[PAGID] Recurrent, vesicular eruption on forehead

[Berger, Melvin]

This sounds possibly analogous to the situation with vaccinia. Past history of eczema is considered a contra-indication, even if not active and no present topical treatment with steroids or calcineurin antagonists.  You say negative DHS candida skin test- was he positive for DTH to another antigen ?
 
Melvin Berger, M.D., Ph.D.
Adjunct Professor of Pediatrics and Pathology
Case Western Reserve University
Cleveland, OH 44106

________________________________

From: pagid-bounces at list.clinimmsoc.org on behalf of Colin_Freccia at Rush.Edu
Sent: Tue 5/4/2010 11:48 AM
To: pagid at list.clinimmsoc.org
Subject: [PAGID] Recurrent, vesicular eruption on forehead



17YO Caucasian male with a painful, recurrent, vesicular cutaneous eruption (HSV-1 positive by PCR on multiple occasions, VZV not detected) involving the forehead only.  Since January 2009 he has had 7-8 localized recurrences despite suppressive doses of valacyclovir, taken as directed, and severe post-herpetic neuralgia requiring pain management and a recent trigeminal nerve block.  The only known risk factors are moderate-to-severe eczema as a young child, resolved, with residual xerosis; uncomplicated chickenpox in early childhood, and aseptic meningitis without sequela at age 10; otherwise healthy, without genital herpes.  No family history of similar illness or immune deficiency disease.

 

Pertinent laboratory tests:

- CBC:  WBC 5000/mcL, absolute neutrophils 2000, lymphocytes 1580, monocytes 440, eosinophils 870 and basophils 40

- quantitative IgGAM all normal; IgE 3200 U/L

- negative HIV antibody screen

- lymphocyte flow cytometry immunophenotyping:  ALC 1269 (1140-4430/mcL), CD19+ 203 (34-1019), CD3+ 964 (638-3721), CD4+ 546 (364-2659), CD8+ 381 (239-1728) and CD56+ 38 (23-797)

- in vitro PBMC mitogen stimulation:  slightly low responses to PHA and PWM, low to ConA

- anergy to candida DHS skin test

Has anyone had a similar case or cases and what you would recommend re:  Dx, Rx and further work-up?  Also, can anyone assist with in vitro stimulation of PBMC using HSV-1/2 and possibly VZV vs. a reference Ag such as tetanus toxoid?  Thank you.


--
Colin Freccia, MD - Fellow
Section of Allergy/Immunology
Department of Immunology/Microbiology
Rush University Medical Center



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