Small Vessel Vasculitis in Herpes Zoster—Discussion of Current Aspects of Varicella Zoster Virus Vasculopathy

Abstract

Varicella zoster virus (VZV) vasculopathy was initially described as herpes zoster ophthalmicus with contralateral hemiplegia in 1896. VZV is able to infect endothelial cells directly, leading to a thickened intima and vascular remodeling due to inflammation. Therefore, a spectrum of vasculopathies is induced, ranging from a discrete capillaritis-to-granulomatous vasculitis and obliterative angiitis. Cutaneous vasculitic changes sui generis with leukocytoclasia, cell debris, vascular damage, and endothelial swelling are very rare feature of herpetic infections in skin biopsies. We report an immunocompetent patient who presented with a rare form of cutaneous VZV infection of the upper leg characterized by vasculitic changes of the small vessels without typical herpetic epidermal features or neural involvement. Intriguingly, the vasculitis appeared prior to the characteristic vesicular rush without any pain symptoms. Because VZV can cause vasculopathic damage mainly within the central nervous system in immunocompetent and immunosuppressed patients, we recommend continuous clinical controls to recognize central symptoms that are related to VZV vasculopathy or giant cell arteriitis.

A case of synchronous herpes zoster infection and leukocytoclastic vasculitis localized to the same dermatome

“…12 Additionally, dermatomal LCV prior to the diagnosis of zoster infection has also been reported. 8 Our case demonstrates the onset of localized bullous HZ and coincident small-vessel LCV to the same dermatomal distribution, raising our awareness of such a synchronous clinical manifestation even in a setting of shortterm immunosuppression.…”

“…[2][3][4] Additionally, the virus can affect all vessel types, as small, medium, and large vessel vasculitides related to VZV infection have been described. 2,5,6 While some rare reports demonstrate clinical signs of vasculitis prior to the classic VZV cutaneous eruption, 7,8 the majority of reports demonstrate vasculitis after VZV infection. 2,5 Evidence of LCV with a synchronous VZV infection has been rarely reported.…”

Cutaneous Vasculitis and Central Nervous System Infarctions due to Varicella Zoster Virus Vasculopathy in an Immunocompromised Patient

“…Therefore, rapid diagnosis is essential. Interestingly, our patient did not present with the classic vesicular rash of VZV but rather with cutaneous vasculitis, which is often painless, thought to be a rare manifestation of VZV infection, and reported as preceding the classic vesicular rash [3][4][5]. In our patient's case, a high degree of clinical suspicion was needed to make the diagnosis.…”

Painful cutaneous lesions on the hand palm after Takotsubo cardiomyopathy and coronary angiography

“…VZV is able to produce vasculopathy as a result of endothelial cell infection that generates inflammation, thickened intima and vascular remodelling. The VZV‐mediated vasculopathies include capillaritis, granulomatous vasculitis and occlusive vasculopathy 3 …”

“…Varicella zoster virus (VZV) is an alpha herpesvirus that causes varicella and HZ. [1][2][3] Cutaneous manifestations of HZ include pruritus and intense pain, along with grouped vesicles on an erythematous base in a dermatomal pattern. Sometimes, mainly in immunosuppressed patients, VZV displays atypical clinical presentations, making it difficult to diagnose.…”