Hemorrhagic herpes zoster duplex bilateralis symmetricus: A rare dual phenomenon

Background: Herpes zoster (HZ) arises from the reactivation of dormant varicella-zoster virus, most often affecting elderly patients due to immunosenescence and comorbidities. Rare clinical variants encompass herpes zoster duplex (HZD), characterized by simultaneous involvement of two non-contiguous dermatomes, occurring in less than 0.1% of HZ cases, and hemorrhagic HZ, frequently linked to anticoagulant therapy. We present the case of a 63-year-old male with hemorrhagic HZD bilateralis symmetricus (HZDBS), uncontrolled diabetes mellitus, and atrial fibrillation on warfarin therapy. The patient presented with painful, yellowish-red fluid-filled vesicles over both lower legs and dorsal feet for one week, preceded by neuropathic pain. Dermatological examination revealed bilateral symmetrical vesicles along L4-S1 dermatomes. Tzanck smear demonstrated multinucleated giant cells. Laboratory results were remarkable, except for elevated HbA1c. The patient was prescribed oral acyclovir, gabapentin, and topical therapy. Clinical improvement was noted by day 8, with complete resolution and post-inflammatory hyperpigmentation by day 22. No complications or recurrence were observed at three months. This case exemplifies a rare dual phenomenon of hemorrhagic HZDBS in an elderly patient. Timely recognition of atypical HZ variants in elderly patients with comorbidities and anticoagulant use is warranted, as timely antiviral therapy may lead to a favorable outcome.