EBV-induced erythema multiforme: a case report

To the Editor, Erythema multiforme (EM) is a type of dermatosis That OCCURS as a hypersensitivity reaction in response to medications or infections. Erythema multiforme is mostly Associated With The herpes simplex virus (HSV) or mycoplasma infections, 1-but it is rare EM That is the Epstein Barr Associated With Virus (EBV). We report on an 11-year-old male patient to our hospital ADMITTED With redness, swelling, burning sensation, an itchy rash on hands and feet, and a rash on the body That HAD Begun four days with previously. The patient Suffered fever, sore throat and running a day donot Before These complaints Manifested. The skin rash Began on the sole of the right foot, Which was noticed upon a sensation of something stuck on the right sole, and then a spread to the left sole and the hands. At the outset, the skin rash was pinhead sized, then a Increased in size, and swelling in the hands and feet occurred. Consulted The first physician wrote a prescription for cefuroxime, cetirizine and feniramine. However, the patient’s complaints Were not resolved after one day of using esta medication, and so I was Referred to our hospital. In our physical examination of the patient, to maculopapuler That included rash desquamation Which regions paled under pressure, was Observed on Both palms, soles, arms and legs. His body temperature was 37 ° C. Other system examinations revealed no abnormal findings (Figure 1, Figure 2). Face, body and Mucosal Involvement was not noted.

Figure 1. A red-purple dispersed colored maculopapular rash That pales under pressure was shown around ankle and medial side of the foot. Figure 2. Red-purple erythematous maculopapular lesions colored show desquamation That Were seen in patches on bilateral palmar regions. Laboratory examination revealed leukocyte count: 9900 / mm3, hemoglobin: 14. 1 g / dl, platelet count: 214,000 / mm3, erythrocyte sedimentation rate: 22mm / hour, urea: 32mg / dl, creatinine: 0. 8mg / dl, serum sodium: 134 MEq / L, potassium: 4. 5 mEq / L, AST 31 IU / L, ALT: 22 IU / L. The patient was Also tested for the Rickettsia IgG, HSV type I IgM, HSV type II IgM, EBV VCA IgM, CMV IgM, the Parvovirus IgM, and Mycoplasma pneumoniae IgM antibodies in order to rule out rickettsial diseases and other infectious skin eruptions Because of the symmetrical maculopapular rash Involving the Hands and Feet. Doxycycline treatment was subsequently Initiated with a presumptive clinical diagnosis of rickettsial diseases. On the second day following the patient’s admission to hospital, Appeared typical target lesions, the largest of Which was 2cm in diameter, on the proximal Both thighs and area of ​​the forearms (Figure 3). EBV VCA IgM and IgG Rickettsia Were positive at a titer of 1/10 and 1/64 respectively. Repeated tests in the week and one Performed one month later, there was no Increase in the Rickettsia IgG titres.


Doxycycline treatment was halted on day seven, and EBV infection was thought to be responsible for EM in our patient. Other viral markers and examinations for mycoplasma Were found to be negative. On the fifth day of admission, the patient was discharged from the hospital as the rash had a tendency to pale. The rash Disappeared on the 14th day from the beginning and the patient was cured without sequela. Figure 3. Were Dispersed target lesions shown on the proximal part of the fore arm. One month later, in order to rule out a possible adverse drug reaction due to cefuroxime Reported use in the patient’s history, a patch test (10 mg / ml) was done, Which came out negative. Then a prick test and an intradermal test using cefuroxime Were applied. These tests since turned out negative Also, an oral provocation test was Performed using cefuroxime, Which turned out negative too. Erythema multiforme is acute, self-limited and Usually at times life threatening dermatosis With Which May multiforme lesions present. They include multiple, symmetric, persistent macules, papules, vesicles, and bullae. What has pathognomonic for erythema multiforme Become is the so-called iris or targetoid lesions, plaques Representing center of duskiness in expanding erythematous macules and papules. Commonly Involved areas are extensor surfaces: the palms, the soles, and sites of trauma.

