Case 1: A two-year-old boy with fever and widespread vesicular lesions

A previously healthy two-year-old boy presented to the emergency department at the authors' hospital following a two-day history of fever, oral sores and widespread vesicular lesions with increased irritability, decreased oral intake and persistent fever over the course of the day. His medical history was significant for eczema. Otherwise, he was a healthy child delivered at term after an unremarkable pregnancy. He had no recent travel and no exposure to visitors from foreign countries. Growth parameters and developmental milestones were normal, and his immunizations were up to date. On examination, he appeared mildly distressed, but systemically well. White, well-demarcated lesions were observed on the anterior two-thirds of the lingual and buccal mucosa. Perioral blistering with several monomorphic lesions were noted superior to the vermillion border. Similar vesicles were present bilaterally on the hands, forearms (Figure 1), inguinal regions, distal-medial aspects of the lower limbs and buttocks. Minimal clear-yellow fluid weeped from several lesions and crusting was evident. The remainder of the physical examination was unremarkable. Vesicular exanthem in a two-year-old patient distributed along the upper extremity The patient was given a working diagnosis of eczema herpeticum and swabs were sent for bacterial and viral culture, and viral polymerase chain reaction (PCR) testing of deroofed lesions. He was admitted to hospital for rehydration and intravenous acyclovir. Swab results were returned on day 2 of admission. Tests for herpes simplex virus 1 and 2 were negative. PCR testing determined the infection to be enterovirus positive. A subpopulation of children with eczema may develop a super-infection with herpes simplex virus, resulting in a vesicular rash referred to as eczema herpeticum. In most cases, eczema herpeticum starts with small, monomorphic, dome-shaped vesicles that may, in severe cases, extend from the face to the entire body (1). Eczema coxsackium was first described in 1968 in a case report by Nahmias et al (2) involving a one-year-old boy with a history of eczema who presented with a generalized, nonpruritic exanthem characterized by vesicular lesions on his trunk, back and extensive involvement on the arms, legs, palms and soles. The vesicles appeared to be superficial and measured 3 mm to 8 mm, with no apparent surrounding inflammatory reaction. There were no pustular lesions noted. Vesicular and ulcerative lesions were observed on the palate and tongue (2). A recent study by Mathes et al (3) investigating atypical presentations of coxsackievirus infections highlighted the eczema herpeticum-like presentation of eczema coxsackium as a variant of hand, foot and mouth disease caused by coxsackievirus A6. Mathes et al (3) characterized four presentations describing the severe end of the spectrum of disease associated with this atypical exanthem, distinguishing it from classic hand, foot and mouth disease: An eczema herpeticum-like eruption (eczema coxsackium) Widespread vesiculobulbous and erosive lesions extending beyond the palms and soles An eruption similar to that observed in Gianotti-Crosti syndrome A petechial or purpuric eruption. The present case reflects this variety in presentation; we initially suspected that our patient had a cutaneous herpesvirus infection and treated him accordingly. The PCR result was surprising and prompted us to search the literature for similarly described exanthems. Eczema coxsackium is an uncommon cutaneous manifestation of coxsackievirus infection that can easily be mistaken for eczema herpeticum. While rare, eczema coxsackium and other atypical cutaneous manifestations of coxsackievirus infection should be included in the differential diagnosis for the child with a vesicular rash. Swabs from an unroofed lesion should be sent for viral PCR testing while treatment for suspected herpesvirus infection is initiated pending viral investigations in the hospitalized patient.

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