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CASE REPORT
Year : 2018  |  Volume : 2  |  Issue : 1  |  Page : 28-30

“Localized” Kaposi's varicelliform eruption caused by varicella zoster virus in a patient of irritant dermatitis


Department of Dermatology and Venereology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Web Publication5-Jan-2018

Correspondence Address:
Naveen Kumar Kansal
Department of Dermatology and Venereology, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_28_17

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  Abstract 


Kaposi's varicelliform eruption (KVE) refers to disseminated viral infections due to herpes simplex, coxsackie A16, etc., in patients of preexisting skin disease. Localized forms of KVE are less well characterized. We hereby describe localized eruption of KVE caused by varicella zoster virus in a patient of irritant dermatitis.

Keywords: Eczema herpeticum, irritant dermatitis, Kaposi's varicelliform eruption, varicella zoster virus


How to cite this article:
Kansal NK. “Localized” Kaposi's varicelliform eruption caused by varicella zoster virus in a patient of irritant dermatitis. Clin Dermatol Rev 2018;2:28-30

How to cite this URL:
Kansal NK. “Localized” Kaposi's varicelliform eruption caused by varicella zoster virus in a patient of irritant dermatitis. Clin Dermatol Rev [serial online] 2018 [cited 2022 Jan 27];2:28-30. Available from: https://www.cdriadvlkn.org/text.asp?2018/2/1/28/222274




  Introduction Top


Kaposi's varicelliform eruption (KVE) is defined as a viral exanthem with extensive skin involvement of preexisting dermatoses. Most commonly, it is caused by a herpes simplex virus type 1 (HSV-1) infection in patients with atopic dermatitis and has been called as “eczema herpeticum.” KVE can be severe and may progress to disseminated infection with significant morbidity and occasional mortality, if not diagnosed and treated timely. In milder cases, however, the skin lesions may often be restricted in distribution: the less commonly used term is “localized” KVE/eczema herpeticum.[1],[2] Here, we report a case of localized KVE due to varicella zoster virus (VZV), which occurred secondary to irritant dermatitis of groins and scrotum.


  Case Report Top


A 22-year-old male patient presented with complaints of fever, sore throat, malaise and an itchy, erythematous rash for last 2–3 days. The rash was very irritating to the patient, particularly around genitalia with burning sensation and pain. On direct questioning, the patient stated that he had applied a nonprescription hair removal cream (active ingredient “potassium thioglycolate”) to remove his pubic hair and hair around genitalia and scrotum about 10 days back, which had caused much itching and burning. He had not taken any treatment for this irritant reaction. On general examination, the patient was febrile (100.4 F), and inguinal lymph nodes were palpable and tender. Systemic examination was within normal limits. The rash consisted mainly of vesicles on an erythematous base on trunk [Figure 1], extremities, face, and oral mucous membrane. The skin on pubic area, scrotum, and genitocrural folds was erythematous, and multiple vesicles and pustules were present [Figure 2]. The routine blood counts showed raised erythrocyte sedimentation rate (34 mm 1st h); liver function tests, renal function tests, urine examination, and random blood glucose level (109 mm/dL) were within normal limits. A Tzanck smear from the base of a vesicle showed multinucleated giant cells with hyperchromatic nuclei [Figure 3]. On the basis of clinical presentation, a diagnosis of varicella (chicken pox) with localized KVE of irritant dermatitis due to varicella zoster virus was made. The patient was prescribed tablet valacyclovir 1000 mg three times a day along with supportive treatment for fever and itching. For lesions around genitalia, he was advised to use bland emollient cream (soft paraffin cream). The patient responded well to treatment, and at the follow-up visit, almost all the lesions were crusted and healing. The patient was counseled and advised to avoid potassium thioglycolate containing hair removal creams as well.
Figure 1: Chest vesicular lesions on erythematous base - classical dew drop on rose petal appearance of varicella

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Figure 2: Involvement of scrotum and penoscrotal area. Many pustules are seen

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Figure 3: Tzanck smear giant cells with hyperchromatic nuclei (Giemsa, ×200)

