Simplex Virus Polymerase Chain Reaction Research Articles

Facial rash with exuberant crusting in pregnancy

Case Summary A woman in her 20s with a history of systemic lupus erythematosus controlled with azathioprine and low-dose prednisone presented at ten weeks of pregnancy after developing pruritic, painful facial lesions over three weeks. She had no history of rosacea, topical corticosteroid use, or recent fevers, but was wearing masks frequently. On examination, she appeared non-toxic and had numerous coalescing erythematous papules and pustules with yellow-gray crusting around her nose, mouth, and glabella (Fig. 1). The vermilion border was spared. No comedones were present. Herpes simplex virus polymerase chain reaction (PCR), varicella zoster virus PCR, bacterial cultures, and fungal cultures were negative. Punch biopsy of a pustule showed intraepidermal neutrophilic spongiosis with subcorneal pustules, diffuse dermal neutrophilic inflammation, and dermal edema.Fig. 1.: Clinical presentation of the (A) frontal and (B) right face showing erythematous papules and pustules coalescing into plaques with thick, yellow-gray crust around the nose and mouth with sparing of the vermilion border and extension onto the glabella.Question 1 Which of the following is the most likely diagnosis? A. Pyoderma faciale B. Impetigo C. Acute lupus flare D. Pyostomatitis vegetans E. Amicrobial pustulosis associated with autoimmune disease (APAD) Correct answer: A. Pyoderma faciale. Disease is characterized by numerous erythematous nodules, papules, and pustules erupting on the central face. She was diagnosed with periorificial pyoderma faciale. With her obstetrician’s approval, we initiated a three-month course of cephalexin, in line with standard treatment durations for rosacea. At two months follow-up, there was near-resolution. Discussion Pyoderma faciale, also known as rosacea fulminans, is a rare inflammatory facial dermatosis most commonly affecting women between 20 and 40 years old with a history of flushing or rosacea.1 Approximately 10% of cases occur during pregnancy, and around 40% can be triggered by menopause, medication changes, or emotional stressors.1 Patients present suddenly with tender coalescing inflamed pustules, nodules, draining sinuses, and cysts/abscesses on the central face.2 Our patient presented with numerous pustules, with the additional and unique feature of thick, confluent, yellow-gray crusting. To our knowledge, prior reports of patients with crusted papulopustules have not shown such exuberant facial crusting.3 The reasons for our patient’s dramatic presentation are unclear. Possibly, her underlying systemic lupus erythematosus (SLE), stress and altered immunity during pregnancy, and mask wearing promoted vascular hyperreactivity and inflammation predisposing to development of pyoderma faciale.2 Pyoderma faciale can mimic infectious and inflammatory processes. In our patient with SLE on immunosuppression, the differential diagnosis included infections such as impetigo, an acute lupus flare, pyostomatitis vegetans, or an atypical facial presentation of amicrobial pustulosis associated with autoimmune disease (APAD). Given the patient’s pregnancy status, morphology of lesions with centrofacial distribution and sparing of the vermilion border, non-toxic appearance, stable SLE and negative infectious work-up, pyoderma faciale was felt to be the best diagnosis. Notably, the perioral and perinasal distribution of the rash resembled periorificial dermatitis, which is on the rosacea spectrum, much like pyoderma faciale. Typically, pyoderma faciale is treated initially with systemic corticosteroids to rapidly reduce inflammation, followed by longer courses of isotretinoin or tetracyclines to maintain improvement. In our patient, the latter 2 treatment options were contraindicated due to pregnancy. Beta-lactam antibiotics can improve pyoderma faciale, although they often fail to achieve resolution as monotherapy and are typically given in conjunction with corticosteroids or isotretinoin.1 Recently, erythromycin monotherapy has shown promising results in pregnant individuals.1 Our case provides evidence that a robust presentation of pyoderma faciale with a periorificial distribution can be treated safely and successfully with cephalexin monotherapy during pregnancy. Question 2 What dermatologic disorder is most associated with pyoderma faciale? A. Atopic dermatitis B. Acne C. Rosacea/flushing D. Impetigo E. Folliculitis Correct answer: C. Rosacea/flushing. Walsh et al.1 demonstrated that history of rosacea/flushing is present in 80% of cases of pyoderma faciale. Conflicts of interest None. Funding None. Author contributions Raymond Zhao contributed to the drafting of the manuscript, figure design, and background research. Severine Cao and Frank Wang contributed to the conception and overall planning of the project, supervision of the project, and critical revision of the manuscript. Study approval N/A.

