Recurring Herpes Zoster in a Healthy Patient
Case Report Insights are in-depth interviews that take you inside the diagnosis with clinicians who recently published a Consultant case report.
In this Consultant Case Report Insights, Juan Qiu, MD, PhD and Alice Lin, BS, BA, speak about their study, “A Healthy Male With Recalcitrant Herpes Zoster.” Dr Qiu and Alice Lin give a detailed overview of the case they presented, how clinicians can approach the treatment of an unusual case of herpes zoster, and the importance of talking about vaccinations with patients.
Additional Resource:
Qiu J, Lin A, Ferguson S. A healthy male with recalcitrant herpes zoster. Consultant. Published online May 9, 2024. doi:10.25270/con.2024.05.000001
To read the full Photoclinic case report, visit: www.consultant360.com/photoclinic/healthy-male-recalcitrant-herpes-zoster
Juan Qiu, MD, PhD, is a professor and family physician in the Department of Family Medicine at Pennsylvania State University (State College, PA)
Alice Lin, BS, BA, is currently a third-year medical student at the University of Pittsburgh School of Medicine (Pittsburgh, PA)
TRANSCRIPTION:
Juan Qiu MD, PhD: Hello, my name is Juan Qiu. I'm a professor and family physician in the Department of Family Medicine in the Pennsylvania State University College of Medicine. I currently practice medicine in State College, Pennsylvania in the College of Medicine, the University Park Regional Campus in State College, Pennsylvania. Thank you.
Alice Lin, BS, BA: My name is Alice Lin, and I'm a third-year medical student at the University of Pittsburgh School of Medicine.
Consultant360: How did you approach this case and did your approach change during the patient’s continuum of care?
Dr Qiu: This patient is an otherwise healthy 62-year-old male. He presented to my clinic with a painful vesicular rash on his right mid-back and chest in the distinct T5 to T7 dermatomes after several days of a burning sensation in the same location. This clinical presentation is typical for herpes zoster, so I really did not have any doubt that it was the right diagnosis.
I treated him with the conventional seven-day course of valacyclovir 1,000 milligrams three times a day. His pain improved, and the rash fully crusted as expected. Two days after he finished valacyclovir, the burning sensation recurred, followed by the appearance of a few new vesicles in the same area. He was treated with another course of valacyclovir—1,000 milligrams three times a day for seven days—and his symptoms resolved. However, two weeks after he completed the second course of valacyclovir, the burning sensation recurred on the right chest slightly above the previous rash area in the, now, T3 to T4 dermatomes.
I felt this was quite unusual and I treated him with the third course of valacyclovir 1,000 milligrams three times a day for seven days, followed by 500 milligrams of valacyclovir daily to prevent the recurrence. His symptoms resolved, however, two weeks later, the burning sensation recurred while the patient was still taking the 500 milligrams valacyclovir daily to prevent the recurrence.
Dr Qiu: At this point, I was really concerned and puzzled. I was concerned about immunodeficiency. I recommended evaluation for immunodeficiency because this is quite unusual. I have never seen that herpes zoster recur so many times with appropriate treatment. The patient declined the evaluation because he had been very healthy, and he really did not believe that he had any immunodeficiency.
At this point I decided to refer the patient to an infectious disease specialist who felt that the patient's zoster was undertreated, and he prescribed valacyclovir 1,000 milligrams three times a day for two weeks. The patient finished the treatment. Fortunately, he has not had any recurrence of the symptoms.
C360: What was the key piece of information or data point that confirmed your diagnosis? How did it help you determine the patient’s diagnosis of herpes zoster?
Alice Lin: As Dr Qiu mentioned, in immunocompetent individuals, diagnosis of uncomplicated herpes zoster is usually based solely on clinical presentation of a unilateral painful vesicular eruption within well-defined dermatomes. This patient was otherwise healthy and presented with a painful vesicular rash in the T5 through T7 dermatomes after several days of burning sensation in the same location, which is typical of herpes zoster. In addition, he had a history of chicken pox in childhood, which further supported the diagnosis.
