Thymidine Kinase Sequence Analysis of Herpes Simplex Virus Type 1 Strains Present in Different Compartments in an Atypical Impetiginous Rash on the Lesional Skin of a Burn Patient

Abstract

We report the case of a 23-year-old male burn patient with an unusual herpes simplex virus (HSV) skin manifestation. The clinical symptoms and results of HSV type 1 (HSV-1) UL23 polymorphism analysis from saliva and lesional skin underscores the need for performing molecular analysis of HSV-1 infections in burned patients presenting unusual skin lesions. CASE REPORTAn otherwise healthy, 23-year-old male patient with 32% total body surface area burns was transferred to our burn center. The patient sustained superficial second-degree burns on the face and neck, on both arms, extending from the hand to the upper arms, and on front and back areas of both lower legs and knees. The injury was caused by a workplace-related gas burner explosion.Initially the patient was intubated and a bronchoscopy was performed. There were no signs of an inhalation injury. The wounds were surgically debrided, and a Vaseline gauze dressing was applied. Daily dressing changes were performed.Due to gram-positive bacteria in tracheal secretions, antibiotic treatment with a cephalosporin was administered for 7 days. The patient was extubated on day 7.On postburn day 10, a sudden increase in the patient's temperature to near 39°C was noticed, and a deterioration of his general condition was evident. Pneumonia was excluded by X rays of the chest. At this point we also removed the central line catheter.Twenty-four hours after the onset of fever, the patient developed yellowish seromucus-covered erosions in the burned skin areas. The focal point of the rash was on the arms, the neck, and the underpart of the face ( Fig. 1 and 2). The patient reported merely some light tension on the affected areas but severe pain. Based on the symptoms and the shape of the blisters, we suspected both bacterial and herpes simplex virus type 1 (HSV-1) infection. Swabs of the blister revealed Staphylococcus epidermidis, and molecular analysis for HSV-1, cytomegalovirus (CMV), and varicella-zoster virus (VZV) revealed HSV-1 infection.On admission the patient was immunoglobulin G (IgG) positive for HSV, CMV, and VZV (20 July 2006). No enhanced CMV IgG levels were observed, and no antiherpesvirus IgM was detectable by enzyme-linked immunosorbent assay. A lesional wound swab from skin of the upper arm on postburn day 11 (1 August 2006) revealed the presence of HSV-1 DNA (H724) by a real-time PCR protocol with melting-point analysis for discrimination between HSV-1 and -2 (5). From the same swab, PCR for VZV and CMV DNA was negative. Serology for HSV IgM was negative, and complement fixation revealed an enhanced titer of 160 at 11 days postburn (1 August 2006). On day 12 after the thermal insult (2 August 2006), HSV-1 was isolated from a throat swab (H723) and a throat wash by microculture using monolayers of human foreskin fibroblasts and Vero cells. The HSV-specific cytopathic effects in both cell cultures were confirmed by immunoperoxidase staining of HSV glycoprotein D by an in situ enzyme-linked immunosorbent assay. At the same time, PCR results for CMV from leuko...

Human herpes viruses in burn patients: A systematic review

“…However, no benefits of the acyclovir treatment could be seen. In most case reports and case series, authors suggest intravenous acyclovir therapy for clinically manifested HSV infections in burns [19,42 – 48]. Matthews et al [26] discussed a prophylactic therapy with idoxuridine for acute HSV infections, however, this therapy was not used in their study.…”

Comprehensive clinical and virological characterization of three cases of fulminant liver failure owing to HSV1 primary infection

“…Clinical isolates of HSV‐1 were obtained by microculture using human foreskin fibroblasts and Vero‐cell microculture. Specific cytopathic effects (CPE) were confirmed by anti‐HSV‐1/2‐gD‐immunoperoxidase staining as reported earlier 9 . In order to analyse potential HSV‐1 genotype variations of viral DNA from throat swabs, plasma and whole EDTA blood, we sequenced the viral UL23 and UL30 genes as described previously 9,10 .…”

“…Specific cytopathic effects (CPE) were confirmed by anti-HSV-1/2-gD-immunoperoxidase staining as reported earlier. 9 In order to analyse potential HSV-1 genotype variations of viral DNA from throat swabs, plasma and whole EDTA blood, we sequenced the viral UL23 and UL30 genes as described previously. 9,10 The relative frequency of distinct patterns of HSV-1 UL23/ UL30 polymorphisms from critically ill and surgical ICU patients were derived from the medical thesis of Emrich H (2013), those from SCT recipients from the medical thesis of Moritz (now Lohrengel) K. (2013) (Supplementary Methods, Tables S1-S4).…”

Viral Infections in Burn Patients: A State-Of-The-Art Review

“…Because of the rapid state of unconsciousness, PCR tests were performed to investigate the potential cause of infection and the results showed HSV-1-related encephalitis, probably due to viral reactivation [ 49 ]. However, milder symptoms such as a rash, vesicles, or vesicopustules might be quite easily misdiagnosed and treated as impetiginous, eventually leading to much more severe complications of the HSV infection [ 50 ]. In 1996, Byers et al demonstrated that 50% of burn patients showed the presence of HSV in the lung tissue and 16 patients developed acute respiratory distress syndrome (ARDS), among which 13 were infected by HSV [ 51 ].…”