Pediatric burn wound complicated with herpes simplex virus infection: A rare case report and literature review

Mukta Verma

doi:10.4103/ijb.ijb_19_21

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CASE REPORT

Year : 2021 | Volume : 29 | Issue : 1 | Page : 87-89

Pediatric burn wound complicated with herpes simplex virus infection: A rare case report and literature review

Mukta Verma
Department of Plastic and Reconstructive Surgery, Super Speciality Cancer Institute and Hospital, Lucknow, Uttar Pradesh, India

Date of Submission	27-Aug-2021
Date of Decision	03-Dec-2021
Date of Acceptance	05-Jan-2022
Date of Web Publication	08-Jun-2022

Correspondence Address:
Dr. Mukta Verma
8/189, Jankipuram Extension, Sitapur Road, Lucknow - 226 031, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ijb.ijb_19_21

Abstract

Herpes simplex virus infection in major burn wounds is a well-known entity. Here, I am reporting a relatively rare case of a pediatric patient who presented with superficial partial-thickness scald burn injury over his face and neck. He was managed in outpatient department services with topical antibiotic dressings. After 2 weeks, he presented with multiple vesicular lesions over his lower face and neck with delayed wound healing in that area. Clinical suspicion of superadded viral infection was made. Tzanck smear and polymerase chain reaction test confirmed the infection with herpes simplex virus. Antiviral treatment was started, and regular dressings were continued. The patient responded well to the treatment, and lesions were disappeared. Later, he developed hypertrophic scarring over the lower part of face. Now, he is being managed on massage and pressure therapy. There has been no relapse of viral infection till 6 months of follow-up.

Keywords: Burn, herpes simplex virus, infection, pediatric

How to cite this article:
Verma M. Pediatric burn wound complicated with herpes simplex virus infection: A rare case report and literature review. Indian J Burns 2021;29:87-9

How to cite this URL:
Verma M. Pediatric burn wound complicated with herpes simplex virus infection: A rare case report and literature review. Indian J Burns [serial online] 2021 [cited 2023 Jun 8];29:87-9. Available from: https://www.ijburns.com/text.asp?2021/29/1/87/346905

Introduction

Acute management of facial burns is a demanding endeavor with the ultimate goal of optimal esthetic and functional outcomes as the outcome can be critical to patient's positive self-esteem.

Infection is one of the major threats to the patients with burn injuries. Bacterial and fungal infections are more common as compare to viral infections in patients with burn injuries.^[1],[2] Herpes simplex virus (HSV) is a DNA virus and it affects mainly the immunocompromised (malignancy, malnutrition, burn, and transplant-recipient) host.^{[1],[3],[4],[5],[6]} It is more commonly associated with major burn wounds as compared to small and superficial burn wounds.^[6],[7],[8] On thorough research of the existing literature, I could find only a few case reports mentioning the pediatric burn and HSV infection.^{[9],[10],[11]} Primary HSV infection in a pediatric burn patient is a relatively rare entity which has been described in this case report.

Case Report

A 7-year-old boy presented with hot oil scald burn injury over his face and neck involving approximately 5% total body surface area (TBSA). It was superficial partial-thickness burn involving the right side of the face, ear, and neck [Figure 1].

Figure 1: Superficial partial-thickness scald burn involving the right side of the face and upper part of the neck

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Wound was irrigated with large amount of normal saline and dressed with antibiotic (bacitracin) ointment and chlorhexidine-impregnated paraffin gauze. Regular daily dressing was advised, and he was sent to home with a pain killer and multivitamin syrups. The patient again presented on postburn day 15 with multiple vesicular eruptions over his retro-auricular area and neck [Figure 2]. He also complained of itching and redness over that area. These vesicular eruptions were not associated with fever, sore throat, mucositis, and lymphadenopathy. By this time, most of his superficial burnt area over his cheek and nose was re-epithelialized. A clinical suspicion of HSV was made, and consultation with a pediatrician and dermatologist was taken. There was no history of contact, and family history was also insignificant. Culture of vesicular fluid revealed colonization with Staphylococcus aureus. Tzanck smear of vesicular fluid revealed giant multinucleated cells suggestive of herpes simplex viral infection. Polymerase chain reaction (PCR) test confirmed the HSV infection.

