Herpes-Associated Erythema Multiforme

Oral erythema multiforme attributed to herpes simplex virus: A less recognized variant

Key Clinical Message

Oral Erythema Multiforme (EM) is considered rare and less described variant in the world of EM. Examination of oral cavity lesions poses various diagnostic challenges and thus a thorough examination with history can help to reach a diagnosis. Due to possibility of subsequent severe attacks of EM, it has to be identified early in the course for better outcome of the patient.

Abstract

Erythema multiforme is an intriguing clinical entity characterized by acute, self-limiting mucocutaneous hypersensitivity reactions. It can occur due to various etiological factors including infections, medications, autoimmune diseases, and malignancies; herpes simplex being the most common infection accounting for almost 90 percent of the overall cases. Here, we report a case of EM in an 8-year-old female child. The patient presented with an acute onset of crusting ulcers in the lips and oral cavity along with sparse cutaneous lesions around the lips. Based upon the patient's detailed history of prodromal symptoms, disease course and progression, careful clinical examination of wound and serology test, herpes simplex virus-associated erythema multiforme (HAEM) was diagnosed ruling out other mucocutaneous diseases, such as pemphigus, paraneoplastic pemphigus, mucous membrane pemphigoid, and lichen planus. The patient was admitted and treated for HAEM. To conclude, a detail clinical history and thorough clinical examination suggested the diagnosis of EM followed by serology tests to confirm the HSV1 association where proper medicament with supportive care led to an uneventful management.

Oral Manifestation of Viral-Induced Erythema Multiforme Major: A Rare Presentation

Erythema multiforme is an acute inflammatory mucocutaneous disease manifested as macules, vesicles, bullae, erosion, and papular lesions. In the present case, a 55-year-old female patient reported painful growth in the oral cavity and difficulty in mastication. The patient gave a history of prodromal symptoms before the onset of lesions On intra-oral examination, elevated plaque-like lesions were present bilaterally on lateral borders of the tongue and buccal mucosa near the retromolar region. Extraoral examination revealed concentric erythematous target (or) bull's eye lesions in palms, forearm, and foot. Based on history, clinical examination, and laboratory investigations, recurrent herpes-associated erythema multiforme was diagnosed. We report a rare clinical presentation of recurrent herpes-associated erythema multiforme manifesting as an extensive plaque-like lesion intra-orally.

Erythema multiforme-like lip presentation in pemphigus vulgaris patients: a multicenter case series

Pemphigus vulgaris (PV) is a chronic autoimmune mucocutaneous blistering disease. Autoantibodies are directed against desmogleins, leading to the formation of intraepithelial bullae. PV, as with other autoimmune mucocutaneous disorders of the oral cavity, presents diagnostic and therapeutic challenges. Approximately 50-70% of cases present first with oral lesions. The lesions commonly start as vesicles or bullae that rapidly rupture, leading to erosions and ulcerations. The palatal, gingival, buccal, and labial mucosa are the most commonly affected sites. Oral PV can mimic several other diseases that cause mucosal erosions and/or ulcerations, including erythema multiforme (EM). EM is an acute, immune-mediated, self-limited hypersensitivity condition primarily associated with herpes simplex infection. Oral lesions can be variable, but a very characteristic presentation with labial hemorrhagic erosions, ulcerations and crusting is commonly seen. In this case series, we present six cases of PV: one male patient and five female patients whose ages ranged from 34 to 65 years old. All patients presented with hemorrhage and crusting of the lips in addition to multiple intraoral erosions and ulcerations. Three patients presented with oral and skin lesions. All patients underwent biopsies, and a diagnosis of PV was confirmed. All patients were treated with steroids (topical and systemic) and variable steroid-sparing agents. This case series emphasizes that oral PV may be misdiagnosed as EM in a subgroup of patients who present with persistent lip hemorrhage and crusting. Therefore, a comprehensive history, clinical examination and incisional biopsies should be considered in such patients.

