September 29, 2022
4 minute read
James H. Brien
A 30-month-old man presents to your practice for an evaluation of a few “blisters” on his right hand.
The child complained of some itching and mild pain 2 days earlier, and the next day the blisters appeared and multiplied. With the exception of moderately severe eczema that appears periodically, the child is healthy with no other problems in his history, and his vaccinations are up to date. There has been no recent travel, but there has been some exposure to bugs in their backyard, mostly flies and mosquitoes, and an older brother had numerous chigger bites on his feet there. several days.
On examination, the patient’s vital signs are normal, and he is somewhat fussy with itching and discomfort in his right hand, which reveals numerous vesicles and pustules of various sizes, with some scratching crusts, all on a diffuse erythematous base (Figure 1).
Figure 1. Patient’s hand with numerous vesicles and pustules. Source: James H. Brien, DO.
What is your diagnosis ?
A. Injuries caused by vesicles
B. Chigger (Eutrombicula alfreddugesi) bites
C. Herpetic eczema
D. Shingles (varicella zoster)
Answer and discussion:
This is a child with moderately severe eczema and a secondary herpes simplex virus infection on the damaged skin of his hand (answer C, eczema herpeticum). There are many manifestations of this condition, from localized to generalized, mild to severe, sometimes requiring hospitalization. If you have a child with significant eczema, you know how difficult it can be to “stay ahead” of inflammation with daily moisturizers and topical anti-inflammatories. From time to time, we all periodically let our guard down, and the skin can flare up even more. If this happens during contact with HSV or reactivation of the virus, manifestations will appear accordingly. The rash began to respond within 48 hours to oral acyclovir and intensification of the patient’s eczema treatment (Figure 2, at 72 hours). Other skin viruses can appear very similar when infected skin is damaged, such as coxsackievirus (eczema coxsackium) and molluscum contagiosum poxvirus. The management focus should always start with addressing the underlying problem as well as the HSV. One may not be able to visually distinguish between HSV and coxsackievirus without testing. In case of doubt, the PCR test of an enterovirus (coxsackievirus) and HSV lesion should quickly give an answer.
Figure 2. Photo taken about 72 hours later, showing some resolution. Source: James H. Brien, DO.
The male beetle, when disturbed or after mating with the female, will excrete a substance (cantharidin) which will cause a fairly deep blistering wound on the skin wherever it comes in contact (Figure 3). In the world of insects, this substance is used to cover the eggs laid by the female of the species, to protect against predators.
Picture 3. Acute injury caused by blisters. Source: James H. Brien, DO.
Although not FDA approved, in the medical world it is sometimes used by dermatologists and veterinarians for the treatment of various lesions. Wound healing is slow and leaves a scar (Figure 4). Images of various beetles can be found on the Internet.
Figure 4. Bulb beetle wound scar 2 months later. Source: James H. Brien, DO.
The chigger is a type of very small mite (Eutrombicula alfreddugesi) which will take a blood meal and then leave, unlike the scabies mite which burrows into the skin. The result of the bite is an intense itch, probably due to the insect’s saliva. They are commonly called “mower mites” or “harvest mites”. In adults they are usually found on the lower legs, but in children they can be anywhere. In young boys, they appear to promote migration to the groin for their blood meal, often resulting in massive but harmless swelling of the proximal highly vascular tissues of the glans (Figure 5). It often looks like a need for catheterization, but it really isn’t due to the soft nature of the swelling, which makes it look worse than it is. The best treatment is time and possibly an oral antihistamine. If scratched enough, it can lead to secondary infection.
Figure 5. Acute swelling due to chigger bites. Source: James H. Brien, DO.
Shingles is the rash caused by reactivation of the varicella zoster virus and, when not showing a typical dermatological pattern, may resemble a cluster of HSV skin lesions (Figure 6). Although not common in children, it does occur and can be typical or atypical with lesions that may be scattered in the midline. Usually treatment is of limited benefit unless the patient is immunocompromised. Check your current red book for the recommendations.
Picture 6. Shingles. Source: Col. Tom Murphy, USAF (retired).
With the kids now back in school, hopefully with up-to-date vaccinations, including COVID-19 and the flu, we can all get through winter with just a few less worries. I doubt there are any providers who are against vaccinations who read my column, but if you are one, I implore you to take the time to review the history of vaccine-preventable diseases over the 100 years and the devastating effects on the health of their victims, their families and loved ones. When my wife and I visit our small hometown where we both grew up, we often take long walks through the town cemetery, reading the headstones, which range from little more than a piece of cement to large, elaborate statues, which date from the early 19th century. These engraved monuments often give the cause of death, especially of young adults and children. Children’s markers are usually smaller, as are their burial places. Markers often have a cowering puppy or kitten on top, or perhaps an angel, with a heartbreaking epitaph (Figure 7).
Picture 7. 19th century grave of a 3 year old boy named Benjamin with the inscription ‘Our darling boy is gone so soon’. Source: James H. Brien, DO.
Space prohibits showing more. Diphtheria, tetanus, smallpox, blood poisoning (sepsis and meningitis), influenza, measles and poliomyelitis (to name a few) have been known to kill or cripple countless babies and children. If the epidemiology were the same today as then, the outcry would be deafening to demand that something be done. Well, something has been done, and today we are benefiting from these advances in vaccination. If you’re still against vaccinations, you must have a reason that outweighs the benefits that have been achieved with far, far fewer babies and children in the graves.
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Brien is a member of Healio Pediatrics and Infectious Disease News Editorial Boards and Assistant Professor of Pediatric Infectious Diseases at McLane Children’s Hospital, Baylor Scott & White Health, Temple, Texas. He can be contacted at [email protected]