Bullous Tinea Pedis

A woman in her 70s presented with a skin eruption on the left dorsal foot that had developed spontaneously 2 weeks before. The rash initially appeared with pruritic papules that evolved to fluid-filled blisters and persisted despite self-treatment with topical hydrocortisone 1% cream and antibiotic ointment. Examination revealed an erythematous plaque with tense and denuded bullae (Figure 1). She received oral cephalexin for presumed bullous impetigo. Bacterial culture and herpes simplex virus and varicella zoster virus polymerase chain reaction (PCR) swab results were negative.

Case 302: Supratentorial Lymphocytic Inflammation with Parenchymal Perivascular Enhancement Responsive to Steroids.

Part one of this case appeared 4 months previously and may contain larger images. A 21-year-old immunocompetent man who was a long-term resident of Qatar presented to the emergency department with recurrent episodes of unprovoked generalized tonic-clonic seizures lasting 2-3 minutes that spontaneously resolved and were associated with postictal confusion. The patient also had progressive mild diplopia, intermittent dizziness, and numbness in the left arm over the course of 3 months. The patient did not have any other systemic symptoms or chronic medical diseases. He did not have any history of intake of illicit drugs, supplements, or regular medications; he had not received any recent vaccinations; and he had not undergone any surgical procedures. He had no history of travel. At presentation, vital signs were normal. Neurologic examination showed mild left homonymous hemianopia, normal gait with no cerebellar signs, and preserved sensations, power, tone, and reflexes in all four limbs. An electroencephalogram showed no epileptiform discharges. Chest CT and extensive laboratory work-up, including viral, fungal, bacterial, and parasite work-up, thyroid function tests, and immunologic blood tests yielded normal results. Those included normal complete and differential blood counts and normal serum chemistry. Serum analysis was negative for antinuclear antibody, Sjögren syndrome antigens A and B, cytoplasmic antineutrophil cvtoplasmic antibody, and paraneoplastic profile. Serum evaluation was also negative for human immunodeficiency virus type 1 and type 2 RNA, and Brucella, Schistosoma, and toxoplasma antibodies. Venereal Disease Research Laboratory (VDRL) and rapid plasma regain (RPR) test results were negative. Cerebrospinal fluid (CSF) analysis revealed clear fluid and normal pressure and biochemistry, except for elevated protein concentration (0.48 g/L) (normal range, 0.15-0.45 g/L). There were 43 leukocytes/µL (99% lymphocytes) (normal range, 0-5 leukocytes/µL; lymphocytes range, 40%-80%), with no atypical or malignant cells. CSF Gram staining, acid-fast staining, cryptococcal antigen, varicella-zoster virus polymerase chain reaction (PCR), herpes simplex virus PCR, VDRL, and RPR test results were negative. CSF cultures did not show any evidence of growth of bacteria, fungi, or acid-fast bacillus. CSF flow cytometry did not show a monoclonal lymphoid population. No CSF oligoclonal bands were detected. Conventional brain MRI with intravenous administration of contrast material and perfusion study were performed and included different sequences (Figs 1-3).

Herpes Simplex Virus Encephalitis With Initial Negative Polymerase Chain Reaction in the Cerebrospinal Fluid: Prevalence, Associated Factors, and Clinical Impact.

To describe the prevalence, associated factors, and clinical impact of an initial negative herpes simplex virus (HSV) polymerase chain reaction (PCR) in critically ill patients with PCR-proven HSV encephalitis. Retrospective multicenter study from 2007 to 2017. Forty-seven French ICUs. Critically ill patients admitted to the ICU with possible/probable acute encephalitis and a positive cerebrospinal fluid (CSF) PCR for HSV. None. We included 273 patients with a median Glasgow Coma Scale score of 9 (6-12) at ICU admission. CSF HSV PCR was negative in 11 cases (4%), exclusively in lumbar punctures (LPs) performed less than 4 days after symptoms onset. Patients with an initial negative PCR presented with more frequent focal neurologic signs (4/11 [36.4%] vs 35/256 [13.7%]; p = 0.04) and lower CSF leukocytosis (4 cells/mm3 [3-25 cells/mm3] vs 52 cells/mm3 [12-160 cells/mm3]; p < 0.01). An initial negative PCR was associated with an increased delay between LP and acyclovir treatment (3 d [2-7 ] vs 0 d [0-0 d]; p < 0.01) and was independently associated with a poor neurologic outcome at hospital discharge (modified Rankin Scale score ≥ 4) (adjusted odds ratio, 9.89; 95% CI, 1.18-82.78). In severe herpes simplex encephalitis, initial negative CSF HSV PCR occurred in 4% of cases and was independently associated with worse neurologic outcome at hospital discharge. In these patients, a systematic multimodal diagnostic approach including early brain MRI and EEG will help clinicians avoid delayed acyclovir initiation or early inappropriate discontinuation.

