Disseminated herpes simplex virus type 1 treated with ixekizumab in a patient with erythrodermic psoriasis: A case report

Table 1 Timeline of clinical course, investigations, and interventions

Date/interval	Clinical events	Investigations/labs/vitals	Interventions	Outcomes
2 weeks before first hospital admission	Severe itching and erythema of upper extremities progressing rapidly	-	Self-initiated oral prednisone (unprescribed) → discontinued at dermatology visit; switched to topical corticosteroids and moisturizers	Erythema progressed to > 75% BSA
3 days later	Worsening erythema with fever	Vitals: BP 115/70 mmHg, HR 110 bpm, Temp 38.2 °C, RR 22/min, SpO2 96% RA. Labs: WBC 13.5 × 109/L, eosinophils 0.8 × 109/L, CRP 45 mg/L, other labs normal	Infliximab infusion (5 mg/kg)	No improvement; admitted for first hospitalization
First hospital admission	Diffuse erythema (> 75% BSA) with fever	As above	Broad-spectrum antibiotics → de-escalated to MSSA coverage; discharged on oral Augmentin	Temporary stabilization
10 days later (second admission, ICU)	Increasing chills, diffuse edema, worsening erythema (> 90% BSA). PASI 45 calculated	Vitals: BP 85/55 mmHg, HR 125 bpm, Temp 39.0 °C, RR 28/minutes, SpO2 91% on 2 L O2. Labs: WBC 17.2 × 109/L, eosinophils 1.2 × 109/L, CRP 120 mg/L, albumin 2.6 g/dL, Na 131 mmol/L, creatinine 09 mg/dL	ICU admission; fluid resuscitation	Hemodynamically unstable
Early ICU course (second admission)	Confluent erythroderma and desquamation	Punch biopsy performed: Hypogranulosis, ectatic dermal vessels, neutrophils in stratum corneum, scattered dermal eosinophils	Ixekizumab initiated; topical clobetasol approximately 30 g/day	Recurrent bacteremias; progressive decline in consciousness (GCS 7/15); intubated
1 week after ixekizumab	Disseminated vesicles, erosions, hemorrhagic crusts (Figure 2)	HSV-1 PCR positive	IV acyclovir 5 mg/kg q8h; clobetasol stopped; ixekizumab withheld	Gradual clinical improvement
10 days later	Improvement in HSV lesions	-	Topical corticosteroids reintroduced; ixekizumab restarted	Steady recovery (Figure 3)
6-week follow-up	Resolution of widespread erythema and palmoplantar scaling (PASI 9.7)	-	Continued ixekizumab; oral acyclovir prophylaxis	Stable improvement; no relapses (Figure 3)

BSA: Body surface area; BP: Blood pressure; HR: Heart rate; Temp: Temperature; RR: Respiratory rate; SpO₂: Peripheral capillary oxygen saturation; RA: Room air; WBC: White blood cell count; CRP: C-reactive protein; MSSA: Methicillin-sensitive staphylococcus aureus; ICU: Intensive care unit; PASI: Psoriasis Area and Severity Index; Na: Sodium; HSV-1: Herpes simplex virus type 1; IV: Intravenous; q8h: Every 8 hours (dosing interval); GCS: Glasgow Coma Scale.