Eczema herpeticum (EH), or Kaposi's varicelliform eruption, is a skin infection with herpes simplex type I virus (HSV-1) that occurs in patients with compromised skin integrity, such as atopic dermatitis (AD). Unrecognized, it may be fatal and viremia in pregnancy may lead to fetal demise and miscarriage. We describe a rare case of EH in pregnancy, eczema herpeticum gravidarum (EHG), which is the third published report in the literature to date.

A 22-year-old gravida two para one woman in her 23rd week of pregnancy presented with a painful papular eruption on her face and neck of one week's duration. She had prior history of AD, but has recently stopped topical corticosteroids. She denied history of sick contacts, sun exposure, or sexually transmitted diseases. On examination, her temperature was 37.8°C, heart rate 120 beats per minute, and blood pressure 127/72 mmHg. There were multiple hyperpigmented plaque-like lesions covering 80% of her body surface, and tender umbilicated vesiculo-papular lesions on her face, neck and upper torso in different stages of development. Pus was expressed from several lesions. Shotty cervical lymphadenopathy was noted. Her fundal height was appropriate for stated length of pregnancy and gynecological examination was unremarkable. Laboratory analysis showed white blood cell count of 8.3×103/L. She tested negative for serum rapid plasma reagin and human immunodeficiency virus. She was diagnosed with severe impetiginized EH with underlying severe AD. Intravenous acyclovir 5 mg/kg per dose three times daily and intravenous cefazolin one gram every six hours were administered. Local corticosteroid cream was applied for her severe AD. On day 3, no new lesions were noted, and herpetic rash cleared by tenth day of therapy. Subsequently, viral and bacterial cultures from lesions isolated HSV-1 and methicillin sensitive Staphylococcus aureus, which was also present in her bloodstream. She completed two weeks of intravenous therapy and delivered healthy baby at term.

First described by Dr. Kaposi in 1887, EH is a disseminated herpetic infection of inflamed skin that may complicate AD, Darier-White disease, pemphigus foliaceus, mycosis fungoides, Sezary syndrome, ichthyosis vulgaris, and burns.1 Several theories have been proposed to explain pathogenesis of EH, including decreased skin integrity, impaired plasmacytoid dendritic cell recruitment and local interferon production.2 Associated findings may include fever, malaise, lymphadenopathy, elevated serum IgE levels, and relative lymphopenia.1 Failure of early recognition and prompt treatment with intravenous acyclovir and concomitant antibiotics may carry risk of multiorgan failure and death.1,2 Use of corticostroids has not been shown to cause EH,1 and treatment of the underlying AD is warranted.

To date, only two cases of EHG have been published in English literature.3,4 Acyclovir appears to be safe in pregnancy5 and early therapy of EHG is indicated. Overall, EHG is rare but serious condition that may complicate pregnancy in patients with AD and requires prompt recognition.