Clinical Image: Eczema herpeticum in a patient with rheumatoid arthritis and dry eye syndrome

A 32‐year‐old female patient with a history of rheumatoid arthritis and dry eye syndrome presented to the clinic reporting a rash to her left eye with pain and blurred vision, which quickly migrated to the right eye. The patient also reported a significant amount of stress and increased sun exposure. The patient was previously evaluated in the emergency room for her symptoms and given allergy and antibiotic eye drops without relief in her symptoms. Laboratory results revealed that she was positive for herpes simplex virus (HSV)‐1 by DNA measurement, a C‐reactive protein (CRP) of 31.8, and negative Sjogren's antibodies. Physical examination exhibited monomorphic papules on bilateral eyelids.

On the same day, she was seen by dermatology and was diagnosed with eczema herpeticum on bilateral eyelids. She was seen by ophthalmology the day after, who believed the patient had shingles in an immunosuppressant state in both eyes. The patient was treated with Valacyclovir, 1 g three times per day, Keflex 1,000 mg, and steroid eye drops for one week. The one‐week follow‐up with the ophthalmologist revealed improvement in the stinging sensations in both eyelids. Thus, she was taken off brimonidine eye drops. However, the patient continued to experience blurred vision and eye strain that often led to headaches. These symptoms improved 10 days after. Triggers for the patient's HSV‐1 outbreak could have been her high stress levels due to a housing situation, increased sun exposure, and impaired skin barrier as well as autoimmune.

Prior to her developing symptoms, her rheumatoid arthritis was well controlled with adalimumab 40 mg every two weeks, but this was held due to rash. Her current medication list includes tizanidine, birth control pills, diclofenac 750 mg twice a day, and albuterol. The nature of the patient's clinical presentation indicates immunosuppression, suggesting that her history of rheumatoid arthritis and dry eye syndrome could be a strong contributing factor to her outbreak.

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