1 The appearance of the rash in our patient shortly after pricking Caused us to think That trauma played a role in esta Facilitating case. In MS, aetiology of herpes simplex mostly Consist and mycoplasma. Medications and some vaccines Also Participate in the aetiology, but in half of the cases an underlying cause can not be found. 2 EBV VCA IgM, tested in our patient was found to be positive. Erythema multiforme occurring EBV infection is Dramatically During rare. 2,3,4,5,6 Certain it is not, Although, the pathophysiological mechanism for the EBV-related MS is thought to be immunocomplex mediated. 4 Hughes et al. Demonstrated perivascular IgM and C3 deposition in direct immunofluorescent examination. 2 In Addition, Carrera et al. Investigated the presence of specific gene sequence of EBV and Herpes simplex by PCR in a tissue biopsy of a Case with cholestatic hepatitis and acute MS; however the result was negative. 5 On the other hand, Chen et al. detected an EBV specific gene sequence in two cases by 32 EM PCR.

6 Due to a lack of the facilities for investigating EBV in tissue With PCR, since we clinically diagnosed MS, and Also for ethical issues, we did not perform a tissue biopsy in our patient. It is well Known viral infections During That, drug-related allergic reactions Rashes increase. 7 related to infectious mononucleosis are aminopenicillins During Often seen; however, serious cutaneous lesions: such as MS and Stevens Johnson Syndrome (SJS) are rare. 8 Our patient was EVALUATED for cephalosporin-related drug reaction due to previous cefuroxime use, but skin tests and oral provocation test results came out negative. Delgado et al. Reported a case of MS due to aminopenicillin use EBV infection. 8 During Contrary to our patient, They found a positive patch test and a delayed reading of an intradermal test Performed for an evaluation of drug sensitivity. They Claimed That cell-mediated hypersensitivity was responsible for the development of drug-related MS. In research Conducted by Jappe, WHO EVALUATED 41 Patients With drug eruptions following the intake of amino-penicillins, 20% of Patients had a florid infectious mononucleosis at the time of the drug eruption. 9 In our case, in terms of explaining aetiology, EBV was determined to infection and an evaluation was made due to drug allergy to cefuroxime in light of Existing Knowledge About virus-drug interaction, and the result was determined to be negative to. 80% of erythema multiforme is classified as minor, is postinfectious Usually, the skin and Primarily Affects more than one and no mucosal surface. 1 It is thought That there is a relationship Between the severity of the disease and factors in aetiology That exist. While viral infections cause erythema multiforme minor Usually and major, medications cause SJS Which progresses with a more serious clinical course.

10 Our patient was diagnosed as erythema multiforme minor, Because there was no mucosal Involvement. The drug allergy tests Were case of the negative and the viral infection was mostly related EM Encountered in minor form. Consequently, our patient was diagnosed as EBV related MS. The prognosis is quite good in EM minor, and it can be cured without sequela in 2-4weeks by Eliminating the triggering cause or by treatment of the underlying infection. Progression to SJS does not Occur In These Cases. Our patient was closely for six weeks Monitored With only the first five days in hospital, and it was Observed That His injuries healed completely. As a result, even though HSV is the MOST Observed of viral infections in the aetiology MS, EBV Might be a rare but a causative factor. Corresponding author. drpinar1975@hotmail. com

Infection – More often even think! • general medical-online

HIV infection should be detected as early as possible, because there are good treatment options today, and as otherwise there is a risk that the HIV virus is transmitted. However, an early diagnosis is not always easy. Acute HIV infection is often overlooked because of their non-specific symptoms. Chronic infection can last for years without symptoms. The following items will be identified based on clinical examples, the difficulties in the diagnosis and the risks of late diagnosis. Adjoining case reports (Box 1 and 2) are intended to illustrate how difficult may be the diagnosis of HIV infection. These two cases show that the symptoms of HIV infection can be very unspecific. Primarily, it is important to keep in mind. Case Study 1 Male patient, 58 years old Oral thrush, feels bad, losing weight: 20 kg Professional success, serious demeanor, civil Has children, but now lives by the wife separately and together with a man

In the spring of the first medical consultation, then multiply inpatient investigated without result Finally, after six months of HIV testing during office visits: positive At diagnosis 38 CD4 + / ul, viral load: 665 000 / ml Case Study 2 Male, 71 years Living in a rural area, is married Symptom onset in the summer with pain in the arms and legs, the patient attributes this to a poisoning Intermittent fevers, during inpatient investigations: Diagnostic “Feverish colds”, DD Food Allergy In November, through investigation in other clinic: chest X-ray, ultrasound of the abdomen, MRI skull, gastroscopy, colonoscopy, and bone marrow aspirate In the bone marrow aspirate is striking: 41 CD4 + / ul HIV test: positive Why it is important to detect a HIV infection at an early stage? To answer this question it is first helpful to look at the natural history of infection (see.

