Disseminated Herpes Zoster in an Apparently Healthy Middle-Aged Woman

Abstract

H erpes zoster is a characteristic dermatomal maculovesicular rash that results from reactivation of varicella-zoster virus (VZV). Dissemination, or widespread distribution of vesicular lesions beyond the limits of the primarily involved dermatome, occurs almost exclusively in individuals with severe underlying immunodeficiency, such as malignancy, human immunodeficiency virus, and advanced age. Waning cell-mediated immunity is thought to be the final common pathway permitting reactivation and dissemination. Here, however, we present a case of disseminated herpes zoster (DHZ) that occurred in an apparently immunocompetent patient without any traditional risk factors. CaseUpon returning from a vacation in Palm Springs, California, a 58-year-old white female presented to the emergency department (ED) with a 5-day history of headache and progressive pain, redness, and rash over her right forehead and eyelid. Pain was the initial manifestation, with small vesicles then appearing at her hairline and progressing caudally to involve the eyelid (Figure 1). In addition to significant periorbital edema, she reported a "burning" sensation in her right eye. While still on vacation, on the day prior to her presentation, she had presented to an ED and was given a prescription for acyclovir 800 mg PO five times daily. This patient suffered from hypertension, hypercholesterolemia, a longstanding peripheral sensory neuropathy that had not yet been diagnosed, and chronic ethanol abuse (one bottle of wine per day for at least 10 years) and had a previous 60 pack-year smoking history. She had no known history of immunodeficiency or malignancy. Her medications included a perindopril/indapamide combination tablet and the recently prescribed acyclovir. She reported an allergy to penicillin, the nature of which was unclear.On examination, she was febrile, with a temperature of 38.4°C; the remainder of her vital signs were within normal limits. An exquisitely tender, erythematous, papulovesicular rash covered her right forehead and eyelid but spared the tip of her nose and did not cross the midline. She had significant periorbital and eyelid edema, effectively closing her right eye. She had jolt accentuation of her headache but no other signs of meningismus. On her torso, back, right arm, and right upper thigh, she had multiple (>30) small erythematous, non-tender About the Authors