Disseminated Skin lesions on an immunocompromised patient Authors: Jose Javier GuzmĂĄn; Ileana Violeta Barrientos; Marielys Otero Maldonado
Abstract: Herpes Zoster or Shingles results from reactivation of endogenous latent Varizella-Zoster Virus (VZV) within the sensory ganglia. It is an acute vesicular cutaneous infection typically presenting in dermatomal distribution. Non-contiguous multidermatomal herpes zoster is very rare in both immunocompetent and immunocompromised patients, with an incidence of less than 0.1% of cases. We herein report a case of a 56 year old male that presented with extensive painful vesicular cutaneous lesions on his trunk, arms, armpits, legs, head and groin of 4 days of progression consistent with non-contiguous bilateral HZV infection (ICD10 diagnostic code B.02.7) that also developed a superimposed fungal and bacterial infection. The patient had been treated for Granulomatosis with Polyangiitis (GPA) with methylprednisolone for the last two years. He was successfully treated with antiviral therapy for 21 days. These patients, especially immunocompromised ones, are at risk of serious life threatening complications like encephalitis. Therefore, for the purpose of rapid diagnosis and initiation of appropriate therapy clinicians should be aware of these more atypical presentations of VZV infection.
Case Description: A 56 year old male with past medical history of type 2 Diabetes Mellitus, Asthma, Hypertension, and Hypothyroidism; was diagnosed with Granulomatosis with Polyangiitis in October 2013. At that time, he was started on Cyclophosphamide for four months until the condition was stabilized and was currently on immunosuppressive therapy with methylprednisolone 16mg daily. The patient presented to the Emergency Department due to a painful rash that started 4 days before. He stated that the rash started with a burning sensation on the right armpit, afterwards he noticed an eruption of vesicles that spread to the chest, back, groin and extremities associated with pruritus, redness,
warmth and tenderness of affected areas of the skin. The patient denied any fever, chills, hemoptysis, cough, dysuria or hematuria. On examination, the patient was hemodynamically stable and in no distress. He presented with painful vesicular lesions on the anterior and posterior thorax, neck, abdomen, both arms and right armpit in different stages and some of them crusted. Also noticed were multiple ring enhancing lesions associated to vesicular groups on the right armpit, right upper back, left lower back, lower abdomen and right forearm. He was admitted with a diagnosis of Disseminated Herpes Zoster (ICD10 diagnostic code B.02.7) with a superimposed bacterial and fungal skin infection. The patient was placed on airborne isolation and was evaluated by the Infectious Diseases specialist who started the patient on Acyclovir 700 mg IV every 8h for the HZV infection, cefazolin 500mg IV every 8h to cover the skin organism causing cellulitis and fluconazole 200mg orally daily for the superimposed Tinea Corporis. On the 4th day of therapy some improvement was observed. The patient referred less pain, and less itchiness. Renal function was monitored closely during hospitalization to avoid any kidney injury secondary to antiviral therapy and other adverse effects given the patient’s underlying disease. Steroid therapy was tapered down to prevent further spreading and complications of infection. The patient was monitored daily for any visual loss, hearing loss, fever, hematuria or cough that could suggest complications. The patient was successfully treated with acyclovir for 14 days IV and switched to acyclovir PO for 7 more days to complete 21 days, Cefazolin for 10 days and then switched to PO Cephalexin to complete 14 days and fluconazole for 14 days.
Discussion: Dissemination of Herpes Zoster is defined as more than 20 vesicles outside primary and adjacent dermatomes(1). Noncontiguous multidermatomal herpes zoster is very rare in both immunocompetent and immunocompromised individuals. Medicina de Familia Diciembre 2016-29