Differential Diagnosis of Lesions

There have been many uncertainties during the coronavirus pandemic. New studies emerge about new symptoms associated with the virus that include dermatological disorders. Lesions with an unknown cause can be a challenge to diagnose and treat. Some lesions have nonspecific symptoms associated with viral infections, immune-mediated reactions, autoimmune disease, malignancy, radiation, immunizations, and sarcoidosis. These lesions may be associated with erosions and bullae that can involve the mucosa. Nurse practitioners must be aware of the clinical manifestations of various lesions and need to determine when patients should be hospitalized or managed in the outpatient setting.

Herpes Simplex Associated Erythema Multiforme: A Case Report and Review of the Literature

Erythema multiforme (EM) is an acute immune-mediated disease with multifactor etiology, which presents with symmetric target-like lesions on the skin. Probably the most common etiological factor of EM is viral infections, particularly herpes simplex virus (HSV). Herpes-associated erythema multiforme (HAEM) is an acute exudative dermatosis, caused mostly by HSV-1 and much rarely by HSV-2. A 44-year-old female patient with herpes associated erythema multiforme was consulted with initial appearance of typical target lesions on the dorsal surface of both hands, after long history of labial herpes episodes. The diagnostic algorithm included routine laboratory tests, histological examination and serologic test for HSV-1 and 2. Our first choice of treatment was acyclovir 5 x 200 mg/24 h and dexamethasone 4 mg/24 h, however due to increased anxiety and tachycardia reported by patient the corticosteroid therapy was discontinued and promethazine was initiated. The patient responded well to the therapeutic regimen and at the follow-up visit was in clinical remission. In conclusion, the diagnosis of HAEM is mainly clinical, when the patient develops target lesions and coexisting HSV infection is detected.

Stevens Johnson Syndrome – “Steven Who? And Why I Should Care About His Johnson?”

Diagnosing rashes in the emergency department can be challenging. If the rash is extensive and targetoid, include Stevens-Johnson Syndrome (SJS) on your differential and be sure to obtain a thorough history to identify possible offending agents. Additionally, prioritize supportive care and obtaining a dermatology/burn consult to coordinate appropriate care.

[Targeting the skin - erythema multiforme in dogs and cats]

This review article will describe the complex nature of erythema multiforme in dogs and cats. The disease pattern will be illustrated in terms of etiology, pathogenesis, clinical signs, diagnostics and therapy. Erythema multiforme is a rare, immune-mediated skin disorder with an acute specific reaction pattern of skin and mucous membranes against different underlying causes. Reported triggering factors include drugs, food ingredients and neoplasias, but viral or bacterial infections and vaccine reactions were also identified. In over 20% of the cases the cause cannot be identified. The German Shepherd dog and Pembroke Welsh Corgi seem to be predisposed. Erythematous macules, slightly elevated and peripherally spreading papules as well as circular to arciform patterns were described frequently in the dog. Wheals, plaques, vesicles and bullae that develop into ulcers, are also seen. Frequently affected areas in the dog are the ventrum, mucocutaneous junctions, mouth, pinnae and foot pads. Histopathological findings include single cell necrosis in all layers of the epidermis with lymphocytic satellitosis and a cell-poor interface dermatitis. Elimination of the causative factors and concurrent symptomatic therapy are recommended. The prognosis varies from guarded to fair, depending on the underlying cause, presenting clinical signs and response to therapy.

Lichenoid and interface dermatoses

The terms 'lichenoid' and 'interface' dermatitis are often used interchangeably to describe an inflammatory pattern characterized histologically by damage to the basal keratinocytes in the epidermis. The mechanism of cell damage of such cells is now best understood as apoptosis, or programmed cell death. This inflammatory pattern of dermatoses, is also accompanied frequently by a band of lymphocytes and histiocytes in the superficial dermis, that often obscures the dermal-epidermal junction, hence the term 'lichenoid'. A discussion of the more common lichenoid/interface dermatitides encountered in the routine clinical practice encompasses the following entities: lichen planus, lupus erythematosus, dermatomyositis, erythema multiforme, graft versus host disease, fixed drug reactions, and multiple others.

Immune-mediated dermatoses

Pemphigus foliaceus is the most common autoimmune skin disease in horses and is associated with the production of autoantibodies directed against surface proteins of the keratinocyte. Pemphigus vulgaris is a rare autoimmune skin disease in horses. Systemic lupus erythematosus and cutaneous lupus erythematosus are recognized in horses and both are rare. Bullous pemphigoid is a rare autoimmune disease in horses caused by immunologic attack of the basement membrane zone by autoantibodies. Erythema muliforme is an immunologic reaction in the skin in which keratinocyte cell death is the prominent change seen on biopsy. Purpura hemorrhagica is thought analogous to nonthrombocytopenic purpura in humans.