Fig. 1). At the beginning and at the end of the course of the viral load in the patient’s blood is very high. The level of CD4-positive leukocytes (helper cells) falls over time slowly until it finally to manifest immunodeficiency comes (AIDS). Early detection of infection is important for two reasons: Late diagnosis worsens the prognosis of the person concerned. Early diagnosis reduces the likelihood of further infections. 1. A late diagnosis worsens the prognosis of the person concerned The diagnosis “HIV infection” is made even today very late yet in many cases. Then the helper cells are often very low. According to current recommendations half of patients already need antiretroviral therapy at diagnosis. This leads initially often due to present opportunistic infections hospitalizations, which is associated with increased morbidity and mortality.


In addition, initially mean very low helper cell count often that no normalization of helper cell count can be achieved by antiretroviral therapy. This is particularly often in elderly patients. The fact that this unfortunately is the reality in Germany, numbers published by the Robert Koch Institute (see. Fig. 2). Following the current therapeutic recommendations in Europe, then patients with helper cell counts below 350 / ul in need of therapy [3]. Considering the recommendations in the US or the latest WHO recommendations as a basis zoom, should already be initiating therapy with 500 / ul helper cells [4]. The decrease in helper cells correlates roughly with the period of the disease, where there is considerable individual differences. If require therapy now already 50% of patients at diagnosis, this leads to the conclusion that the diagnosis is often made too late. 2. Early diagnosis reduces the likelihood of further infections As these individuals for many years without knowing a test nothing of their disease, the risk of transmission is increased to other people. It may be that are not taken adequate precautions during sexual contacts with non-knowledge of the infection.

On the other hand, is increased by the high viral load at the initial stage, the risk of infection. So here are two circumstances together: Affected are unaware of their infection and may not behave accordingly, thus giving the virus very “effective” on. If it is possible to diagnose the infection at an early stage by an HIV test, then can take steps to protect other people concerned. Through antiretroviral therapy, viral load can be reduced to below the detection limit and thus infectivity can be significantly reduced. GPs play a very important role: You can create awareness and offer the HIV test. When thinking about HIV? The HIV infection is clinically often very non-specific or not. Acute HIV infection presents itself as mononukleoseartiges disease. Typical symptoms include fever, fatigue, arthralgia. In about half the cases, a rash is added. These symptoms come now, however, in general practice very frequently. It is correspondingly difficult to detect the infection in the acute stage is. A mononukleoseartiges disease, a sensitive inquired risk anamnesis and frequent testing might help here.

In acute HIV infection is very important to remember that the antibody test will be negative in many cases. A definite exclusion can be assumed only about three months after the issue date of infection. In unclear cases, a virus direct detection are carried out by PCR. This is positively usually within two to three weeks. An HIV test after three months is recommended in any case. In the chronic stage, the infection is very long largely asymptomatic. One should think of an already occurred immunodeficiency certain markers diseases and symptoms. In the area of ​​skin diseases which are for example a herpes zoster, a poorly treatable seborrheic dermatitis or Kaposi’s sarcoma. In the area of ​​the oral cavity are not otherwise declared thrush (especially a thrush esophagitis) to call or oral hairy leukoplakia. But recurrent pneumococcal pneumonia or tuberculosis may indicate an immunodeficiency. How difficult can be the diagnosis, shows the Pneumocystis jirovecii pneumonia (PJP). Here at first lead only history and clinical (risk factors, dyspnea at rest) on. The auscultation is often normal and in the conventional chest X-ray recording is little to see or nothing.

