Adrenal necrosis in generalized herpes simplex.

For a number of years after the first isolation of a virus from a case of human keratitis (Griuter, 1913, quoted by Lowenstein, 1919) the true nature of herpes remained in doubt because it did not seem to follow the hitherto accepted pattern of infectious disease (Doerr, 1938). But in 1938 Dodd, Johnston and Buddingh showed that herpes simplex virus could frequently be recovered from the saliva of cases of ulcerative stomatitis in children (Dodd et al., 1938). These findings were confirmed the following year by Burnet and Williams who showed that after the acute phase of the illness herpes-neutralizing antibody appeared for the first time in the blood (Burnet and Williams, 1939). It was thus possible to distinguish between a primary herpetic infection in an individual with no previous immunity and a recurrent infection in which antibody was already present (Andrewes and Carmichael, 1930) and from these observations the modern concept of herpes as an infectious disease has developed (McNair Scott, 1954). As in many other virus diseases inapparent infection is extremely common and it has been estimated that as many as 90 to 95% of all herpetic infections are asymptomatic (McNair Scott, 1954; Blank and Rake, 1955). In symptomatic infections the clinical picture is extremely variable both as regards site of infection and severity (Brain, 1956) and, also, children with eczema are particularly prone to develop a generalized infection due to virus dissemination. This is usually referred to as Kaposi's varicelliform eruption (K.V.E.) or eczema herpeticum. Many of these cases run a severe course (Jackson and Dudgeon, 1951). In recent years another and even more severe form of herpes has been recognized in which there is a fulminating infection with widespread visceral necrosis. Zuelzer and Stulberg first reported from the United States eight such patients among whom the most gross and widespread visceral lesions were found in a group of premature infants (Zuelzer and Stulberg, 1952). Subsequently, in this country, cases have been recorded of generalized herpes with hepatitis and encephalitis in newborn twins (France and Wilmers, 1953) and disseminated herpes with hepatic necrosis and isolation of virus from the liver at necropsy (Pugh, Newns and Dudgeon, 1954). However, visceral necrosis is not confined to this group of fulminating cases but may also occur in K.V.E. An instance of this was the finding of typical viral and atypical necrotic visceral lesions in a fatal case of K.V.E. seen in a small outbreak of herpes in a children's ward (Pugh, Dudgeon and Bodian, 1955). The case described here is another example of fatal K.V.E. occurring in a ward for the treatment of skin disease, in which there were almost certainly two other cases of herpes simplex infection at the same time. After an illness which initially ran a not unusual course sudden deterioration with clinical evidence of adrenal insufficiency developed. At necropsy many necrotic lesions were discovered in both adrenals and herpes simplex virus was recovered from the adrenals, skin, brain, lymph nodes and uvula.