Atypical Locations of HSV Infection

Painful eczematous lesions at the angle of her mouth and the base of her nostrils had been bothering a 52-year-old woman for 3 days. Some of the vesicles had ulcerated and left a crust over the region. The patient said she had had similar attacks in the past. The diagnosis of recurrent herpes simplex virus 1 (HSV 1) infection was made. The patient was treated with acyclovir for 1 week, and all the lesions disappeared.

The painful vesicles of HSV 1 infection appear most commonly on the lip and rarely on other regions of the face, as in this patient. It is frequently difficult to distinguish primary HSV infection from a recurrent attack, because the presentation can be similar. Unless the history suggests otherwise, write Drs Sonia Arunabh and Naveen Verma of Mineola, NY, assume that an HSV infection is primary and treat the patient accordingly.

In a second atypical case, numerous small pustules with surrounding erythema were seen on the thumb of a 5-year-old girl, a thumb-sucker. She also had recurrent tiny ulcerations on one side of her tongue. The thumb lesions developed 2 days ago as clear vesicles and became pustular overnight. She now had a low-grade fever and decreased appetite.

Robert P. Blereau, MD of Morgan City, La, deroofed one lesion with a fine scalpel and cultured the fluid, which grew HSV 1. After treatment with mupirocin ointment, three times daily, the thumb lesions resolved rapidly.