Uncommon Presentation: Simultaneous Herpes Zoster Infection in Immunocompetent Patients

BACKGROUND: Herpes Zoster occurs due to reactivation of the varicella zoster virus (VZV). It mainly affects patients with suppressed cell-mediated immunity, however, there have been cases reported in immunocompetent patients. THE CASES: Case 1: A 26-year-old male presented with severe headache in the frontal region on his right side, nausea and dizziness. Analgesic treatment with oral Diclofenac every 12 hours at unspecified dose was indicated. Three days later she returned with vesicles with erythematous base in the course of the ophthalmic trigeminal branch (Figure 1). The patient referred varicella at 6 years of age. Treatment was started with 1 tablet of Acyclovir 400 mg per oral (PO) every 6 hours for 8 days, Diclofenac Complex B intramuscularly (IM) at a dose of 1 ampoule every 24 hours for six days and sublingual ketorolac every 24 hours for eight days. Case 2: A 19-year-old woman with erythematous lesions with vesicular lesions in the abdominal region. She reported a history of chickenpox at 3 years of age. Treatment with 1 tablet of Acyclovir 400 mg PO every 6 hours for 8 days, B complex with Diclofenac IM every 24 hours for six days and ketorolac sublingual every 24 hours. Case 3: A 56-year-old male with erythematous lesions and papules on the neck with mild pain and a history of chickenpox in childhood, without the presence of any immunosuppressive symptoms. She started treatment with oral acyclovir 400 mg every 8 hours PO for 7 days and diclofenac every 12 hours PO. All three patients presented at the follow-up visit with disappearance of all skin lesions, and without any complication. CONCLUSION: All patients had an atypical presentation, secondary to the lack of a history of immunosuppression. Although advanced age is one of the most important risk factors, the three patients did not meet this factor. There are few cases of immunocompetent patients reported in the literature, which were treated mainly with Acyclovir, as used in our patients, obtaining a positive response. This type of presentation is important for medical literature, mainly because it is not considered as differential diagnosis, therefore it is important to consider it due to the recent cases reported in the last years.