P2.233: An Unusual Rash in a 2 y.o. Female with burns: A Case of HSV-1 Superinfection

Introduction: After experiencing a severe burn injury, patients often enter a severely immunocompromised state. Pediatric patients are especially susceptible and often will be hypermetabolic and hyperinflammatory after losing their skin barrier. Due to the severity of injury that burns can cause, burn patients are highly susceptible to infection. This case report highlights an instance of Herpesvirus-1 (HSV-1) superinfection in a two-year-old who experienced a severe burn injury, with a characteristic rash similar to what is seen in eczema herpeticum.

Case Description: The patient was a 21-month-old who was transferred to our facility after experiencing 22% total body surface scalding injury from an accident while family was cooking. She had second-degree burns on face and head, chest, and right arm. In the emergency room, she underwent fluid resuscitation and stabilization, followed by debridement in the operating room, and was admitted intubated to the PICU. Subsequent days were complicated by acute respiratory distress syndrome (ARDS) and respiratory failure requiring continued intubation. Facial burns limited use of adhesives, complicating endotracheal tube securement, which was achieved by with a gingival suture. On day 11, the patient developed fevers, as well as punched-out lesions over the burn sites, concentrating over the face, along with beefy red inflammation of the gingiva. Herpes simplex 1 (HSV-1) PCR from the gingiva and burn sites was positive, indicating an HSV-1 super-infection of the burns; acyclovir was initiated and corresponded with defervescence and improvement of the rash.

Discussion: We describe a case of HSV-1 superinfection of facial and chest burns following a scalding injury, identified clinically following the appearance of characteristic, “punched-out” lesions, similar in appearance to what is seen with Eczema herpeticum. The immunological disturbances caused by the burn injury, coupled with gingival sutures and disturbance of the mucosal barrier, contributed to reactivation of HSV-1 with the subsequent superinfection. While typically HSV presents as vesicular lesions on an erythematous base, in the case of compromised skin integrity, for example in a burn or in a patient with severe eczema, the rash may instead appear as “punched-out” lesions, or “moth-eaten.” The absence of the typical vesicular lesions could result in a delayed diagnosis, without an understanding of the varied presentations in different clinical settings.

Conclusion: Burn injuries are one of the top 5 common pediatric injuries, and infection is a major cause of morbidity and mortality in these patients. In this case, appropriate testing and treatment was quickly initiated secondary to the “punched-out” and “moth-eaten” lesions which were identified, increasing the suspicion for HSV. While HSV on intact skin has a characteristic appearance, those caring for burn patients, or patients with compromised skin integrity, should be aware of this other type of characteristic appearance, so they may rapidly initiate appropriate treatment for their patient.