Diffuse Large B-Cell Lymphoma at the Site of a Herpes Zoster Scar

Abstract

Herpes zoster, also known as shingles, occurs upon reactivation of a primary infection with varicella zoster virus (VZV). Risk factors for reactivation include stress, older age, and immunosuppression, all of which are associated with a decrease in host immunity. Common complications of herpes zoster include scarring and post-herpetic neuralgia (PHN). Cutaneous lesions such as granuloma annulare, lymphomas, and sarcoid granulomas have also been reported to potentially arise at the site of herpes zoster. Here, we report a case that to our knowledge is the first presentation of diffuse large B-cell lymphoma with its only cutaneous manifestation arising in a herpes zoster scar. Punch biopsy was performed on a nodule appearing in a dermatomal distribution within the herpes zoster scar. Histopathology revealed an atypical lymphoid infiltrate in the dermis that was determined to be CD20 positive B-cells. Immunostains for CD20, CD79a, and PAX-5 showed strong positive staining of the atypical cells, confirming B-cell origin and resulting in the diagnosis of lymphoma, large B-cell type. This case highlights the importance of raising clinical suspicion for a malignant process in patients who present with a changing or unresolving skin manifestation after infection with varicella zoster virus.

Zosteriform mycosis fungoides and lymphomatoid papulosis arising in an area of prior herpes zoster

“…Multiple cutaneous malignancies have been reported within areas of prior herpes zoster, including squamous cell carcinoma, angiosarcoma, Kaposi sarcoma, CTCL, and cutaneous B-cell lymphoma. 6 , 7 , 8 , 9 , 10 Zosteriform MF is an exceedingly rare variant of MF characterized by lesions that occur in a dermatomal distribution. 11 In 1991, Williams et al 12 described a case in which several firm nodules in a zosteriform distribution over the left neck and shoulder were found to be MF on biopsy.…”

Varicella zoster virus presenting as lower extremity ulcers and an atypical myeloid infiltrate

“… 3 In addition to mimicking neoplasms, cutaneous VZV may serve as the initial locale of hematologic malignancies. 4 As VZV may demonstrate either histopathologic mimicry or Wolf's isotopic response, a complete workup may include bone marrow analysis.…”

The beneficial effects of varicella zoster virus

“…VZV infections have been reported to cause not only transient pancytopenia but also aplastic anemia that may require allogeneic HSCT [66,227,[235][236][237]. Several studies have shown that HZ is associated with increased risk of developing solid tumors as well as lymphoid malignancies [238][239][240][241][242].…”