The patient
‘Eczema shouldn't make you ill, should it, doctor?'
Despite the fact that I was running the emergency surgery and was already more than half an hour late, I resisted the urge to simply answer ‘no'. Even though it's years since I did my MRCGP, I ‘explored the question'.
The mother had brought in her one-year-old girl for an urgent appointment. The only relevant past history was eczema, for which she'd been prescribed the usual emollients and mild steroid ointments, with occasional courses of antibiotics.
Mum explained that the girl had been ‘really out of sorts this last couple of days – feverish, off her food and grumpy. And I noticed her eczema has suddenly flared up'.
First instinct
Even before mum had undressed the child for me to give her a general check-over, and a peek at the eczema in particular, I had decided that this was probably just an eczema flare – possibly infected – with a coincidental viral illness.
We see infected eczema commonly, but the affected child is usually well, albeit itchy. This little girl, though, did look out of sorts and certainly felt feverish to the touch. When mum took off the child's vest, I was confronted by some pretty nasty-looking eczema around the left shoulder and chest wall.
Differential diagnosis
• Eczema exacerbation
• Bacterial infection of eczema
• Eczema herpeticum
• Herpes zoster.
A simple eczema flare is a common presentation in children. But, as per the mum's opening gambit, this shouldn't make the child unwell.
Either this really was a flare with a coincidental viral illness such as a developing URTI or gastroenteritis – or there was something about the eczema itself that was making the child ill.
At first glance, it looked infected – and bacterial infection is often implicated in exacerbations of eczema. But I've never known this complication to cause systemic illness.
This raised the possibility of some other infection. The clustering of blistering and ulcerated lesions reminded me of herpes zoster, though the patient was very young for an attack of shingles. Herpes simplex, though, was a distinct possibility.
The hidden clue
There were two clues, in fact.
First, the mum's gasp as she removed her child's vest – because the affected area was more extensive and angry-looking than it had been just a couple of hours before.
And the second was the pattern of uniform, punched-out erosions. These lesions, together with the rapid deterioration, suggested eczema herpeticum.
Getting on the right track
Now the whole presentation made sense.
A quick call to the duty paediatrician secured the child's urgent assessment – at which point the diagnosis was confirmed and intravenous aciclovir was commenced. A couple of days later she was discharged, much better in herself and with much improved eczema.
Dr Keith Hopcroft is a GP in Laindon, Essex
Eczema accompanied by a fever Eczema accompanied by a fever