Seizures in a Term Newborn.

Seizures in a Term Newborn.

Case 302.

History A 21-year-old immunocompetent man who was a long-term resident of Qatar presented to the emergency department with recurrent episodes of unprovoked generalized tonic-clonic seizures lasting 2-3 minutes that spontaneously resolved and were associated with postictal confusion. The patient also had progressive mild diplopia, intermittent dizziness, and numbness in the left arm over the course of 3 months. The patient did not have any other systemic symptoms or chronic medical diseases. He did not have any history of intake of illicit drugs, supplements, or regular medications; he had not received any recent vaccinations; and he had not undergone any surgical procedures. He had no history of travel. At presentation, vital signs were normal. Neurologic examination showed mild left homonymous hemianopia, normal gait with no cerebellar signs, and preserved sensations, power, tone, and reflexes in all four limbs. An electroencephalogram showed no epileptiform discharges. Chest CT and extensive laboratory work-up, including viral, fungal, bacterial, and parasite work-up, thyroid function tests, and immunologic blood tests yielded normal results. Those included normal complete and differential blood counts and normal serum chemistry. Serum analysis was negative for antinuclear antibody, Sjögren syndrome antigens A and B, cytoplasmic antineutrophil cvtoplasmic antibody, and paraneoplastic profile. Serum evaluation was also negative for human immunodeficiency virus type 1 and type 2 RNA, and Brucella, Schistosoma, and toxoplasma antibodies. Venereal Disease Research Laboratory (VDRL) and rapid plasma regain (RPR) test results were negative. Cerebrospinal fluid (CSF) analysis revealed clear fluid and normal pressure and biochemistry, except for elevated protein concentration (0.48 g/L) (normal range, 0.15-0.45 g/L). There were 43 leukocytes/µL (99% lymphocytes) (normal range, 0-5 leukocytes/µL; lymphocytes range, 40%-80%), with no atypical or malignant cells. CSF Gram staining, acid-fast staining, cryptococcal antigen, varicella-zoster virus polymerase chain reaction (PCR), herpes simplex virus PCR, VDRL, and RPR test results were negative. CSF cultures did not show any evidence of growth of bacteria, fungi, or acid-fast bacillus. CSF flow cytometry did not show a monoclonal lymphoid population. No CSF oligoclonal bands were detected. Conventional brain MRI with intravenous administration of contrast material and a perfusion study were performed and included different sequences (Figs 1-3).

A Rare Skin Disorder with Bacteremia in a Neonate.

A Rare Skin Disorder with Bacteremia in a Neonate.

Abnormal Lower Extremity Movements in a Term Infant.

Abnormal Lower Extremity Movements in a Term Infant.

Determining Normative Values for Cerebrospinal Fluid Profiles in Infants.

Previous studies of reference values for cerebrospinal fluid (CSF) profiles have been limited by small sample size and few exclusion criteria. To determine age-specific normative CSF white blood cell count (WBC), glucose, and protein values in infants ≤90 days old. Performed a retrospective cross-sectional study of infants ≤90 days old who had a diagnostic lumbar puncture between 2008 and 2016. Infants with bacterial meningitis, bacteremia, UTI, positive CSF herpes simplex virus polymerase chain reaction (PCR) result, traumatic lumbar puncture, ventriculoperitoneal shunt, prematurity, recent seizure, previous antibiotic use, and history of a complex chronic condition were excluded for calculations to determine normative values. Data on demographics and CSF values (WBC with differential, protein, glucose, enterovirus PCR) were collected. CSF values were compared by age and by enterovirus PCR results using Kruskal-Wallis and Wilcoxon rank tests. A total of 1029 out of 2000 patients were included and divided into 3 age groups: 0 to 28 days, 29 to 60 days, 61 to 90 days. CSF WBC values were significantly greater for 0- to 28-day old infants (median: 3, 95th percentile: 14) than for 29- to 60-day and 61- to 90-day old infants (median: 2 and 2; 95th percentile: 7 and 11, respectively) (P < .001). With each month of life, the median CSF protein significantly decreased and glucose significantly increased. In the CSF WBC differential, monocytes were found to be prevalent. We determined age-specific normative components for CSF profile values for infants 0 to 90 days.

Evolving Scalp Lesions in an 8-day-old Infant

Evolving Scalp Lesions in an 8-day-old Infant

Outcomes of Patients with Herpes Simplex Keratitis Before and After the Implementation of a New Treatment Guideline in Sydney, Australia.

