A 28-year-old asthmatic patient on short-acting inhaled b2-agonists on request, with the notion of taking oral corticosteroids by self-medication at the time of the attacks. She was consulted for liquid lesions on the face that had been evolving for three days with a tingling sensation not preceded by the application of a topical. The patient had a history of herpes labialis.

The clinical examination found a patient in good general condition with a dermatological examination of a roughly oval plaque of 4.5 cm in size at the mid-frontal level with vesicles grouped in a cluster at the periphery and melicoid and hemorrhagic crusts in the center. The patient also had a slight bilateral conjunctival hyperemia (Fig. 1). The examination of the cervical lymph nodes revealed bilateral sub-mandibular adenopathies; the diagnosis of giant cutaneous herpes was retained. The patient was put on local fulcidic acid and oral valaciclovir at a dose of 1000 mg/dr for 5 days and eye drops by the ophthalmologists, with good improvement.

Figure 1: Clinical picture showing oval plaque of 4.5 cm in size at the mid-frontal level with vesicles grouped in a cluster at the periphery and melicoid and hemorrhagic crusts in the center.

HSV is a common opportunistic infection in immunocompromised patients. Characteristically painful vesicles develop in a localized area like the lip, which subsequently go forward over days to form non-scarring scabs. The clinical expressions of HSV-1 infection in immunosuppressed hosts can be uncommon, including giant, erosive, ulcerative, vegetating, or hyperkeratotic lesions, with a higher incidence of chronicity, dissemination, recurrence, and acyclovir resistance [1,2]. It is explained by a number of host considerations such as age, immune status, intercurrent disease, and the presence of a preceding skin illness [3].

Intravenous antiviral therapy may be required in immunocompromised patients and those with severe disseminated infections [1]. However, in our case, the oral treatment was sufficient with a satisfactory response.

REFERENCES

1. Khera P, Haught JM, McSorley J, English JC 3^rd. Atypical presentations of herpesvirus infections in patients with chronic lymphocytic leukemia. J Am Acad Dermatol. 2009;60:484-6.

2. Metin A, Kanik-Yuksek S, Ozkaya-Parlakay A, Tezer H. Giant Herpes Labialis in a Child with DOCK8-deficient Hyper-IgE Syndrome. Pediatr Neonatol. 2016;57:79-80.

3. Qian YT, Ma JY, Liu JW, Liu W, Ma DL. Chronic Herpes Simplex virus infection in an immunosuppressed girl. J Pediatr. 2019;212:237-237.e1.