The patient  is a thirty-two year old female with three-month history of high fevers which are intermittent. Examination demonstrated multiple erythematous papules on the face and scalp associated with pain, itching, crusting and scarring.

CBC indicated hemoglobin of 13.8 g/dL, white cell count of 18,800 /uL and normal platelet counts of 276,000 per microliter. Examination of the smear demonstrated 86.7% lymphocyte with only 11% neutrophils.

The findings of this case with numerous cytotoxic cells associated with EBV is in keeping with the diagnosis of hydro-vacciniforme-like LPD recognized to be part of the spectrum of cutaneous manifestation of chronic active EBV infection in the WHO 2016 which also includes 'severe mosquito bite allergy' in this spectrum. This condition presents primarily in children and is derived from T-cells with risk of progression to EBV+ NK/T-cell lymphoma.

Learning points:

1. Proliferation of cytotoxic T-cells within lesion with abundant EBV+ cells.
2. Often associated with expansion of gamma-delta T-cells in the blood.
3. Recently, there is a change in the terminology in the new International Consensus classication from "HV-like" LPD to "HV-LPD" recognizing that all these lesions harbor EBV.
4. While the classic form remains skin limited (often in Caucasians), the systemic form is seen more often in patients of Asian ethnicity.