Kaposi’s varicelliform eruption in herpes simplex encephalitis
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Herpes simplex encephalitis (HSE) is the most common cause of sporadic viral encephalitis that is characterized by a severe headache, fever, seizures, and a decline in consciousness. In adults, the majority of cases are caused by HSV-1, which is believed to represent the reactivation of latent HSV in situ within the central nervous system. The diagnosis of herpes simplex encephalitis is based on clinical features (a triad of fever, headache and an altered mental state), cerebrospinal fluid examination, and brain imaging . HSV DNA detection by polymerase chain reaction using the cerebrospinal fluid has a sensitivity of 98 % and a specificity of 94–100 %. Edematous changes in the temporal lobe and high red cell count in the CSF are typical features of HSE, and were observed in our patient . The association between poor outcome and the presence of red blood cells in CSF has been reported, which may be result from a severe immunological reaction . The mortality rate occasionally exceeds 70 % without antiviral medication. Prompt initiation of therapy with acyclovir within 72 h is important to obtain maximal clinical benefit, and to reduce the mortality rate to <30 % .
The neuropsychiatric symptoms of HSE are associated with anatomic structures, such as the fronto-orbital region, hippocampus, cingulate gyrus and insular cortex. The temporal and orbitofrontal lobes involvement may also elicit personality changes, anosmia, or olfactory or gustatory hallucinations in the acute phase . The inflammatory process of the limbic cortex may also manifest in disorganized behavior and emotional dysregulation occurring during the course of HSE. An altered mental state is often preceded by a period of delirium . We did not observe the other mentioned psychotic symptoms except for disorganized behavior in our patient, which might be related to his level of consciousness during the initial evaluation.
Kaposi’s varicelliform eruption (KVE), also known as eczema herpeticum, is the dissemination of HSV in the setting of pre-existing inflamed skin, typically involving atopic dermatitis. KVE is often misdiagnosed as an exacerbation of the patient’s pre-existing skin lesion. Its diagnosis is generally established by Tzanck testing. Once KVE is suspected, it is imperative to initiate antiviral treatment because of high mortality rate of the untreated encephalopathy .
In conclusion, we present the case of a man with the combination of herpes simplex encephalitis and Kaposi’s varicelliform eruption, which may mimic a skin rash caused by a bacterial infection in the acute care setting. This unusual presentation indicates a severe infection and a poor prognosis. An immediate lumbar puncture is essential and helpful for establishing the correct diagnosis, and initiating helpful therapy.
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The authors declare that they have no conflict of interest.
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The authors hereby declare that the research documented in the present manuscript, involving human participant, has been carried out in accordance with the ethical standards of the institutional and national research committee and have been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendment or comparable ethical standards.
Written informed consent was obtained from the patient.