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CORRESPONDENCE
Year : 2020  |  Volume : 65  |  Issue : 3  |  Page : 234-235
Bullous pemphigoid-like presentation of disseminated herpes zoster: A case report


Department of Dermatology, Venereology and Leprology, Mahatma Gandhi Medical College and Research Institute, Puducherry, India

Date of Web Publication14-Apr-2020

Correspondence Address:
Roshni Kakitha
Department of Dermatology, Venereology and Leprology, Mahatma Gandhi Medical College and Research Institute, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_337_18

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How to cite this article:
Kakitha R, Shanmugam S. Bullous pemphigoid-like presentation of disseminated herpes zoster: A case report. Indian J Dermatol 2020;65:234-5

How to cite this URL:
Kakitha R, Shanmugam S. Bullous pemphigoid-like presentation of disseminated herpes zoster: A case report. Indian J Dermatol [serial online] 2020 [cited 2020 Sep 20];65:234-5. Available from: http://www.e-ijd.org/text.asp?2020/65/3/234/282449




Sir,

Herpes zoster is an acute viral infection characterized by vesicular skin lesions in a dermatomal pattern due to reactivation of varicella zoster virus from the dorsal root ganglion.[1],[2] It is characterized by unilateral vesicular eruptions within a dermatome.[3] Disseminated cutaneous zoster has been defined as >20 vesicles outside the area of the primary and adjacent dermatomes.[3] This complication of zoster has been described in the immunocompromised in the form of human immunodeficiency virus (HIV) infections, underlying malignancies (especially lymphoproliferative), immunosuppressive drugs, and sometimes old age and diabetes mellitus.[4]

In a typical case of herpes zoster, the cutaneous lesions are largely localized to the sites of initial involvement and manifestations of a constitutional disturbance are minimal.[2] However, in about 2% to 5% of cases of zoster, hematogenous dissemination of virus occurs and leads to the development of widespread cutaneous lesions.[5]

A previously healthy 74-year-old woman presented to the emergency department with large fluid-filled blisters over the body for last one day. There was a 3-day history of the lesions being limited only to the right thigh with prior numbness and pain before a widespread eruption.

The patient did not give a history of chickenpox during childhood or any recent exposure to it. There was no past history of diabetes, cardiac or pulmonary disease, or any malignancy. The patient was not on immunosuppressive or other medications.

On examination, the patient was afebrile. She had bullae that were present in groups over the face [Figure 1] and were discrete over the trunk and limbs [Figure 2]. Over the thighs, they were large and fusing over an erythematous base [Figure 3].
Figure 1: Facial lesions

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Figure 2: Abdominal lesions

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Figure 3: Thigh showing bullae – dermatomal involvement where lesions started initially Figure 4: Repeat Tzanck smear showing multinucleated giant cells

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Few were clear fluid filled, while few were hemorrhagic. A provisional diagnosis of disseminated herpes zoster or bullous pemphigoid was made. Tzanck smear showed multinucleated giant cells and secondary acantholytic cells [Figure 4] and [Figure 5].
Figure 4: Repeat Tzanck smear showing multinucleated giant cells

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Figure 5: Tzanck smear showing multinucleated giant cells and secondary acantholytic cell

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On clinical examination, large axillary lymphadenopathy was present and complete blood picture with peripheral smear was suggestive of chronic myeloid leukemia.

There was no hepatosplenomegaly. Liver function tests and chest X-ray were normal. Serology for HIV, hepatitis B, and hepatitis C was negative.

The patient was treated with intravenous acyclovir 800 mg 8th hourly.

Although dissemination of herpes zoster in immunosuppression is not so uncommon,[5] this case is worth reporting due to its atypical clinical picture resembling bullous pemphigoid and other bullous disorders. This presentation is one of its kind to the best of our knowledge. It is also worthwhile to notice how a cutaneous condition was a key to the diagnosis of an underlying chronic malignancy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Griffiths C, Barker J, Bleiker T, Chalmers R, Creamer D, editors. Rook's Textbook of Dermatology. 9th ed. Chichester, West Sussex ; Hoboken, NJ: John Wiley & Sons Inc.; 2016.  Back to cited text no. 1
    
2.
Koshy E, Mengting L, Kumar H, Jianbo W. Epidemiology, treatment and prevention of herpes zoster: A comprehensive review. Indian J Dermatol Venereol Leprol 2018;84:251-62.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Malkud S, Patil SM. Disseminated cutaneous herpes zoster in a patient with uncontrolled diabetes mellitus. J Clin Diagn Res 2015;9:WD01-2.  Back to cited text no. 3
    
4.
Kar PK, Ramasastry CV. HIV prevalence in patients with herpes zoster. Indian J Dermatol Venereol Leprol 2003;69:116-9.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Merselis JG Jr., Kaye D, Hook EW. Disseminated herpes zoster. A report of 17 cases. Arch Intern Med 1964;113:679-86.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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