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Eczema Herpeticum and Clinical Criteria for Investigating Smallpox

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Eczema Herpeticum and Clinical Criteria for Investigating Smallpox DISPATCHES (Figure 1, panel A). Cerebrospinal fluid, obtained because Eczema Herpeticum of his obtunded mental status, was unremarkable. The work- ing diagnosis was Sezary syndrome with erythroderma. He and Clinical Criteria was transferred to our intensive care unit with widespread umbilicated pustules and normal mental status. The pus- for Investigating tules were deep seated, monomorphic, dome shaped, and Smallpox firm and were distributed densely on the patient’s forearms and abdomen (Figure 1, panels B and C). He showed no David A. Boyd, Leonard C. Sperling, enanthem or lesions with an erythematous base. Lesions and Scott A. Norton were abundant on his dorsal hands, but were not palmar. His vital signs were significant only for 100.4ºF tempera- Eczema herpeticum can clinically resemble smallpox. ture. He reportedly had received vaccinia. On the basis of the algorithm for rapid evaluation of patients At our hospital, his oral temperature fluctuated dra- with an acute generalized vesiculopustular rash illness, a matically, from 89.3ºF to 101.3ºF, with rectal confirmation patient met criteria for high risk for smallpox. The Tzanck <95ºF (<35ºC), indicating hypothermia (5). He remained preparation was critical for rapid diagnosis of herpetic infec- tion and exclusion of smallpox. normotensive, but his mental status fluctuated. We believed this smallpox-like eruption most likely re- sulted from a herpesvirus. We performed a Tzanck prepara- fter the 2001 anthrax bioterrorism incidents, public tion, which showed multinucleated giant keratinocytes with Ahealth officials became concerned about bioterrorist nuclear molding and margination (online Appendix Figure, threats of smallpox. The Centers for Disease Control and available from www.cdc.gov/EID/content/15/7/1102-appF. Prevention (CDC), along with interested partners, devel- htm). A direct fluorescent antibody (DFA) test was posi- oped a clinical algorithm for rapid evaluation of patients tive for varicella zoster virus (VZV). A biopsy specimen with acute generalized vesiculopustular rash illness (AGV- showed epithelial necrosis with cellular ballooning and PRI) (1). In a surveillance system designed to detect an multinucleated giant cells, plus intranuclear inclusion bod- index case of smallpox, high specificity is critical to mini- ies (Figure 2, panels A and B). Subsequently, special im- mize false-positive reports of a disease that no longer exists munohistochemical stains were positive for herpes simplex in nature (2). virus (HSV) (Figure 2, panel C), and a viral culture grew CDC’s algorithm emphasizes 3 major clinical features HSV type 2. His illness was diagnosed with disseminated of smallpox: febrile prodrome, typical appearance of char- HSV concurrent with underlying atopic dermatitis (i.e., ec- acteristic lesions, and uniform lesion morphology (Table). zema herpeticum). The algorithm stratifies AGVPRI cases into high, moderate, Within minutes of the Tzanck smear evaluation, our and low likelihood of smallpox (3). Passive and active sur- patient was given intravenous acyclovir. When cutaneous veillance has stratified no case to high risk (4). We describe improvement was evident, he was switched to oral vala- a patient whose illness fulfilled CDC’s high-risk criteria for cyclovir. Within days, his skin lesions largely resolved smallpox, although he actually had eczema herpeticum. without conspicuous crusting or scarring, but he remained intermittently hypothermic for several weeks. The Case A 45-year-old man with a lifelong history of atopic Conclusions dermatitis had a year-long unremitting exacerbation for This patient was markedly ill on admission and had a which he had started systemic therapy. After treatment distinctive varioliform eruption with lesions in a uniform with cyclosporine for several weeks, laboratory abnormali- ties and nonspecific neurologic signs prompted a switch to Table. Major clinical criteria for smallpox* methotrexate. Within 4 weeks, he was hospitalized (in an Febrile prodrome Occurring 1–4 days before rash onset; fever >101ºF; and >1 of the following: overseas US military hospital) for generalized umbilicated prostration, headache, backache, chills, papulopustules accompanied by profound hypothermia, vomiting, or severe abdominal pain. hypotension, and mental status changes. He had large Classic smallpox Deep-seated, firm/hard, round, well- pustules on his trunk, inner thighs, and upper extremities lesions circumscribed vesicles or pustules; as they evolve, lesions may become umbilicated or confluent. Author affiliation: Naval Hospital Jacksonville, Jacksonville, Florida, Lesions in same stage On any single part of the body (e.g., face USA (D.A. Boyd); and Uniformed Services University, Bethesda, of development or arm); all lesions are in the same stage Maryland, USA (L.C. Sperling, S.A. Norton) of development (i.e., all are vesicles or pustules). DOI: 10.3201/eid1507.090093 *Source: (3). 