The patient is a four year-old boy with a three year history of recurrent vesicular lesions around the mouth. He has two to three episodes a month. His mother had a similar problem as a child, but now she takes valcyclovir only on an episodic basis.
He was started on acyclovir and treated with suppressive regimen but he still had breakthroughs. He refuses to take the medication on a regular basis but is willing to take it episodically. (How does one reason with a four year old?)
EXAMINATION: The examination shows a pleasant, outgoing 4-year-old. He has a cluster of vesicles on his left lower lip. A Tzanck smear was positive for multinuclear giant cells.
Clinical Image:
Diagnosis: Recurrent oro-labial herpes simplex in an apparently immunologically normal child.
Questions:
In a normal (stubborn) four year-old, is there any therapeutically suppressive approach that will help? A suspension of acyclovir is available, but famcyclovir and valcyclovir only come as tablets with no pediatric formulations.
Do you know of other instances where frequently recurrent HSV runs in families? It makes sense that there is some subtle problem with normal immune suppression in this family.
Have you had any luck with any of the topical
antivirals? The discounted price of
Denavir (penciclovir) is almost $900 for a 5 gram tube?
