Dear Editor, Kaposi’s varicelliform eruption (KVE), also known as eczema herpeticum, is a disseminated cutaneous infection caused by a virus that typically produces localized or mild vesicular eruptions in patients with preexisting dermatoses. The most common causative agent is herpes simplex virus (HSV), but rarely Coxsackie A-16 and Vaccinia are also implicated. It is commonly reported in atopic dermatitis and has been described rarely in other dermatoses.1 KVE, if left untreated, is a potentially fatal condition due to systemic viremia and involvement of visceral organs. Herein, we report a case of erythroderma secondary to Parthenium dermatitis that was complicated by superimposed KVE. A 48-year-old farmer, with no known history of atopy, presented with severe pruritus, generalized redness, and scaling that began on his face and progressively spread to his abdomen, limbs, and back over 10–15 days. The lesions initially manifested as red, raised papules over his eyelids, retro-auricular areas, and skin folds that coalesced into larger erythematous plaques with dry and profuse scaling. There was a history of multiple fluid-filled lesions 7 days back, which eventually formed raw areas overlying the red scaly plaques. This was associated with a painful burning sensation and fever with chills. The patient gave history of regular exposure to Parthenium due to his daily work and lifestyle which was associated with photoexacerbation of symptoms of pruritus and eczema of exposed areas of body in the past as well. On general physical examination, the patient was in a state of hypovolemic shock and was hemodynamically unstable on the day of admission. The patient had extensive bright red erythema with confluent erythematous plaques covering almost the entire body. There were multiple superimposed punched-out grouped erosions and crusted lesions over the flexural areas, face, and trunk Figure 1a and b. Tzanck smear from the erosions revealed multinucleated giant cells, confirming HSV infection. Histopathological examination of one of the oozing erosions showed ballooning of keratinocytes, spongiosis, intra-epidermal vesiculation, acantholysis, and multinuclear giant cells Figure 2a and b. The patient was admitted and given fluid and vasopressor support along with intravenous acyclovir at a dose of 10 mg/kg/day for 7 days. This led to a rapid resolution of pain and burning sensation. The patient had resolution of fever, the vitals, and the hemodynamic status within 24 h of initiating treatment. This was followed by healing of the erosions over the next 2–3 days Figure 1c and d. Following this, oral corticosteroids were started at 1 mg/kg/day dose which was gradually tapered over 3-month duration along with topical emollients and corticosteroids. After erythroderma had settled in around 2-week time, azathioprine was started at 2 mg/kg/day dose for long-term control of preexisting Parthenium dermatitis such that corticosteroids could be withdrawn later. The patient was continued on azathioprine for about 6 months of duration.Figure 1: (a) “Multiple punched-out grouped erosions on the face,” (b) “Multiple punched-out grouped erosions on the back of the trunk,” (c) “Healed erosions on the face after treatment with acyclovir,” (d) “Healed erosions on the back of the trunk after treatment with acyclovir”Figure 2: (a) “Histopathological section showing ballooning of keratinocytes, spongiosis, intra-epidermal vesiculation, acantholysis, and multinuclear giant cells (H and E, ×10),” (b) “Higher magnification showing ballooning of keratinocytes, spongiosis, intra-epidermal vesiculation, acantholysis, and multinuclear giant cells (H and E, ×40)Parthenium dermatitis is a dermatitis caused by Parthenium hysterophorus, which is a major environmental allergen in tropical and subtropical regions. It has a myriad of clinical presentation patterns, including erythroderma, as in our case.2 KVE is a serious dermatological emergency that occurs when HSV infects a preexisting dermatosis, the most common being atopic dermatitis. KVE has also been reported in dyskeratosis follicularis, pemphigus foliaceus, mycosis fungoides, ichthyosis vulgaris, burn patients, irritant contact dermatitis, Parthenium dermatitis, psoriatic erythroderma, lupus vulgaris, etc.3,4 However, there is a paucity of literature on KVE superimposed over cases of erythroderma. In a case series of 20 cases of KVE by Nath et al., seven cases had erythroderma, of which three were secondary to airborne contact dermatitis.1 There have been a few reports of KVE complicating Parthenium dermatitis from India.5,6 The presence of erythroderma exacerbates the susceptibility to viral dissemination due to extensive epithelial compromise, leading to widespread erosions and systemic involvement. Without early recognition and intervention, KVE can result in severe complications such as viremia, encephalitis, bacterial superinfection, sepsis, and multi-organ dysfunction, which can be life-threatening.7 Key diagnostic clues, as highlighted by our case, include painful monomorphic vesicles and pustules, and characteristic “punched-out” erosions on areas of preexisting dermatitis. Prompt initiation of systemic antiviral therapy, primarily with acyclovir, is essential in managing KVE to prevent disease progression. Supportive care must include adequate fluid management, prevention of secondary bacterial infections, and careful skin barrier protection. A high degree of suspicion in cases with Parthenium dermatitis is warranted, as highlighted by our case, and can prevent fatal complications. 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. Authors’ contributions Literature search: S. Data acquisition: SN. Manuscript preparation: NS. Manuscript editing: AA. Manuscript review: SN. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Sushantika et al. (Wed,) studied this question.