Disseminated Cutaneous Herpes in a Patient With Rheumatoid Arthritis
A 70-year-old man was admitted with generalized erythematous-violaceous cutaneous vesicles and papules, some of which with ulcerated center, besides oral moniliasis (Fig. A and B), rheumatoid arthritis (RA) 20 years ago, irregular use of methotrexate 15 mg weekly, and smoking 20 pack-years. Patient did not receive corticosteroids or biological therapy in the last few years. There were no signs of neurological impairment or joint activity. C-reactive protein was 54.2 mg/L. He was anti–herpes simplex virus types 1 and 2 immunoglobulin G positive, and immunoglobulin M negative. Serology for HIV was negative. Blood count, serum biochemistry, and renal and liver function were within reference ranges. In view of the disseminated cutaneous herpes hypothesis, acyclovir was instituted. Biopsies of lesions were performed and showed keratinocytes with viral inclusions (Fig. C). Disseminated cutaneous herpes is the result of reactivation of latent virus. Both varicella and herpes simplex virus types 1 and 2 have been found in blood and synovial fluid from patients with RA.1 Patients with RA have a 2-fold increased risk of herpes zoster compared with general population.2 Rheumatoid arthritis disease severity, aging, increased burden of comorbidity, disease-modifying antirheumatic drugs, and biological agents have been associated with herpes infection.1–3 Other differential diagnoses should be considered as coxsackiosis, bacillary angiomatosis, erythema multiforme, and Kaposi sarcoma.