Severe herpes simplex virus – 1 Kaposi's varicella rash and SARS-CoV-2 infection in atopic dermatitis treated with dupilumab | BMC infectious diseases

In this case, the patient presented with uncontrolled AD and clinical examination revealed varicella eruption (CVE) and a positive result for SARS-CoV-2 virus. Once the infection was confirmed, the patient was administered dupilumab and cyclosporine, which have been shown to have the potential to inhibit cellular immunity. The results of the T cell subset test confirmed that the patient had reduced immunity and low cellular immune function, which made him susceptible to viral infections, including HSV and SARS-CoV-2. In addition, pooled analyzes in adults with moderate to severe AD showed that the incidence rate of all herpesvirus infections was slightly higher in the dupilumab group. However, most of these infections were mild, while the incidence of more serious infections, including CVD, was higher in the placebo group. This suggests that uncontrolled AD may be a major factor in the development of such infections.

To our knowledge, this is the first case of a severe HSV-1 Kaposi's varicella eruption following AD and SARS-CoV-2 infection, which is an example of a strong predisposition to severe viral outbreaks. This may indicate a possible association between impaired immune function and the occurrence of CVD. It is recommended to emphasize the warning signs of HSV infection, especially in patients with other immunosuppressive diseases [10]. The hemorrhagic crusted lesions that have developed over pre-existing erosions of pemphigus vulgaris and can cause CVD can occur within 2 weeks of acyclovir, suggesting an association between CVD and immunodeficiency [11]. Our case highlighted the challenges in treating severe cutaneous viral infections in individuals with pre-existing dermatological diseases such as atopic dermatitis, which are exacerbated by concurrent SARS-CoV-2 infection. This case highlights the need for prompt recognition and diagnosis as well as the importance of aggressive antiviral therapy in such complex scenarios.

The severe manifestation of CVD after viral disease and immunomodulatory therapy highlights the need for a differentiated approach to the treatment of individuals with pre-existing dermatological diseases during and after viral infections. Early diagnosis of CVD is crucial as it allows for prompt intervention and has the potential to prevent rapid progression to a severe condition characterized by the presence of extensive vesicles, pustules, and systemic symptoms [12]. Prompt initiation of antiviral therapy, as shown in this case with valacyclovir, in conjunction with supportive measures, including corticosteroids, resulted in a favorable outcome. The comprehensive treatment approach resulted in the resolution of CVD lesions, the disappearance of systemic symptoms, and a decrease in IgE levels. This is consistent with the results of dupilumab treatment, which has been shown to improve the HSV-1-specific immune response in AD as a result of an enhanced type I immune response and a reduction in HSV-1-specific IgE, indicating disease control [13].

Furthermore, the co-occurrence of a mild SARS-CoV-2 infection along with CVD raises interesting questions about the possible interplay of viral infections and their impact on the immune landscape. The absence of severe lung involvement despite a positive RT-PCR for SARS-CoV-2 highlights the diverse and often unpredictable nature of viral manifestations. In addition, SARS-CoV-2 infection showed an increase in pityriasis rosea, which may indicate that SARS-CoV-2 infection triggers herpes viruses [14]. Further investigations should investigate their immunological basis.

In conclusion, this case highlights the need for vigilance and a personalized approach in the management of patients with underlying dermatological diseases following viral infections. Further research is needed to elucidate the immunological aspects of virally induced exacerbations in dermatoses and the effects of immunomodulatory therapies. This will facilitate optimization of patient care and outcomes in such complex clinical scenarios.