Herpesvirus Infections

Ten days before presenting for evaluation, a 69-year-old man began to experience neuralgic pain and noticed the eruption of painful erythematous macules and papules on the right side of his chest. Within 24 to 72 hours, vesicles and pustules arose at the site. One week after onset, several of the lesions dried and crusted (Figure A).

Six months before the rash erupted, oat cell carcinoma of the middle lobe of the right lung had been diagnosed. The patient was treated with radiation therapy, and the tumor regressed.

These lesions are characteristic of herpes zoster. The patient had chickenpox as a child; reactivation of the varicella-zoster virus in the dorsal root ganglion caused the disease. The rash is usually unilateral and limited to one or two dermatomes. The thoracic region is often affected, accounting for more than half of reported cases. Herpes zoster rarely occurs below the elbows or knees. This patient was treated with intravenous acyclovir. The lesions subsided in 14 days.

Herpes zoster commonly afflicts immunocompromised patients like this one. The immunodeficiency may be secondary to HIV infection, malignancy, radiation therapy, or chemotherapy. Another manifestation of herpes zoster in an immunocompromised person appears in a 55-year-old woman pictured in Figure B. This patient was undergoing chemotherapy for metastatic breast carcinoma. Herpes zoster was heralded by itching, pain, and tenderness in the perianal region.

Groups of vesicles on an erythematous base were evident on examination. The vesicles erupted along the distribution of the nerves, causing pain.

A clinical diagnosis of herpes zoster was made, and the patient was treated successfully with topical acyclovir cream. Oral acyclovir and analgesics also can be used; rest and application of heat may be helpful. Consider systemic corticosteroids for older patients who have severe pain.

Figure C shows multiple areas of postinflammatory hyperpigmentation over the sacral region of a 40-year-old woman that had previously been incorrectly diagnosed as herpes zoster and a staphylococcal infection. A culture of material from the clustered vesicles confirmed the diagnosis of herpes simplex. The hyperpigmented lesions represent old sites of recurrent extragenital herpes simplex virus infection. With each reactivation of the latent virus, the patient experienced prodromal symptoms of burning and itching.

Valacyclovir therapy, 500 mg/d, has successfully suppressed subsequent outbreaks in this patient.

Figures D and E show another case of herpes simplex. A 44-year-old man experienced recurrent episodes of a burning, itchy, swollen rash on the right side of his face. He believed it to be “skin irritation from the sun.” Each episode lasted for 7 to 10 days and resolved without scarring. Lesions were always localized to the same region.

The patient was not taking any medications and denied having allergies. His physical examination was unremarkable, except for the slightly edematous, pink, crusted patch overlying the zygoma and inferior orbital ridge (E).

The patient recalled that the original lesion occurred soon after a rugby match 10 years earlier. His position in the game required that his head be pressed together with the heads of two other players.

No vesicles were available from which to obtain a specimen for a viral culture, but the history, recurrent nature of the lesions, association with sun exposure, and appearance supported a clinical diagnosis of herpes simplex virus infection.

The patient was treated with acyclovir without further incident. He was told that herpes is contagious and was cautioned to avoid close-contact sports while the lesion was present. The need for sun protection was emphasized, since UV light is a well-known trigger for herpes simplex outbreaks.

Herpes simplex can be transmitted by skin-to-skin contact in any sport. Herpes gladiatorum, or traumatic herpes, is seen in wrestlers who acquire the infection via body contact. Because of the potential for ocular involvement, reinforce the need to avoid close contact until the crusted lesions have disappeared.