24-year-old woman with fever and painful rash
A 24-year-old graduate student with a long history of atopic dermatitis presents to the emergency department for a painful, rapidly worsening rash. For the past two days, she has had fever, malaise, and new blisters developing within her chronic eczema patches. Temperature is 38.7°C (101.7°F), heart rate is 112/min, and blood pressure is 108/68 mmHg. Examination reveals tender, erythematous plaques on her cheeks and in both antecubital fossae. Superimposed on these areas are numerous monomorphic 2- to 3-mm vesicles and punched-out erosions with hemorrhagic crusting. Laboratory results include a white blood cell count of 11.4 x 10^9/L with a normal differential. Which of the following is the most appropriate next step in management?
See the answer and explanation below:
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View on AmazonThe Correct Answer
D
Explanation
Clinical Pearl:
Eczema herpeticum is a dermatologic emergency characterized by the rapid development of monomorphic vesicles and "punched-out" erosions in a patient with underlying atopic dermatitis. Prompt initiation of systemic antiviral therapy is crucial and should not be delayed for diagnostic confirmation.
Explanation:
This patient's presentation of fever, malaise, and painful, monomorphic vesicles and punched-out erosions superimposed on chronic eczematous plaques is classic for eczema herpeticum, a disseminated cutaneous herpes simplex virus infection. Eczema herpeticum is a medical emergency that can lead to significant morbidity, including viremia and death, if not treated promptly. Standard of care, particularly in patients with systemic symptoms like fever, is immediate initiation of intravenous acyclovir. Intravenous vancomycin would be appropriate for a severe bacterial superinfection, which typically presents with pustules or honey-colored crusting, not monomorphic vesicles. Applying topical corticosteroids or initiating systemic prednisone is contraindicated, as immunosuppression can worsen the dissemination of herpes virus. While viral polymerase chain reaction testing can confirm the diagnosis, treatment should not be delayed pending results in a patient with a clear clinical presentation and systemic illness.
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