We present a rare cutaneous presentation of herpes simplex virus type 1 (HSV-1). A 79-year-old patient was admitted to the ICU with respiratory failure due to bilateral pneumonia complicated by development of a non-dermatomal pruritic rash on his back. The rash was characterised by partly confluent pustules with a raised erythematous base. A skin biopsy was taken and serological tests were performed. Skin biopsy showed typical cytopathic effects of herpetic infection: ground-glass nuclei, multinucleation, moulding, intranuclear inclusion bodies and acantholysis. Immunohistochemical stain on skin biopsy showed HSV positivity. Polymerase chain reaction with skin biopsy confirmed HSV-1 infection. No antiviral medication was started since the erythematous stage of the illness had pasted. After five weeks the patient was discharged from the hospital.
Conclusion: Besides orolabial lesions, reactivation of HSV-1 infection can present anywhere on the body. HSV-1 reactivation is common with prolonged sepsis and seems related to development of an immunosuppressive state. Our patient developed a widespread HSV-1 infection on his back. The unusual distribution of his skin lesions was probably triggered by the abrasive properties of a bed causing disruption of skin integrity and enabled cutaneous extension of the infection. Skin biopsy was of greatest value since the gross morphology of the lesions was not diagnostic or characteristic.
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