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Herpes Simplex Virus Type 2 Infection and Acute Urticaria


A 37-year-old woman complains of “itchy bumps” that erupted just above herwaist 2 or 3 days earlier. She denies having had this condition in the past.The patient is otherwise healthy and takes no medications. An avid gardener,she claims to be able to identify and avoid poisonous plants.

Case 1:A 37-year-old woman complains of "itchy bumps" that erupted just above herwaist 2 or 3 days earlier. She denies having had this condition in the past.The patient is otherwise healthy and takes no medications. An avid gardener,she claims to be able to identify and avoid poisonous plants.

What condition is responsible for these lesions?

A. An acute contact dermatitis to something in the garden.
B. An acute contact dermatitis to something other than plant material.
C. Herpes simplex.
D. Herpes zoster.
E. Impetigo.

Your initial approach includes which of the following?

F. Perform a bacterial culture.
G. Perform a viral culture.
H. Postpone antibiotic therapy pending culture results.
I. Prescribe a potent topical corticosteroid.
J. Prescribe a systemic corticosteroid.

Figure 1

Figure 2

Case 2:
A pruritic eruption developed on the trunk and extremities of a 9-year-oldgirl 1 day after she started taking amoxicillin/clavulanate. The antibiotic hadbeen prescribed for a sinus infection of 2 days' duration.

Which course of action do you pursue?

A. Change the antibiotic to an erythromycin-based agent, and prescribe anantihistamine.
B. Continue the amoxicillin/clavulanate, and add an antihistamine.
C. Continue the amoxicillin/clavulanate, and add a systemic corticosteroid.
D. Discontinue the amoxicillin/clavulanate, and prescribe an antifungal antibiotic.
E. Continue the current regimen.

Case 1: The papulovesicular, unilateraleruption was the initial clinical episodeof a culture-proven, G,herpes simplexvirus type 2 infection, C. Since the patienthad no history of genital herpes,this outbreak most likely was a recurrenceof an earlier subclinical vaginalor rectal inoculation. As many as 80%of initial herpes simplex virus infectionsare subclinical; recurrences arenot uncommon. Initiate either topicalor systemic antiviral therapy early formaximum efficacy.

Herpes zoster mimics herpessimplex; determine the culprit organismvia culture to predict the clinicalcourse and offer appropriate treatment;higher dosages of antivirals areneeded for herpes zoster. Impetigofeatures more fragile blisters andmore crusting. The discrete eruptionseen here is not typical of a contactdermatitis.

Figure 1

Figure 2

Case 2: This patient had acute urticaria exacerbated by both the upper respiratorytract infection and the penicillin-based antibiotic. An erythromycin-basedantibiotic was substituted for the amoxicillin/clavulanate; a nonsedatingantihistamine also was initiated, A. The symptoms abated gradually over thenext few days. A systemic corticosteroid in a tapering dosage is appropriate indisease that is unresponsive to conventional antihistamines or when thepruritus is severe and intolerable.

Figure 1

Figure 2

Case 3:
For the past month, a 16-year-old boy has had pruritic lesionson his upper arms and thighs; he has no othercomplaints. The patient has been taking isotretinoin forcystic acne for 3 months. The boy is a member of thewrestling team; he denies playing with the family cats.

Which condition in the differential is the likely cause?

A. A dermatophyte infection transmitted by the cats.
B. A dermatophyte infection picked up from thewrestling mats.
C. Asteatosis caused by the isotretinoin.
D. Asteatosis caused by more frequent bathing sincewrestling began.
E. Herpes simplex virus infection from skin-to-skincontact during wrestling.

Which strategy do you employ?

F. Perform a potassium hydroxide evaluation.
G. Perform a viral culture.
H. Prescribe a topical antifungal agent.
I. Prescribe a systemic antifungal agent.
J. Prescribe a corticosteroid cream.

Case 4:

A 12-year-old boy presents with asymptomatic, erythematous, follicular papuleson his upper trunk. The parents suspect he has acne. Similar papules have appearedon the patient's upper outer arms for most of his life. During the last fewmonths, early facial hair has grown over his top lip.

The patient has a history of seasonal allergies and has taken a nonsedatingantihistamine for years. Because of his participation in many sports, the boybathes twice a day.

What are your thoughts about the cause of these lesions?




Staphylococcal folliculitis.


Pityrosporum folliculitis.


Keratosis pilaris.


Molluscum contagiosum.

Which treatment do you offer the patient?