Outcomes of Patients with Herpes Simplex Keratitis Before and After the Implementation of a New Treatment Guideline in Sydney, Australia.

Unexplained oral and extremity ulcerations in an infant

A 5-month-old healthy, developmentally appropriate male presented to the emergency department with a 2-month history of bleeding ulcerations of the lower lip and floor of the mouth, (Fig 1) and several healing ulcerations on the fingers and toes. The child appeared well and was in no distress on examination. Vital signs were normal. Bacterial, fungal, and enterovirus cultures from the mouth, as well as herpes simplex virus polymerase chain reaction and HIV and syphilis testing were negative. Complete blood count and comprehensive metabolic panel were unremarkable.

Ulcerated Arm Lesion in a 10-day-old Girl

1. Brittany Lehrer, MD* 2. Kyle Pronko, MD*,† 3. Alina G. Burek, MD*,† 1. *Medical College of Wisconsin, Milwaukee, WI 2. †Children’s Wisconsin, Milwaukee, WI 1. Address correspondence to Brittany Lehrer, MD, Children’s Corporate Center, Suite 730, 999 N 92nd St, Milwaukee, WI 53226. E-mail: blehrer{at}mcw.edu A 10-day-old girl presents with a progressive right upper extremity skin lesion. She was born large for gestational age at term via cesarean delivery for fetal distress. Pregnancy was complicated by diet-controlled gestational diabetes and a maternal history of genital herpes. The mother received prophylactic valacyclovir and no active herpes lesions developed during pregnancy. Immediately after birth, the infant was noted to have a 2-cm, tender, well-circumscribed area of erythema and induration over the right antecubital fossa. The extremity also had decreased movement, diminished radial pulse, and weak grasp reflex. Otherwise, she was well-appearing and her examination was normal. Radiographs of the forearm and clavicle were negative for fracture. She was diagnosed with hematoma and possible brachial plexus injury and discharged from the nursery on postnatal day 3 with the arm immobilized in a sling and acetaminophen as needed for pain. Since discharge from the nursery, the lesion has spread, ulcerated, and started draining malodorous white discharge, so the patient returns for evaluation on postnatal day 10. On physical examination, she has a poorly demarcated, erythematous, tender, indurated, circumferential plaque that extends from the mid-upper arm through the antecubital fossa to the mid-forearm. The center of the lesion is violaceous and ulcerated with white discharge (Fig 1). The affected extremity has decreased spontaneous movement, weak radial pulse, nearly absent grasp reflex, and she has pain with passive manipulation of the affected elbow. Her vital signs and the remainder of her physical examination are normal. Complete blood cell count with differential, procalcitonin, and c-reactive protein are within normal limits for age. Blood culture and herpes simplex virus polymerase chain reaction …

What is the True Etiology of “Recurrent Shingles”?

Purpose: To determine the true etiology of cases of putative recurrent shingles referred to a dermatology clinic. Methods: A prospective cohort study of patients aged 15-87 years with reported recurrent herpes zoster was conducted. Vesicular fluid and serology for herpes simplex 1, 2, and varicella zoster virus immunoglobulins were obtained from patients presenting with vesicles. Biopsies were obtained from patients with ambiguous presentations. Results: 44 patients (56%) had evidence of herpes simplex virus infection. 32% of patients had positive herpes simplex virus cultures or polymerase chain reaction sequencing, and 24% additional patients were diagnosed with presumptive simplex infection based on elevated antibody titers. 44% of patients had a diagnosis other than zoster or simplex. One individual had a positive viral culture for varicella zoster virus. 99% of patients who presented with suspected recurrent herpes zoster had no definitive evidence of varicella zoster virus reactivation. Conclusions: The most common diagnosis was herpes simplex infection. Our results suggest that true recurrent shingles in immunocompetent patients is rare.

P550 DIFFERENCES IN ADMISSION COMPLETE BLOOD COUNT PARAMETERS IN ECZEMA HERPETICUM IN CHILDREN

Eczema herpeticum (EH) is a significant infectious complication of atopic dermatitis (AD). However, the clinical diagnosis of EH can be challenging as AD exacerbation and bacterial infection may be mistaken for EH. This may impact treatment decision pending herpes simplex virus polymerase chain reaction (PCR) results. In this study, we investigated whether complete blood count (CBC) can distinguish EH from AD patients with bacterial infections or exacerbation.

Lues Maligna in an Immune-Reconstituted Patient with Retroviral Infection: A Case Report

Lues Maligna in an Immune-Reconstituted Patient with Retroviral Infection: A Case Report

Impact of a Multiplex Polymerase Chain Reaction Assay on the Clinical Management of Adults Undergoing a Lumbar Puncture for Suspected Community-Onset Central Nervous System Infections.

