A Fatal Case of Eczema Herpeticum With Septic Shock Due to Methicillin-Resistant Staphylococcus aureus

Abstract

A 62-year-old woman treated with several courses of corticosteroids for an undifferentiated rash came to the emergency department with progressively worsening cutaneous signs and symptoms and generalized weakness. She had scabies, and despite treatment continued to decompensate. Repeat skin biopsies revealed disseminated herpes simplex virus infection, and results of blood cultures were consistent with infection by methicillin-resistant Staphylococcus aureus. Despite antiviral and antimicrobial therapy, sepsis and multiorgan failure developed, and the patient died. This case illustrates the complications of the rare entity eczema herpeticum, which occurs most often in immunocompromised patients and is associated with a high mortality. Maintaining a high index of suspicion for this disease in decompensating patients with an unidentified rash is essential to avoid catastrophic outcomes. (American Journal of Critical Care. 2016;25:379-382 M any life-threatening diseases initially have seemingly innocuous dermatological findings, and subtle abnormalities may only be evident to an astute clinician considering a broad range of potential diagnoses. Although chronic skin conditions, such as atopic dermatitis, are common and are relatively benign, severe complications can occur. For example, eczema herpeticum is a cutaneous dissemination of herpes simplex virus (HSV) in patients with a chronic skin condition, most commonly atopic dermatitis. Because of the rare occurrence and difficult diagnosis, the true incidence and prevalence of eczema herpeticum are unknown, although the condition is thought to affect 3% to 6% of patients with atopic dermatitis.1 Even though eczema herpeticum is exceedingly rare, 6% to 10% of immunocompetent hosts and up to 50% of immunocompromised patients can die of the viremia, multiorgan involvement, and bacterial superinfection potentially associated with it. highlights an important condition to consider in both critical care and primary care assessment of a patient with an undiagnosed rash.A 62-year-old woman with a history of mild mental retardation, diabetes, hypertension, and hypothyroidism who was living in a group home came to the emergency department with a rash and generalized weakness. She had intermittently experienced a pruritic, generalized rash for approximately 1 year before she came to the hospital. Her caregivers at the group home had taken her to the primary care doctor for the workup of this rash throughout the year. The results of an outpatient skin biopsy were consistent with a drug eruption, thus prompting her primary care physician to have her stop taking hydrochlorothiazide and sitagliptin. Despite this step, the rash did not resolve.The patient had an empiric trial of prednisone, which resulted in temporary resolution of the rash.However, whenever prednisone was discontinued, the rash would promptly reappear. The patient received repeated short courses of steroids (< 7 days each) throughout the year. Despite the prednisone therapy, during the week before she ca...

Recurrent eczema herpeticum – a retrospective European multicenter study evaluating the clinical characteristics of eczema herpeticum cases in atopic dermatitis patients

“…The time frame seems unacceptably long, considering the high mortality of untreated disseminated HSV infections . Delayed initiation of acyclovir is associated with an increased length of stay of hospitalized EH patients, and just recently, a lethal case of EH has been reported . Therefore, immediate diagnosis and treatment initiation are crucial.…”