Severe Recurrent Herpes Labialis with Angioedema in a 29-Year-Old Female

Case at a Glance

A 29-year-old female with a history of asthma and recurrent herpes labialis presented with acute, severe lip swelling and lymphadenopathy. Her symptoms progressively worsened despite self-treatment with oral and topical acyclovir, highlighting the need for optimized antiviral therapy.

Patient's Story

The patient, a 29-year-old female with a medical history of asthma and recurrent cold sores (HSV-1), presented with a chief complaint of acute and progressive lip swelling. She reported waking up one morning to find her lip swollen to approximately five times its normal size. Over the following 24 hours, the edema continued to worsen. She also developed tender, palpable lymph nodes under her chin and in her neck. The patient noted that she had recently been treated for a staphylococcal infection in her eye. Concerned by the escalating symptoms, she had initiated self-treatment with ice packs, topical Zovirax (acyclovir) cream, and oral acyclovir tablets from a prior prescription, but observed no improvement.

Initial Assessment

Physical examination revealed significant, tense edema of the lip, consistent with the patient's description. The area was erythematous and tender. Palpation confirmed the presence of tender submental and cervical lymphadenopathy. While a classic vesicular rash was not the primary feature described, the patient's history of recurrent outbreaks in the same location was highly indicative of a herpetic etiology. The primary clinical concern was the severity of the associated angioedema and the lack of response to initial treatment.

The Diagnostic Journey

The diagnosis was made on clinical grounds. The patient's history of recurrent herpes labialis, combined with the acute presentation of localized swelling and regional lymphadenopathy, strongly pointed to a severe HSV-1 flare. The lack of response to her current medication raised suspicion that the dosage or bioavailability of the oral acyclovir was insufficient to manage this severe outbreak. A differential diagnosis including bacterial cellulitis or allergic angioedema was considered but deemed less likely given the classic history of recurrence in the same location.

Final Diagnosis

Severe Recurrent Herpes Labialis (HSV-1) with associated angioedema.

Treatment Plan

Based on the assessment that the current antiviral regimen was suboptimal, the recommendation was to initiate a more aggressive treatment course. The plan involved prescribing a therapeutic dose of an oral antiviral with higher bioavailability, such as valacyclovir. An adequate dosage is critical for controlling viral replication in severe cases. Continued symptomatic management with cold compresses was also advised.

Outcome and Follow-up

Upon starting a high-dose course of valacyclovir, the patient's swelling began to subside within 48-72 hours, with significant improvement in pain and tenderness. The edema and lymphadenopathy fully resolved over 7-10 days. Due to the severity of this episode, the patient was counseled on the option of starting suppressive daily antiviral therapy. This prophylactic approach was recommended to help decrease the frequency and severity of future outbreaks, thereby preventing similar debilitating episodes.