Patients admitted from the community with a suspected central nervous system (CNS) infection require prompt diagnostic evaluation and correct antimicrobial treatment. A retrospective, multicenter, pre/post intervention study was performed to evaluate the impact that the BioFire® FilmArray® meningitis/encephalitis (ME) panel run in-house had on the clinical management of adult patients admitted from the community with a lumbar puncture (LP) performed for a suspected CNS infection. The primary outcome was the effect that this intervention had on herpes simplex virus (HSV) polymerase chain reaction (PCR) turnaround time (TAT). Secondary outcomes included the effect that this intervention had on antiviral days of therapy (DOT), total antimicrobial DOT, and hospital length of stay (LOS). A total of 81 and 79 patients were included in the pre-intervention and post-intervention cohorts, respectively. The median HSV PCR TAT was significantly longer in the pre-intervention group (85 vs. 4.1 h, p < 0.001). Total antiviral DOT was significantly greater in the pre-intervention group (3 vs. 1, p < 0.001), as was total antimicrobial DOT (7 vs. 5, p < 0.001). Pre-intervention hospital LOS was also significantly longer (6.6 vs. 4.4 days, p = 0.02). Implementing the ME panel in-house for adults undergoing an LP for a suspected community-onset CNS infection significantly reduced the HSV PCR TAT, antiviral DOT, total antimicrobial DOT, and hospital LOS.

Utility of Surface and Blood Polymerase Chain Reaction Assays in Identifying Infants With Neonatal Herpes Simplex Virus Infection.

Of 27 neonates with herpes simplex virus, DNAemia was observed in 100% with disseminated disease, 57% with central nervous system disease and 28% with skin, eye, mouth disease, suggesting DNAemia occurs frequently in these infants. Herpes simplex virus culture and polymerase chain reaction were performed on surface specimens from 13/27 infants, and ~50% tested positive only by polymerase chain reaction, suggesting the superiority of this technique.

Utility of Lumbar Puncture in Children Presenting With Status Epilepticus.

Because meningitis may trigger seizures, we sought to determine its frequency in children with first-time status epilepticus (SE). We performed a retrospective cross-sectional study of children aged 1 month to 21 years who presented to a single pediatric emergency department between 1995 and 2012 with SE and who had a lumbar puncture (LP) performed as part of the diagnostic evaluation. We defined bacterial meningitis as a cerebrospinal fluid (CSF) culture positive for a bacterial pathogen or CSF pleocytosis (CSF white blood cells ≥10 cells/mm) with a blood culture positive for a bacterial pathogen. We defined viral meningitis or encephalitis using a positive enterovirus or herpes simplex virus polymerase chain reaction test. Among 126 children with SE who had an LP performed, 8 (6%) had CSF pleocytosis. Of these, 5 had received antibiotics before performance of a diagnostic LP. One child in the cohort was proven to have bacterial meningitis (0.8%; 95% confidence interval [CI], 0%-6%). Two other children had enteroviral meningitis (2/13 tested, 15%; 95% CI, 3%-51%), and 1 had a herpes simplex virus infection (1/47, 2%; 95% CI, 0%-15%). Bacterial meningitis is an uncommon cause of SE.

Kaposi varicelliform eruption in patients with autoimmune bullous dermatoses.

Viral superinfection of skin affected by preceding dermatosis has been studied extensively in eczema and reported anecdotally in pemphigus. Little is known about its involvement and complications in patients with other immunobullous diseases. To investigate clinical features and complications of viral superinfection in patients with immunobullous diseases, we performed a retrospective chart review. We identified 12 patients with immunobullous diseases (linear immunoglobulin A bullous dermatosis, n = 2; pemphigoid, n = 3; pemphigus, n = 7) and superinfection by herpes simplex virus 1 (n = 9) or 2 (n = 3). Complications included inpatient hospitalization for intensive management of skin lesions during viral flare (n = 6), herpes keratitis (n = 1), and death due to sepsis (n = 1). Five patients previously had a skin swab negative for herpes simplex virus polymerase chain reaction before a positive test. Nine patients were taking systemic corticosteroids or corticosteroid-sparing agents at herpetic infection; two with linear immunoglobulin A bullous dermatosis and one with a new diagnosis of pemphigus vulgaris had not. Viral superinfection is a potentially serious complication in patients with immunobullous diseases. Clinicians should have a high index of suspicion for this phenomenon, even when patients are not otherwise immunosuppressed or when previous viral skin assays have been negative.