Figure 2: Multiple shiny vesicular lesions involving retro-auricular area and neck

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As there were no constitutional symptoms and general condition of the child was fair, oral acyclovir suspension (20 mg/kg/dose; four times a day for 7 days) was given, and the wound was dressed with acyclovir topical ointment along with chlorhexidine-impregnated paraffin gauze (nonadherent dressing). After 5 days of treatment with acyclovir, there was a significant improvement in the vesicular lesions, they started crust formation and itching was reduced. Only a small raw area was leftover forehead on postburn day 25 [Figure 3] for which neomycin antibiotic ointment dressing was continued for about a week.

Figure 3: Healing of vesicular eruptions after antiviral treatment and residual raw area over the forehead which was managed with regular nonadherent antibiotic dressings

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Afterward, the patient was advised to avoid direct sun, and the application of sunscreen was also advised 10 min before going outdoors. He again visited after 20 days with the complaint of severe itching over the re-epithelialized area over the cheek. On examination, redness and hyperpigmentation were present over the cheek, and some amount of hypertrophic scarring was noticed (Vancouver Scar Scale: vascularity -pink [1], pigmentation-hyperpigmentation [2], pliability- supple [1], height- <2mm [1]; total score = 5). Massage with silicone-based formula gel at least five times a day was advised. Pressure garments and the application of silicone gel sheets over the hypertrophied scars as a part of pressure therapy to relieve the symptoms were also advised. Now, he is doing well on massage and pressure therapy regimens.

Discussion

Literature supports that major burn injuries lead to massive inflammatory responses and immunosuppression.^{[1],[2],[4],[6],[8]} Wurzer et al. showed that infection with Herpesviridae family members usually occurred in major burn wounds with 53% TBSA.^[8],[12] As the total burn surface area increases, host immunity decreases. Burn-induced immunosuppression may expose a pediatric burn patient to primary HSV infection.^[1],[2],[8] In the present case, only the right side of the face and neck (5% TBSA) was involved in burn injury, and the wound was infected with HSV. Similar to the results of the current study, Chen et al. and Sobouti et al. reported a rare case of an infant with HSV vesicular lesions developed in minor burn wounds (4% TBSA and 0.5% TBSA, respectively); they emphasized that although such cases rarely happen, a careful medical history and clinical examination are necessary to make the accurate diagnosis and uneventful recovery.^[10],[11]

In burn victims, viral infections promote other bacterial and fungal infections which in turn lead to sepsis and other complications (impaired wound healing, scarring, prolonged hospital stay, and financial losses).^[7] Early detection and prompt management of such infections are a key components in reducing the morbidity and achieving early recovery in burn victims.

The human herpesvirus (HHV) family includes HSV type 1 (HSV-1), HSV-2, varicella-zoster virus, cytomegalovirus, Epstein–Barr viruses, and HHV 6 to 8 [1-4]. HSV-1 infections (oral herpes) are located around the mouth and lips, i.e., above the waist, whereas HSV-2 infections (genital herpes) usually occur on the skin around the genitals, i.e., below the waist.^[3],[13] In burns, primary infection with HSV or reactivation due to immunodeficiency is possible.^[14] Severe HSV infections promote bacterial infections in burns and prolong the postburn recovery process,^[4],[7],[9] and thus, HSV infections can be associated with a higher morbidity and mortality if not addressed in time.^{[1],[2],[3],[10],[13]} Early clinical suspicion and confirmation with the recent advanced molecular diagnostic techniques (genetic engineering: DNA amplification by PCR) are essential to avoid complications. PCR has 96% sensitivity and 99% specificity.^[5],[11] Western blot is the gold standard for the detection of antibodies to HSV. This test is highly sensitive and it can differentiate between HSV-1 and HSV-2 antibodies as well. In this case, only PCR was done to confirm the diagnosis and antiviral treatment was started accordingly. The patient was not hospitalized throughout the course of the treatment as there were no severe complications and he recovered well.

Since HSV infection is very contagious, early detection, isolation, and treatment are essential to avoid future complications.

Consent

Consent has been obtained from the parents of the child for the publication of the clinical case and images.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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