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  Discussion Top


The first description of HSV infection of atopic dermatitis was provided by Moriz Kaposi in 1887.[3] Most of the cases of KVE are due to infections of atopic dermatitis with HSV-1 and are usually referred to as eczema herpeticum. It has been suggested that the eponymous title (KVE) should be used to encompass similar widespread infections with other viruses, for example, coxsackie A16 and vaccinia (also called eczema vaccinatum). Atopic eczema is certainly the most common predisposing condition for KVE; however, list of other dermatoses reported to be associated with KVE/eczema herpeticum continues to expand and includes cutaneous T-cell lymphoma, Sézary syndrome and bullous mycosis fungoides,[4] Darier's disease, seborrheic dermatitis, pemphigus foliaceus, Hailey–Hailey disease, Grover's disease, ichthyosis vulgaris, Wiskott–Aldrich syndrome, congenital ichthyosiform erythroderma, Netherton's syndrome, allergic contact dermatitis, irritant contact dermatitis, psoriasis (psoriasis herpeticum),[5] pityriasis rubra pilaris, toxic epidermal necrolysis, rosacea, lupus erythematosus, drug eruptions, staphylococcal scalded skin syndrome as well as following certain dermatological procedures, for example, dermabrasion.[6]

Patients of severe KVE are very ill with generalized painful skin lesions (usually in the form of vesicles/bullae, pustules, crusted lesions, or punched out ulcers), high-grade fever, anorexia, malaise, lymphadenopathy, and possible systemic involvement. Skin lesions may continue to evolve for 7–10 days and may heal with considerable scarring. Diagnosis of KVE/eczema herpeticum is primarily clinical confirmed with laboratory evidence of the viral infection, a Tzanck smear from vesiculopustular eruptions. Viral cultures and polymerase chain reaction for virus identification are to be performed depending upon availability of laboratory services.[5] However, in cases of limited involvement of skin by the susceptible dermatosis, the viral vesicular eruption may be limited to the affected skin and has been called “localized” KVE/eczema herpeticum. In our patient, prior application of the hair removal (Veet) cream had caused an irritant dermatitis in the genitocrural area and scrotum, and VZV caused severe involvement resulting in a localized KVE. Although varicella is generally more severe in adults, in our patient, systemic involvement was absent and the patient responded well to oral antiviral treatment.

Garg and Thami reported an uncommon presentation as “psoriasis herpeticum” due to VZV, in which herpes zoster had presented as KVE in a patient of erythrodermic psoriasis. The patient responded well to intravenous acyclovir therapy.[5]

The concept of a “localized” form of KVE seems very intriguing. The classic definition of KVE requires “generalized” involvement by a virus which normally causes “limited” skin disease. However, this original definition includes only certain viruses and limited number of skin diseases. Our case is unique as it shows extensive “localized” involvement by VZV, which causes subclinical/mild infection (chicken pox) in pediatric age group and relative more severe infection of susceptible adults with a potential of systemic involvement. It seems likely that this type of presentation of KVE is underrecognized. We propose that eponymous title of KVE should be used to indicate severe viral infections of preexisting dermatoses.


  Conclusion Top


We report a case of localized KVE caused by VZV infection in a patient with irritant contact dermatitis. The timely clinical recognition of KVE is very important for proper management to minimize morbidity and occasional mortality.[7],[8] Furthermore, guidelines are needed to clinically define and delineate “localized” and “generalized” forms of KVE.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fivenson DP, Breneman DL, Wander AH. Kaposi's varicelliform eruption. Absence of ocular involvement. Arch Dermatol 1990;126:1037-9.  Back to cited text no. 1
[PUBMED]    
2.
Parker RK, Guin JD. Hand eczema herpeticum. Cutis 1993;52:227-8.  Back to cited text no. 2
[PUBMED]    
3.
Criton S. Viral infections. In: Valia RG, Valia AR, editors. IADVL Textbook of Dermatology. 3rd ed., Vol. 1. Mumbai: Bhalani Publishing House; 2008. p. 331-96.  Back to cited text no. 3
    
4.
Xu XL, Huang YX, Lin L, Zhang ML, Jiang YQ, Sun JF. Bullous mycosis fungoides: Report of a case complicated by Kaposi's varicelliform eruption. J Dermatol 2013;40:844-7.  Back to cited text no. 4
[PUBMED]    
5.
Garg G, Thami GP. Psoriasis herpeticum due to Varicella zoster virus: A Kaposi's varicelliform eruption in erythrodermic psoriasis. Indian J Dermatol 2012;57:213-4.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Sterling JC. Virus infections. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's Textbook of Dermatology. 8th ed., Vol. 2. Oxford: Blackwell Publishing Limited; 2010. p. 33.35-33.37.  Back to cited text no. 6
    
7.
Sais G, Jucglà A, Curcó N, Peyrí J. Kaposi's varicelliform eruption with ocular involvement. Arch Dermatol 1994;130:1209-10.  Back to cited text no. 7
    
8.
Liaw FY, Huang CF, Hsueh JT, Chiang CP. Eczema herpeticum: A medical emergency. Can Fam Physician 2012;58:1358-61.  Back to cited text no. 8
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