Clinical features, diagnosis, and treatment of erythema multiforme: a review for the practicing dermatologist

Erythema multiforme (EM) is an uncommon, immune-mediated disorder that presents with cutaneous or mucosal lesions or both. In herpes simplex virus (HSV)-associated EM, the findings are thought to result from cell-mediated immune reaction against viral antigen-positive cells that contain the HSV DNA polymerase gene (pol). The target lesion, with concentric zones of color change, represents the characteristic cutaneous finding seen in this disorder. Although EM can be induced by various factors, HSV infection continues to be the most common inciting factor. Histopathologic testing and other laboratory investigations may be used to confirm the diagnosis of EM and to differentiate it from other clinical imitators. Imitators of EM include urticaria, Stevens-Johnson syndrome, fixed drug eruption, bullous pemphigoid, paraneoplastic pemphigus, Sweet's syndrome, Rowell's syndrome, polymorphus light eruption, and cutaneous small-vessel vasculitis. Because disease severity and mucosal involvement differ among patients, treatment should be tailored to each patient, with careful consideration of treatment risk vs benefit. Mild cutaneous involvement of EM can be managed primarily with a goal of achieving symptomatic improvement; however, patients with HSV-associated recurrent EM and idiopathic recurrent EM require treatment with antiviral prophylaxis. Inpatient hospitalization may be required for patients with severe mucosal involvement that causes poor oral intake and subsequent fluid and electrolyte imbalance. With this review, we strive to provide guidance to the practicing dermatologist in the evaluation and treatment of a patient with EM.

Herpes associated erythema multiforme

Erythema multiforme is an acute and a self-limiting mucocutaneous hypersensitivity reaction triggered by certain infections and medications. One of the most common predisposing factors for erythema multiforme is infection with herpes simplex virus. Herpes associated erythema multiforme (HAEM) is an acute exudative dermatic and mucosal disease caused by the infecting herpes simplex virus. It has recurrence and idiorestriction, characterized by increasing of CD4+T leukomonocyte. This article reports a case of HAEM in a 9-year-old girl, with a review of relevant literature, and discusses the pathophysiology and treatment of erythema multiforme triggered by herpes simplex virus

Canine parvovirus-2b-associated erythema multiforme in a litter of English Setter dogs

Erythema multiforme (EM) was diagnosed in a litter of English Setter puppies. The puppies developed erythematous cutaneous lesions at the age of 2 weeks. Microscopically, there was individual keratinocyte apoptosis associated with lymphocyte exocytosis in all layers of the epidermis. Intranuclear viral inclusions were seen in multiple tissues and organs. Tissues from the tongue, lymph node, spleen, skin, and small intestine were positive for Canine parvovirus-2 (CPV-2) and negative for Canine distemper virus (CDV) and Canid herpesvirus 1 by fluorescent antibody test. Negative-staining electron microscopy detected parvovirus particles in the intestinal contents. The skin and small intestine were positive for CPV-2b and negative for CDV by polymerase chain reaction. The mucocutaneous junctions and small intestines stained positive for CPV by immunohistochemistry. The present report documents CPV-2b-associated EM in a litter of English Setters and substantiates the single previous report associating EM with CPV-2. The finding suggests that CPV should be considered as a possible cause of EM in dogs.

Human herpes simplex virus infections: epidemiology, pathogenesis, symptomatology, diagnosis, and management

Eight of the more than 80 known herpesviruses are human pathogens. Human herpes simplex virus (HSV) is a contagious infection with a large reservoir in the general population. It has a potential for significant complications in the immunocompromised host. In addition, psychological distress caused by the negative stigma associated with genital herpes and visible facial lesions in those experiencing frequent outbreaks renders it a challenging clinical dilemma. This article reviews the epidemiology, pathogenesis, and diagnostic features of HSV infections, providing the clinician with an up-to-date understanding of the available management strategies for mucocutaneous HSV-induced disease.