Peer Reviewed

Photoclinic

Disseminated Cutaneous Herpes Zoster in an Immunocompetent Woman With Diabetes

Volume 56 - Issue 9 - September 2016

AUTHORS:
Chetan Dhoble, MD; Julie Taylor, MD; and Wahaj Ahmed, MD

CITATION:
Dhoble C, Taylor J, Ahmed W. Disseminated cutaneous herpes zoster in an immunocompetent woman with diabetes. Consultant. 2016;56(9, Suppl):S15-S16.

 

A previously healthy 39-year-old woman presented with a 2-day history of severe pain, fever, and a vesicular eruption that had initially developed over her right forehead and right middle thumb but had spread to involve her chest, back, and upper and lower extremities bilaterally.

History. The woman’s medical history was negative for chickenpox during childhood and for any recent exposure to it. She had diabetes and deep vein thrombosis but no history of lymphoma. She had undergone amputation of her left great toe a week prior secondary to osteomyelitis. Her medications included ciprofloxacin and clindamycin, alogliptin and pioglitazone, and apixaban. She was allergic to enoxaparin sodium, with a history of anaphylactic reaction to it.

Physical examination. On examination, the patient was febrile (temperature, 38.3°C), with a heart rate of 122 beats/min. Pustules and vesicles at different stages of development with crusting and swelling were present on her trunk and extremities, including the palms and soles. Scabs and pustules were seen on the face, trunk and extremities (Figures). The oropharynx was spared. Examination findings of the head, eyes, ears, nose, and throat, as well as the cardiovascular system, the pulmonary system, and the abdomen were all within normal limits.

Herpes zoster

Herpes zoster on hand

Herpes zoster

Diagnostic tests. Results of a complete blood cell count, peripheral smear, comprehensive metabolic profile, urinalysis, chest radiography, and electrocardiography were normal. Serologic tests for HIV, syphilis, and hepatitis A, B, and C were negative. Results of polymerase chain reaction (PCR) and antibody tests for herpes simplex virus (HSV) were negative, while PCR results for varicella-zoster virus (VZV) were positive. The VZV immunoglobulin M immune status ratio (ISR) was 1.29 (reference value, ≤ 0.91), and VZV immunoglobulin G was 2.33 (reference value, ≥ 1.09).

Discussion. Herpes zoster (HZ) is the consequence of reactivation of latent VZV from dorsal root ganglia. Disseminated cutaneous HZ (DCHZ) is by definition the presence of greater than 20 lesions outside the area of primary or adjacent dermatomes.1 It presents within a week of the primary lesion. Greater than 65% cases of HZ are in persons at least 50 years of age,2 unlike our patient, who was 39.

DCHZ is most commonly seen in immunocompromised patients such as those with malignancy, with HIV disease, with a recent solid organ transplant, or on immunosuppressive drugs such as corticosteroids.2 However, it is very unusual for a healthy person such as our patient to present with DCHZ. While 10% to 40% of HZ-infected immunocompromised patients present with DCHZ, the prevalence of DCHZ in immunocompetent patients has not been established.2

Although our patient was only 39 years of age and was immunocompetent, her diabetes may have contributed to the development of DCHZ. The incidence of HZ is higher in persons with diabetes because of the low VZV-specific immunity.3-5 Very limited studies of patients with DCVZ and diabetes have been published.6,7

DCHZ treatment is intravenous acyclovir, 10 mg/kg every 8 hours for 5 to 7 days.8 Aggressive treatment is critical in a patient with diabetes, even if the patient is immunocompetent. DCHZ is a serious condition for which early diagnosis and prompt aggressive treatment are crucial to decrease morbidity and complications.

Outcome of the case. The patient’s condition improved, with the cessation of new vesicle eruption and resolving of the rash, after 3 days of treatment. She was discharged on oral acyclovir, 800 mg 4 times daily for 10 days.

Chetan Dhoble, MD, is in the Department of Internal Medicine at Getwell Hospital and Research Center in Nagpur, India.

Julie Taylor, MD, is in the Department of Family Medicine at Advocate Trinity Hospital in Chicago, Illinois.

Wahaj Ahmed, MD, is in the Department of Internal Medicine at Mount Sinai Hospital in Chicago, Illinois.

Alaine S. Ainsley, MD, is a graduate student at Atlantic University School of Medicine in Saint Lucia.

REFERENCES:

  1. Brown TJ, McCrary M, Tyring SK. Antiviral agents: nonantiviral drugs. J Am Acad Dermatol. 2002;​47(4):​​581-599.
  2. Arvin AM. Varicella-zoster virus. Clin Microbiol Rev. 1996;9(3):361-381.
  3. Aldaz P, Díaz JA, Loayssa JR, Dronda MJ, Oscáriz M, Castilla J. Herpes zoster incidence in diabetic patients. An Sist Sanit Navar. 2013;36(1):57-62.
  4. Hata A, Kuniyoshi M, Ohkusa Y. Risk of herpes zoster in patients with underlying diseases: a retrospective hospital-based cohort study. Infection. 2011;​39(6):537-544.
  5. Heymann AD, Chodick G, Karpati T, et al. Diabetes as a risk factor for herpes zoster infection: results of a population-based study in Israel. Infection. 2008;​36(3):226-230.
  6. Graue N, Grabbe S, Dissemond J. Disseminated herpes zoster in diabetes mellitus. Dtsch Med Wochenschr. 2006;131(8):384-386.
  7. Panwar RB, Kochar DK, Gupta BS, Bhatnagar LK, Saxena HC. Herpes generalisata associated with diabetes mellitus and pulmonary tuberculosis (a case report). J Postgrad Med. 1979;25(3):171-173.
  8. Gupta S, Jain A, Gardiner C, Tyring SK. A rare case of disseminated cutaneous zoster in an immunocompetent patient. BMC Fam Pract. 2005;6:50.