Disseminated Herpes Zoster: Managed by Acyclovir, Intravenous Immunoglobulin, and Granulocyte Colony-stimulating Factor

Dear Editor, A 51-year-old female, a recently diagnosed case of carcinoma breast (T4bN0M0) who was administered four cycles of neo-adjuvant chemotherapy consisting of injection doxorubicin and cyclophosphamide (last dose received 10 days back) and presented with complaints of multiple painful fluid-filled lesions over the body since a week. She initially noticed few tiny fluid-filled lesions over the inner aspect of the left thigh in a linear fashion. Over the next few days, some of the lesions enlarged and coalesced to form larger lesions. She also noticed similar lesions scattered over the face, scalp, trunk, and both upper and lower limbs. The eruption of the lesions all over the body was associated with fever which was high grade, continuous but was not associated with chills or rigors. The pain in the left thigh was sharpshooting in character which was precipitated on touching the affected area or rubbing of clothes. It was severe in intensity which affected her day-to-day activities, any movement or sleep. Dermatological examination revealed involvement of the L1-L4 dermatomes of the left lower limb, in the form of multiple discrete to coalescent vesicles on an erythematous base [Figure 1a]. Nikolsky sign was negative. Multiple similar discrete, scattered lesions were noted over the trunk, arms, face, and scalp with crusting of few lesions [Figure 1b and c]. Tzanck smear from the lesions showed multinucleated giant cells [Figure 1d]. Laboratory investigations revealed pancytopenia with hemoglobin of 8.9 g/dL, total leukocyte count (TLC) – 850/cumm, differential leukocyte count (DLC) – neutrophils-53%, lymphocytes – 33%, and platelets 85,000/cumm. Her liver and renal function tests were within normal limits. Blood glucose levels, serum electrolytes, c-reactive protein, and serum procalcitonin were normal. She was diagnosed a case of disseminated herpes zoster and was admitted to a reverse barrier nursing unit. She was started on intravenous (IV) hydration, IV acyclovir at 10mg/kg/dose for a total of 7 days, once daily injections granulocyte colony-stimulating factor (GCS) 300 mg subcutaneously for three days following which TLC and DLC recovered but anemia persisted. In view of pre-existing immunosuppression, she was also started on IV immunoglobulin (IVIG) infusion at dose of 1g/kg IV infusion over 3 days. Patient responded in 2 days with arrest in fever, appearance of new lesions, and symptomatic improvement with scabbing and crusting of lesions [Figure 2].Figure 1: (a) Involvement of L1-L4 dermatomes of the left lower limb, in the form of multiple discrete to coalescent vesicles on erythematous base. (b and c) Similar but discrete lesions were noted over the face and trunk. (d) Tzanck smear shows multi-nucleated giant cells confirming the diagnosis of disseminated herpes zosterFigure 2: (a and b) Healing of lesions with scabbing and crustingHerpes zoster occurs due to the reactivation of dormant varicella zoster virus in the dorsal sensory root ganglia. This condition is characterized by painful grouped vesicles along the distribution of a single sensory dermatome without crossing the midline, which may be preceded by neuropathic pain.[1] Herpes zoster can also present with multidermatomal involvement at times, which is also known as disseminated herpes zoster. It is defined as at least 20 skin lesions in multiple dermatomes. Disseminated HZ may also present with diffuse typical rash, encephalitis, hepatitis, and pneumonitis occurring in a immunocompromised individual.[2] The risk of zoster increases with old age and in immunocompromised conditions such as patients with hematological malignancies, immunosuppressive and chemotherapies, HIV infection, and transplant recipients. In such patients, the addition of IVIG to IV acyclovir has been proven to have better outcomes and rapid recovery of the patient.[3] We present the case to emphasize on early and aggressive management of disseminated herpes zoster. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.