1102 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 7, July 2009 Eczema Herpeticum and Smallpox Figure 1. Clinical photographs of the patient. A) Patient with generalized pustules, which were deep seated, monomorphic, dome shaped, and firm and were distributed densely on forearms and abdomen. B) Umbilicated papulopustules. C) Umbilicated papulopustules in the same stage of evolution; no herpetiform clusters or red areolae are seen around the lesions. stage of evolution. Consequently, smallpox was included Smallpox was declared eradicated by the World Health in the differential diagnosis. Tzanck preparation prompt- Organization in 1977; nevertheless, some health organiza- ly confirmed herpetic etiology, but we nevertheless used tions consider this illness a bioterrorism threat. Clinical CDC’s algorithm for evaluating AGVPRI, and our patient’s smallpox typically starts with a prodrome of high fever, illness stratified to high risk. headache, myalgia, backache, nausea, vomiting, and diar- CDC has 3 major diagnostic criteria to designate a case rhea. An oropharyngeal enanthem is followed by cutane- as high risk for smallpox (Table) (6). The first is febrile ous eruption of erythematous macules that quickly become prodrome, which typically lasts 1–4 days before cutane- papules. The papules evolve over days into vesicles and ous lesions appear and must include >1 of the following: then pustules, often developing central umbilication. Clas- prostration, headache, backache, chills, vomiting, or severe sic smallpox lesions occur in the same stage of evolution abdominal pain. Body temperature must reach >101ºF. Al- on a body segment, which differentiates it from varicella. though our patient’s illness eventually met the fever crite- Smallpox lesions also tend to start peripherally. Smallpox rion, his 101ºF temperature occurred only after he began pustules have been called “pearls of pus” to help distin- antiviral treatment. He was more often markedly hypother- guish them from the more delicate “dewdrops on rose mic during his hospitalization. petals,” which describes typical varicella. Histopathologi- Prolonged hypothermia is associated with severe illness cally, cutaneous smallpox lesions may resemble herpetic (7) and is equivalent to fever in determining critical illness lesions except that smallpox has intracytoplasmic inclu- (8), which we believe satisfies CDC’s first major criterion. sions (Guarnieri bodies) instead of intranuclear inclusions The second criterion requires classic cutaneous lesions that (Lipschutz bodies) of herpetic lesions. Also, multinucleated are deep seated, firm, round, well-circumscribed vesicles or giant keratinocytes are uncharacteristic of smallpox (9). pustules that may become umbilicated or confluent. The third Eczema herpeticum, described by Kaposi in 1887, is criterion requires the same stage for most cutaneous lesions most common in patients with atopic dermatitis but can on an affected area. Our patient’s illness met all 3 criteria; occur in other conditions that disrupt epidermal integrity. however, laboratory tests confirmed herpesvirus infection. In eczema herpeticum, lesions are typically monomorphic Figure 2. Photomicrographs of the patient’s eczema herpeticum. A) Epithelial necrosis with cellular ballooning and multinucleated giant cells. B) Ballooning degeneration of keratinocytes. C) Positive immunohistochemical stain for herpes simplex virus. Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 7, July 2009 1103 DISPATCHES vesicles that evolve into pustules (10). Fever, malaise, References lymphadenopathy, and tender skin may accompany cutane- 1. Seward JF, Galil K, Damon I, Norton SA, Rotz L, Schmid S, et al. ous eruption (11). The histopathologic features noted in our Development and experience with an algorithm to evaluate suspected biopsy are classic for herpetic skin lesions. smallpox cases in the United States. Clin Infect Dis. 2004;39:1477– Fever is a well-recognized sign of infection; however, 83. DOI: 10.1086/425500 hypothermia can also signal serious disease, including bac- 2. Centers for Disease Control and Prevention. Smallpox case defini- tions [cited 2008 Sept 24]. Available from http://www.bt.cdc.gov/ terial sepsis or viral encephalitis (12), and may be more agent/smallpox/diagnosis/casedefinition.asp dire than fever in severely ill hospitalized patients (13). We 3. Centers for Disease Control and Prevention. Evaluating patients for propose that our patient’s hypothermic temperature dys- smallpox [cited 2007 Dec 4]. Available from http://www.bt.cdc.gov/ regulation is equivalent
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