C360: Could you elaborate on the significance of recurring symptoms in this case, particularly after the standard 7-day valacyclovir treatment?
Dr Qiu: This case really highlights an unusual presentation of acute herpes zoster symptoms in an otherwise healthy male that recurred three times each within 2 weeks after the standard 7-day valacyclovir treatment. I think that a patient with herpes zoster fails to respond to conventional antiviral treatment could be due to several reasons. One is acyclovir-resistant herpes zoster virus; two: an underlying immunodeficiency; and three: chronic herpes zoster or under treatment of the condition.
So let me elaborate a little bit on each of those. For number one, acyclovir-resistant herpes zoster virus: it has been identified in high-risk immunocompromised patients on long-term acyclovir treatment. It is, however, very rare in immunocompetent populations. The prevalence for this is very low, less than 0 .7%. The fact that the lesion in our patient resolved after each treatment and recurred within two weeks of treatment makes acyclovir-resistant herpes zoster virus pretty unlikely.
Number two: regarding immunodeficiency. A patient with underlying immunodeficiency may develop new lesions more than a week after presentation. Our patient was otherwise healthy and at low risk for immunodeficiency. Nevertheless, he was offered evaluation for immunodeficiency, but he declined.
Number three: there is no literature report on chronic cutaneous zoster. Although chronic herpes zoster ophthalmicus (herpes zoster in the eyes) are not uncommon, but not on the skin.
Finally, the fact that a longer course of valacyclovir treatment was successful for long-lasting resolution of symptoms suggested that our patient was undertreated initially with the conventional 7-day treatment. So why did this patient need a longer than 7-day conventional treatment regimen? While most patients with herpes zoster have a rash over one to two dermatomes, interestingly, at least four continuous dermatomes and large areas of the skin from the back to the chest were involved in this patient. So, I think it's possible that this may denote larger burdens of the disease that require longer treatment strategies.
C360: What are the potential areas for future research on this topic?
Alice Lin: There's currently no literature on longer antiviral treatment for acute herpes zoster. So future research is needed to determine the optimal treatment duration for acute herpes zoster, involving larger areas of the skin and multiple dermatomes.
C360: What did you learn from this case and how does this case contribute to the current knowledge of herpes zoster in the primary care setting?
Alice Lin: As we discussed already, herpes zoster is a very common condition encountered by primary care providers, and most immunocompetent patients respond to the conventional seven-day antiviral treatment. However, if a patient's symptoms recur shortly after treatment, providers should consider the possibility of undertreatment, especially if the rash occurs in a large area with more than two to three dermatomes.
It may also be reasonable to empirically treat these patients for a longer duration, for example, at least two weeks. And in these instances, providers should also consider an immunodeficiency evaluation.
Dr Qiu: This presentation is quite unusual and we as a primary care physician normally do not see these recurrences so many times. So, Alice’s two points are very valid.
C360: Are there any points you would like to add that may be valuable for our audience to know?
Dr Qiu: I will go ahead and add a couple of points here. Number one, if unclear about treatment, consult an infectious disease specialist.
Number two, as a primary care physician, I think this case also underscores the importance of vaccination against herpes zoster. Shingrix is a recombinant adjuvant vaccine indicated for immunocompetent adults aged 50 and above, as well as immunocompromised adults aged 19 and over. The overall efficacy is high at 97% against herpes disaster and 91% against postherpetic neuralgia. The protection duration against herpes zoster is more than 10 years. I believe that vaccination is very, very important. Often patients ask me: “If I have had herpes zoster, do I still need this Shingrix vaccine?” The answer is “yes.”
There is no specific amount of time to wait before administering Shingrix vaccine to patients who have had herpes zoster. However, patients should not receive the Shingrix vaccine when they are experiencing acute herpes zoster episode. As a primary care physician, we need to educate our patients and hopefully, that will increase the vaccination rate in the general population.