Painless Multidermatomal Herpes Zoster in an Immunocompetent Elderly Male: a Case Report

Abstract

The varicella-zoster virus is the cause of both varicella and herpes zoster. The primary infection of varicella includes viremia and a widespread eruption, after which the virus persists in nerve ganglion cells, usually sensory. Herpes zoster is the result of reactivation of this residual latent virus. The first manifestation of zoster is usually pain, which may be severe and accompanied by fever, headache, malaise and tenderness localized to one or more nerve roots. The lymph nodes draining the affected area are enlarged and tender. Occasionally, the pain is not followed by eruption (zoster sine herpete). We hereby report an 85-year-old otherwise healthy male patient with a 3-day history of a non-painful rash on the left side of abdomen, pubic and penile regions, left groin and the left leg. He denied any pain and/or abnormal sensations before the rash onset. On examination, there were closely grouped multiple vesicles over the anterior left abdominal wall, left groin, thigh, knee and left upper quarter of penis, involving the left T12, L1-L4 and S2 dermatomes. The patient reported no pain, fever, rigor or any other symptoms; he had no associated cervical, axillary or inguinal lymphadenopathy. He denied any abdominal pain, nausea, vomiting, any weakness or sensory changes in the limbs. There was no history of penile numbness, urinary retention, and increased frequency of micturition or constipation. The varicella-zoster virus serology test performed by Calbiotech VZV IgG ELISA Kit (Calbiotech, Spring Valley, Canada) was strongly positive. The human immunodeficiency virus serology test, as well as herpes simplex virus type 1 and type 2 serology tests performed by ELISA were all negative. The Tzanck smear, stained with Giemsa, demonstrated multinucleated giant cells. The patient responded well to valacyclovir with complete clearance of lesions within one week. An extensive PubMed search revealed only few reports of painless herpes zoster. We present a rather peculiar case of painless herpes zoster in an elderly patient with no apparent systemic immunosuppression, with severe involvement affecting multiple adjacent and one remote dermatome. We hereby propose the term ”herpes zoster sine algesia” in cases where eruption is not followed by pain.

Guillain Barre syndrome mimicking brain death

“…Herpetic blisters are usually painful, but near-painless herpetic blisters have also been reported. 4,5 She was put on mechanical ventilatory support because of type 2 respiratory failure. Causes for fixed dilated pupils with altered sensorium were considered (Table 2).…”

An atypical presentation of multidermatomal herpes zoster: a case report

“…Only a few cases of multidermatomal Herpes Zoster have been reported in the literature. Furthermore, only a handful number of cases with this manifestation were described in healthy immunocompetent individuals [ 9 , 10 ]. A recent case report by Beuerlein et al [ 11 ] summarised the published cases of multidermatomal HZ and found only 9 cases in the literature.…”

Varicella-zoster meningitis in an immunocompetent young man presenting with a painless erythematous rash

“…Hence, in our patient, the occurrence of HZ with complete absence of any preherpetic or postherpetic neuralgia is perplexing. At present, only a few cases of painless HZ have been described in the literature 10–13…”