dermatic and mucosal disease caused by the infecting HSV. It has a recurrence and idiorestriction, characterised by increasing of CD4+ T leucomonocytes. 3 The most common trigger for the development of EM is the HSV (HSV-1 and HSV-2). The pathogenesis of HAEM is consistent with a delayed hypersensitivity reaction. The disease begins with the transport of HSV DNA fragments by circulating peripheral blood mononuclear CD34+ cells (Langerhans cell precursors) to keratinocytes, which leads to the recruitment of HSV-specific CD4+ Th1 cells. The inflammatory cascade is initiated by interferon γ (IFN-γ), which is released from the CD4+ cells in response to viral antigens, and immunomediated epidermal damage subsequently begins. 5 An 18-year-old man reported to the department of oral medicine and radiology, with extensive painful ulcers and haemorrhagic crusts on the lower lip for the past 5 days. The patient presented with a 1-week history of fever and headache, for which he took capsules containing dry extract of A. galanga, prescribed by a Siddha physician.Three days later, he developed multiple small ulcerations with fragile haemorrhagic crustations on the lower lip. Extra-oral examination revealed multiple irregular ulcers with bloody crustations on the lower lip (figure 1). Both submandibular lymph nodes were enlarged and tender. Intraorally, multiple erosions were seen on the left buccal mucosa and gingiva, and these areas were covered with erythematous halos (figure 2). There were no ulcers elsewhere on the body. Based on the drug history and clinical