Bilateral corneal geographic ulcers in a patient with eczema herpeticum

Dear Editor,

1.

Herpes simplex virus (HSV) keratitis is typically unilateral. The reported incidence of bilateral involvement is rare, ranges from 1% to 10%, particularly in patients with atopy, graft‐vs‐host disease (GVHD), measles, and immunodeficiency.1, 2, 3 In immunocompromised patients, they may develop eczema herpeticum, also known as Kaposi's varicelliform eruption (KVE), which is characterized by extensive vesicular eruptions over entire body surface and can cause multisystem failure.4 Here we report a rare case of eczema herpeticum with bilateral geographic corneal ulcers.

A 26‐year‐old man with atopic dermatitis since childhood who did not have regular follow‐up visits at dermatology clinic, presented to our ophthalmology one with severe photophobia and foreign body sensation in both eyes for 1 week. The patient also had had a common cold 10 days ago, and a flare of atopic dermatitis. He was started on steroid ointment and eye drops for the diagnosis of blepharoconjunctivitis for 6 days prior to this consultation. On examination, there were multiple excoriated papules, plaques on the face, trunk and limbs along with periorbital ulcerated plaques (Figure 1A). Fluorescein staining revealed bilateral corneal ulcers in a geographic pattern with few terminal bulbs (Figure 1B,C). Such lesions are typically caused by active replication of the HSV on the corneal surface. In addition to oral acyclovir tablet, acyclovir 3% ophthalmic ointment five times per day was prescribed for 14 days. The lesion resolved entirely on the follow‐up examination.

Figure 1.

(A) Multiple excoriated papules and periorbital ulcerated plaques on the face. (B,C) Slit lamp photographs of corneal ulcers with geographic pattern and few terminal bulbs in both eyes

Eczema herpeticum is a distinct cutaneous eruption arising from a preexisting dermatosis, and is mostly caused by HSV.4 Higaki et al proposed that the dysfunction of cell‐mediated immunity and immunosuppressive treatment in atopic dermatitis patients may increase the likelihood of acquiring such infection.5 Not recognized and treated properly, eczema herpeticum can become a possible life‐threatening condition. The mortality rate in an immunocompromised subject is estimated to be about 6% to 10% and even up to 50%.4 The mainstay of treatment for eczema herpeticum is acyclovir. For patients with severe disease or compromised immunity, systemic antiviral drugs and hospitalization are recommended.

To the best of our knowledge, bilateral geographic ulcers in patients with eczema herpeticum have not yet been reported. Such manifestation is unique because previous reports mainly demonstrated dendritic form of bilateral herpetic keratitis.1, 2, 5 Similar to the mechanism of corneal dendritic ulcer, the geographic ulcer was also caused by replicating virus, though with a much larger epithelial defect. This kind of presentation usually occurs in persons with compromised immunity, especially in those taking topical corticosteroids like ours.3 As in our case, the patient had a long history of atopic dermatitis, which made him more susceptible to viral infection. The use of topical steroid ointment and eye drops might intensify such risk and possibly develop bilateral geographic corneal ulcer from dendritic ulcer.

In conclusion, we presented a rare case of simultaneous onset of bilateral herpetic geographic keratitis. The viral susceptibility in atopic dermatitis patient with topical steroid use may exacerbate the corneal lesions. Early treatment with topical or systemic acyclovir is mandatory to prevent potentially sight‐ and life‐threatening condition.

CONFLICT OF INTEREST

All authors declare no conflict of interest.