Erythema Multiforme Associated with Herpes Simplex Virus: A Case Report and Literature Review

Special Article - Oral and Maxillofacial Surgery

J Dent & Oral Disord. 2016; 2(5): 1027.

Erythema Multiforme Associated with Herpes Simplex Virus: A Case Report and Literature Review

Davis K¹*, Smith C², Halpern L¹, Esuruoso O² and Ballard B³

¹Department of Oral and Maxillofacial Surgery, Meharry Medical College, USA

²Department of Internal Medicine, Meharry Medical College, USA

³Department of Pathology, Meharry Medical College, USA

*Corresponding author: Davis K, Department of Oral and Maxillofacial Surgery, Meharry Medical College, USA

Received: July 01, 2016; Accepted: July 18, 2016; Published: July 20, 2016

Abstract

Erythema Multiforme (EM) is an acute inflammatory skin disease where 90% of the minor cases follow outbreaks of herpes simplex. Clinical presentation entails the onset of macular, papular, urticarial, bullous, or purpuric symmetric lesions on extensor surfaces as well as oral mucous membrane involvement. Target lesions with clear centers and concentric erythematous rings may also be noted. This is a case report of HSV-1 associated EM in a 20 year-old female. The pathophysiology of disease presentation is discussed with a review of relevant literature, as well as, treatment options for resolution of EM triggered by HSV-1.

Keywords: Herpes simplex; Erythema multiforme; Infectious; Vesiculobullous; Immune-mediated; Stevens-Johnson syndrome

Abbreviations

AB: Antibody; SLE: Systemic Lupus Erythematosus; HSV: Herpes Simplex Virus; EM: Erythema Multiforme

Introduction

Erythema multiforme is an acute vesiculobullous, mucocutaneous disease that most often occurs concomitantly with exposure to infections or medications most often [1]. It presents with diverse mucocutaneous manifestations and is thought to be a type IV hypersensitivity reaction [1,2]. EM has often been linked to a subsequent exposure to the Herpes Simplex Virus (HSV-1) and is thought to be an immune mediated complication of the viral infection [3]. This is a case report of herpes simplex virus associated EM in a 20 year-old female. The pathophysiology of disease presentation is discussed with a review of relevant literature, as well as, treatment options for resolution of EM triggered by HSV-1.

Case Presentation

Present illness

A 20 year old African-American female presented to the Meharry Medical College Ambulatory Medicine Service complaining of “mouth sores and a rash.” The onset was noticed about 2 weeks prior to her seeking treatment. The patient stated sores were present to both her lips and intraorally with bleeding and pain noted. In addition, she described experiencing fatigue, headache, mild photophobia, sore throat, odynophagia, dysphagia, and mild arthralgias. About a week later, a pruritic rash had also developed involving her hands and elbows prompting her to obtain an emergency medicine evaluation at which time Clindamycin and Acyclovir were prescribed. She previously reported a “canker sore” about 6 months prior resulting in treatment for herpes with Acyclovir, but was also told at another visit that she didn’t have herpes despite noticing a tingling sensation prior to each “canker sore” presentation. The patient denied exposure to medications, food, or allergens that may have precipitated her symptoms.

Past medical history

The patient’s past medical history was unremarkable and there are no known drug allergies. A family history of Hypertension exists on her mother’s side. She denies ever having engaged in oral or vaginal sex as well as any history of tobacco, alcohol, or recreational drug use.

Physical Exam: The patient was febrile with a temperature of 100.1F. Clinical exam revealed tender and erythematous blisters of varying size on extensor and palmar surfaces of the hands (Figures 1 & 2). Violaceous plaques, macules, & blisters were also present to the forearms, and elbows (Figure 3). There were no target lesions on her back or lower extremities. Fundoscopic exam did not reveal any Roth spots or other significant findings suggesting autoimmune phenomena. Both the upper and lower lips were edematous with crusting & dried blood present that bled easily upon manipulation of scabs indicative of a vesiculobullous mechanism (Figure 4). Nikolsky sign was negative. Generalized erythema is visualized throughout the oral cavity. The buccal mucosa was markedly erythematous with hyperkeratotic & white plaque-like lesions present bilaterally. There were 1-2mm sized ulcerations present to both the hard and soft palate on erythematous bases. A palatal torus was present. The dorsal surface of the tongue had a white patch to plaque-type appearance that was not removable with a tongue blade as well as a large ulceration at the tip.