Clinical Image

Hemorrhagic herpes labialis after pneumococcal meningitis

Francisco Martins do Vale1
,  
Telma Azevedo2

1 Infectious Diseases Resident, Department of Infectious Diseases, Hospital São Bernardo, Centro Hospitalar de Setúbal, Setúbal, Portugal

2 Infectious Diseases Specialist, Department of Infectious Diseases, Hospital São Bernardo, Centro Hospitalar de Setúbal, Setúbal, Portugal

Address correspondence to:

Francisco Martins do Vale

Infectious Diseases Resident, Department of Infectious Diseases, Hospital São Bernardo, Centro Hospitalar de Setúbal, Setúbal, Portugal; Rua Camilo Castelo Branco 175, 2910-549 Setúbal,

Portugal

Access full text article on other devices

Access PDF of article on other devices

Article ID: 100058Z09FV2021

doi: 10.5348/100058Z09FV2021CI

How to cite this article

do Vale FM, Azevedo T. Hemorrhagic herpes labialis after pneumococcal meningitis. J Case Rep Images Med 2021;7:100058Z09FV2021.

ABSTRACT

No Abstract

Keywords: Herpes labialis, Herpes phagedena, Herpes simplex virus type 1, Meningitis

Case Report

A 77-year-old man presented to the emergency department with a 48-hour history of fever and altered mental status. The physical examination was notable for a temperature of 39.5°C, psychomotor agitation, and neck stiffness. Laboratory tests showed a white cell-count of 5600/mm3 (4500–11,400) with neutrophilia 85% (45–75%) and C-reactive protein level of 19.01 mg/dL (<0.5). A lumbar puncture was performed and revealed a xanthochromic fluid with uncountable leukocytes with a predominance of polymorphonuclears, glycorrhachia less than 5 mg/dL (40–70) and protein of 1.415 mg/dL (15–45). Empiric antimicrobial therapy was prescribed with high dose ceftriaxone, ampicillin, and acyclovir. After 24 hours of admission, he developed hemorrhagic herpes labialis also known as herpes phagedena presenting with a large and hemorrhagic ulcer involving labial mucosa, oral commissures, and philtrum, which progressed to a necrotic lesion in 48 hours (Figure 1). Streptococcus pneumoniae was isolated from cerebrospinal fluid and antimicrobial therapy was de-escalated to penicillin, according to antimicrobial sensibility testing, and acyclovir was maintained. The patient recovered without neurological deficits in one week and his mucocutaneous lesions healed in three weeks without scars.

Figure 1: Large and hemorrhagic ulcer involving labial mucosa, oral commissures, and philtrum which progressed to a necrotic lesion in 48 hours.

Discussion

Herpes reactivation is a common finding in patients with bacterial meningitis, which is related to disease severity and advance age [1]. In severe infection, the stressed immune system becomes hyporesponsive, a phenomenon called “immune paralysis”, leaving the patient susceptible to secondary infections, and allowing latent viruses to reactivate [2],[3].

REFERENCES

1.

Weerkamp N, van de Beek D, de Gans J, Koehler PJ. Herpes reactivation in patients with bacterial meningitis. J Infect 2008;57(6):493–4. [CrossRef] [Pubmed] Back to citation no. 1  

2.

van der Poll T. Immunotherapy of sepsis. Lancet Infect Dis 2001;1(3):165–74. [CrossRef] [Pubmed] Back to citation no. 1  

3.

Gustot T. Multiple organ failure in sepsis: Prognosis and role of systemic inflammatory response. Curr Opin Crit Care 2011;17(2):153–9. [Pubmed] Back to citation no. 1  

SUPPORTING INFORMATION

Author Contributions

Francisco Martins do Vale - Substantial contributions to conception and design, Analysis of data, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published

Telma Azevedo - Analysis of data, Interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published

Data Availability Statement

The corresponding author is the guarantor of submission.

Consent For Publication

Written informed consent was obtained from the patient for publication of this article.

Data Availability

All relevant data are within the paper and its Supporting Information files.

Competing Interests

Authors declare no conflict of interest.

Copyright

© 2021 Francisco Martins do Vale et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.