A 20-year-old woman comes to the office due to a rash on the face for 2 days. The rash started abruptly as mildly painful vesicles on the eyelids and cheeks. Medical history includes atopic dermatitis involving the face, arms, and legs that has been well controlled with an emollient and low-potency topical corticosteroid as needed. Temperature is 38 C (100.4 F), blood pressure is 115/75 mm Hg, and pulse is 95/min. Examination findings are shown in the exhibit. Tender cervical lymphadenopathy is present. The remainder of the examination is unremarkable. Which of the following is the most likely etiology of this patient's rash?

Question

A 20-year-old woman comes to the office due to a rash on the face for 2 days.  The rash started abruptly as mildly painful vesicles on the eyelids and cheeks.  Medical history includes atopic dermatitis involving the face, arms, and legs that has been well controlled with an emollient and low-potency topical corticosteroid as needed.  Temperature is 38 C (100.4 F), blood pressure is 115/75 mm Hg, and pulse is 95/min.  Examination findings are shown in the exhibit.  Tender cervical lymphadenopathy is present.  The remainder of the examination is unremarkable.  Which of the following is the most likely etiology of this patient's rash?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c124_616a_8f63_7d28dd8e11d4_MD0005_00 This patient has a painful, vesicular rash in addition to fever and lymphadenopathy. These findings are concerning for eczema herpeticum, a primary or reactivated herpes simplex virus (HSV) infection associated with atopic dermatitis. Increased susceptibility to infectious complications is seen in atopic dermatitis due to innate skin barrier dysfunction and immune dysregulation. Eczema herpeticum typically begins as painful vesicles on an erythematous base, most commonly involving the face, neck, and trunk. These vesicles are monomorphic (uniform in morphology) and evolve into "punched-out" erosions that later become covered with hemorrhagic crusts. Systemic symptoms (eg, fever, lymphadenopathy) are common. "punched-out" erosions Although infection may be localized, eczema herpeticum can spread to noneczematous areas, as well as to the eyes and visceral organs (eg, hepatitis, encephalitis). In this case, the patient's periocular lesions increase the risk for local spread and HSV keratitis or for corneal infection, which can lead to blindness. Therefore, all patients with eczema herpeticum warrant immediate systemic antiviral (eg, acyclovir) therapy. (Choice A) Facial and eyelid allergic contact dermatitis may develop following environmental or topical exposures (eg, cosmetics, medications). It presents with intense pruritus, erythema, and, when severe, vesicles and bullae. However, this patient's fever and hemorrhagic erosions are inconsistent with this condition. vesicles and bullae (Choice B) Impetigo caused by Staphylococcus aureus or group A Streptococcus is a common infectious complication of atopic dermatitis and typically presents as erythematous papules, pustules, or vesicles with honey-colored crusts. "Punched-out" erosions and fever make this diagnosis unlikely. honey-colored crusts (Choice D) Molluscum contagiosum, caused by a poxvirus, presents with umbilicated, skin-colored papules, not painful vesicles. Fever and lymphadenopathy are not seen. Molluscum contagiosum (Choice E) Trichophyton rubrum is the most frequent cause of tinea corporis (ringworm), and lesions present as pruritic, scaly annular patches, not vesicles. annular patches Educational objective: Eczema herpeticum is a herpes simplex virus infection associated with atopic dermatitis. Lesions present as painful vesicles that evolve into "punched-out" erosions with hemorrhagic crusting. Disseminated disease (eg, keratitis, hepatitis) is a complication, and systemic antiviral therapy (eg, acyclovir) should be initiated immediately. References: A corneal dendritic lesion with a skin eruption: eczema herpeticum, an important differential diagnosis. (http://www.ncbi.nlm.nih.gov/pubmed/25636633)

A 20-Year-Old Woman Comes to the Office Due to a Rash