Only a HR-CT of the chest often shows then a distinct findings. Furthermore, it should in newly diagnosed viral hepatitis and sexually transmitted diseases (such. As chlamydial infections, gonorrhea, syphilis and herpes simplex) an HIV test is recommended. The difficulty is again to think of these diseases, to ask the patient to risk factors and to perform specific tests. Moreover, the existence of very nonspecific symptoms should suggest HIV. These include unexplained prolonged diarrhea, as well as fatigue and tiredness and a generalized lymphadenopathy. In classic B symptoms with night sweats and weight loss, and fever of unknown origin HIV infection should always be included in the differential diagnosis. As evident from the case studies, it is better to test early and often. Many symptoms can thus be due to the HIV infection. It is important to always: One should think of HIV as a differential diagnosis. The practitioner is a particularly important role to play in the early detection of HIV infection. He has to know the advantage of many of his patients for years. That is however not necessarily mean that he knows everything about his patients.

The question to the patient, whether you can perform an HIV test, requires a lot of tact. Fortunately, the family physician is accustomed to such questions: Finally, the same applies to the question on the level of alcohol consumption or suicidality. A non-judgmental attitude will allow the patient to open up to the doctor. Gerd Geiss, Stuttgart MRCGP Specialist in internal medicine, specialist in general medicine Community practice Schwabstraße 59 70197 Stuttgart Competing interests: lecture fee from AbbVie, conference visits sponsored by AbbVie, Gilead Sciences, Janssen, ViiV Healthcare Published in: The Doctor, 2014; 36 (9) Page 44-48

MuT. gaming – users – view

Oral candidiasis, so called candidiasis is Brought on by a kind of fungus called Candida albicans. At the intermediate stage, angular cheilitis will cause Significantly higher discomfort, and have a pronounced influence on additional dailylife. If you continue to postpone treatment, the irritation and discomfort Brought on by angular cheilitis will become a lot a lot more extreme mild. Extreme angular cheilitis is Characterized by substantial discomfort, swelling and pain. Serious angular cheilitis can be each incredibly painful and embarrassing noticeably. Left untreated, severe angular cheilitis can lead to permanent scarring at the corner of the mouth. But even serious angular cheilitis symptoms can be managed with suitable therapy. It is tough not to lick your lips When They are dry and cracked, nonetheless in terms of Obtaining of angular chelitis therapy, it is important to break this habit and any other people did involve biting nails or sticking objects in the mouth. Commit to every treatment for a good quantity of time ahead of you decide it is Entirely ineffective. No matter Whether it really is angular cheilitis, oral herpes, mouth ulcer or simply chapped lips, it really is imperative to resolve the difficulty proper away prior to it gets worse. This way, you will be able to apply the suitable Appropriate treatment thatwill give you lengthy-term final results. Although not as rife as the frequent cold, angular cheilitis can therefore pose a critical dilemma to young children. Angular cheilitis is a skin disorder Characterized with scaling and fissures on the corners of the mouth.

You also need to get instant healthcare care if you are suffering from any underlying situation that’s Causing your angular cheilitis. This mouth disorder, All which is marked by red and swollen blisters about the mouth, can go away without therapy in two to four weeks. While They Could appear similar, theyhave various causes, symptoms and treatment Approaches. The factthat angular cheilitis is related to Several other sorts of mouth illnesses can make treatment tricky. Household remedies, over the counter merchandise, and prescription options treat only the symptoms of angular cheilitis. Angular Cheilitis Free Forever Focuses not only on Treating the symptoms of cheilitis, so but on Preventing outbreaks. Jason White has created an all-natural therapy and prevention system did Avoids costly tablets, prescription drugs, and slimy creams. If it is painful to open wide and say ahh “then chances are you have started Establishing angular cheilitis. This therapy has helped literally Thousands of men and women, just like you to get rid of this annoying situation forever! You can apply this cure Virtually right away when you finish download this remarkable therapy correct now! Like you, I Suffered with Angular cheilitis over and more than for years and THEREFORE know how disruptive this situation can be in your life, to your self self-confidence not to mention how painful and unsightly the situation is! The condition worin cracks, fissures, or lesions on the mouth and create in the mouth region in basic is known as angular cheilitis, or angular stomatitis, or angular or cheilosis perleche. You are superior armed with information before you check out the dermatologist, it is crucial to look at some of the angular cheilitis remedy possibilities.