F. Recommend a bathing and moisturizing regimen for dry skin.
G. Prescribe a topical erythromycin solution.
H. Prescribe ketoconazole shampoo as a body wash.
I. Prescribe an oral cephalosporin.
J. Prescribe a topical keratolytic agent for molluscum.

Figure 1

Figure 2

Case 3: This patient's nummulareczema, or asteatosis in a coin-shapedpattern, was caused primarily by theisotretinoin, C, and exacerbated bythe patient's bathing habits, D. Dryskin is a very common side effect ofisotretinoin and is particularly prevalentin the winter. Prescribe a corticosteroidcream, J; advise the patientto take fewer and shorter showersand to apply moisturizer frequently.

The sudden appearance of multiplelesions is unusual for a dermatophyteinfection; thus, antifungal therapyis not appropriate. If the diagnosisis uncertain, a potassium hydroxideevaluation can rule out a fungalcause. Herpes simplex is more vesicularthan this patient's eruption; aviral culture is not warranted.

Case 4: This boy with atopy had an exacerbation of keratosis pilaris,D, a conditionthat can mimic acne. Common environmental conditions, such as dry weatherand excessive bathing, can cause the lesions to flare.

Staphylococcal infections generallyare painful; Pityrosporum folliculitisusually is pruritic and confined to thetrunk. Molluscum can spread rapidlyin patients with atopy, but the lesionsare umbilicated-unlike those seenhere. Usually, acne is not confined tothe arms alone.

The patient followed the recommendedbathing and moisturizingregimen, F, consisting of fewer, coolerbaths or short showers with mildsoap and frequent applications ofmoisturizer. His condition improvedmarkedly.

Figure 1

Figure 2

Case 5:
Three days earlier, 3 groups of highly pruritic lesionserupted on 1 side of a 23-year-old woman's trunk. Shedenies any exposure to poisonous plants and has not usednew soaps, detergents, or lotions. The patient, a dogowner, is otherwise healthy; her only medication is an oralcontraceptive.

Which of the following do you suspect?

A. Impetigo.
B. Herpes simplex.
C. Herpes zoster.
D. Contact dermatitis.
E. Folliculitis.

Your treatment approach includes:

F. An oral cephalosporin.
G. An oral antiviral effective against herpes simplex.
H. An oral antiviral effective against herpes zoster.
I. A potent topical corticosteroid.
J. A topical antifungal agent.
K. Recommendation that a veterinarian examine the dog.

Case 6:For 2 months, a 15-year-old boy has had a slowly progressive, asymptomaticrash on his chest. He is otherwise healthy, plays many sports, and takes nomedications.

Do you recognize this condition?

A. Seborrhea.
B. Pityriasis rosea papillomatosis.
C. Contact dermatitis.
D. Tinea corporis.
E. Confluent and reticulated

Your initial approach includes which of the following?

F. Perform a potassium hydroxide evaluation.
G. Perform patch tests.
H. Prescribe a topical corticosteroid.
I. Prescribe an antifungal shampoo.
J. Prescribe an oral antibiotic.

Figure 1

Figure 2

Case 5: Grouped vesicles in dermatomal, unilateral distributionare typical of herpes zoster,C. In young adults, theselesions can be asymptomatic or may be pruritic and painful.The diagnosis can be confirmed by culture, Tzanck preparation,or biopsy.

Impetigo features very fragile vesicles that rarely remainintact and crusting. Contact dermatitis may resemblethis patient's rash, but it rarely erupts in 3 discrete locationsand without a history of exposure. Folliculitis does not appearas grouped vesicles. Herpes simplex resembles herpeszoster; however, concurrent viral inoculation at 3 primarysites in a dermatomal distribution is extremely unusualfor herpes simplex.

The disease responded quickly to antiviral therapyat dosages appropriate for herpes zoster, H; treatmentoptions include acyclovir, 800 mg 5 times per day; valacyclovir,1 g tid; and famciclovir, 500 mg tid.

Case 6: An inframammary, reticulated eruption that starts after pubertyis characteristic of confluent and reticulated papillomatosis,E. This is a poorlyunderstood condition; it may be related to an altered immune response toPityrosporum yeast, but this theory has not been confirmed. Some patientshave responded to systemic antifungal therapy; minocycline and erythromycinalso have been effective, J.1-3

A potassium hydroxide examination and patch tests are negative in this disorder.This eruption's distribution is not typical of seborrhea; the head and scalpwere not involved. Unlike this patient's rash, pityriasis rosea features oval-shaped,scaly, erythematous macules that can resemble ringworm.

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