Most treatments for this sort of infection will be on antifungal and steroid medication. A cream color: such as Mycolog-II includes a combination of antifungal (nystatin) and steroid remedy (triamcinolone). As angular cheilitis Typically outcomes from of infection, it will not totally heal up till this has been gotten rid of. Washing the cuts at every corner of the mouth, and afterwards Likewise rinsing the mouth with salt water, will assist to kill the microorganisms or fungi did are accountable. Honey is an antimicrobial compound did You Could want to look at making use of. In contrast to Numerous things did kann produced use of in organic Angular Cheilitis Treatment Ehow cheilitis remedies, it does not have to undesirable taste. Aloe vera is a single of the most well known remedies for skin issues like angular cheilitis. What most Angular cheilitis therapies do is produce a dry environment in Which the bacteria can not develop and trap them in between the layer of cream and the layer of skin, as a result killing them. Hydrocortisone, Mycolog II cream (Which besteht of triamcinolone acetonide and nystatin) and Miconazole are the most well-known medicines prescribed by dermatologists in seeking circumstances. Immediately after applying the ointment twice a day for two days, my Angular cheilitis is gone.

Cold Sores? Good tips from conventional medicine and alternative medicine

Cold sores is widespread: About 90 percent of the population are carriers of the herpes simplex virus. But only about one in five also the symptoms of cold sores show. They are usually easy to recognize the many small aqueous blisters on the lips, itch or burn often. After a few days they burst and crust over. The initial infection usually occurs in children or adolescents with kisses on an infected mouth. After an infection, the viruses remain in the body for life (in the nerve ganglia) and can be prepared by a variety of causes – stress, sun, cold, disgust, menstruation, immunodeficiency etc. – are repeatedly activated and make a cold sore noticeable. In all treatment options, so it’s always about the weakening of the symptoms. SCHOOL MEDICINE and cold sores: We recommend zinc albums and acyclovir applied in time, zinc sulphate-containing preparations (eg. B. Lipactin gel or Virudermin gel) can help. Even products with the drug acyclovir (z.


B. in “Acic cream”, “Aciclobeta cream” or “Zovirax”) can inhibit herpes development. But the use is associated with side effects. Because to acyclovir develop resistance fairly rapidly, the efficiency decreases. Aciclvir should not be used during pregnancy. PLANTS PEDIATRICS: Melissa extract to help with cold sores Melissa extract at the first tingle to lips. This is to prevent the further spread of bubbles. Good experiences made with honey: NATURAL MEDICINE and cold sores Even with honey to cold sores should be treated. A study was pressed to the affected lip points with honey-soaked gauze for several days four times a day for about 15 minutes. The disease duration was reduced. HOMEOPATHY and cold sores

The following individual agents have proved effective: cold sores in febrile illness: Rhus; as a result of stress: sodium muriaticum; with blisters in the mouth and on the tongue: Thuja; Ingestion: three times daily three globules D 12th ASIAN MEDICINE Acupuncture can be used for general immune strengthening, it is not suitable for the acute relief of cold sore symptoms. NUTRITION and cold sores: amino acid lysine helps – avoid chocolate, peanuts and potato chips There is evidence that certain amino acids inhibit virus growth in food. So to ensure lysine-rich and at the same arginine-free diet that herpes infections are less common; the infection itself to heal even faster. Natural lysine sources are: fish, beef and chicken, and dairy products. The arginine to be avoided lies among others in chocolate, peanuts and potato chips. Note: Arginine is an important amino acid that is needed to maintain bodily functions. This should also help with cold sores: lip protection with a high SPF The triggered by sunrays cold sores can usually be very well be prevented by intensive use of lipsticks with a high sun protection factor. Although the efficacy has not been sufficiently proven, the use of electricity can be useful. About pharmacies a battery powered herpes therapy device in ballpoint pen size is sold, which is placed at the onset of cold sores on the affected skin.

A weak Power makes the manufacturer that the pH of the skin of about five drops below two, which is said to have in laboratory experiments to prevent the spread of viruses. Not recommended is the piercing of the bubbles, so as to speed up the healing process. There is a risk of an additional infection bacteria. → continue