A 25 year old male with a history of acute myeloid leukemia (AML) after an allogeneic stem cell transplant, which has been in remission for 6 years. He presents with a headache and rash. 4 days ago the patient noticed a rash on the abdomen that was itchy, but not painful. Today, he noticed a similar rash on his face.
The headache started yesterday, waking him up from sleep. It is now slowly getting worse. He endorses chills, nausea, neck stiffness, neck pain, myalgias, and photophobia. He denies fevers, vomiting and phonophobia. He does have small headaches regularly but this headache is one of the most painful of his life. He does not take any immunosuppressants or medications.
Vitals: Temp 98.2F; HR 84; RR 18; BP 136/103
HENT: Dry mucous membranes
Neck: Nuchal rigidity present
Neurological: He is alert and oriented to person, place, and time. He has normal muscle tone and coordination, 5/5 strength in all extremities, intact light touch sensation, normal cranial nerves, and a normal steady gait.
Skin: There is a 3 cm x 3 cm maculopapular rash with small grouped vesicles in the center of the abdomen. Smaller 1 cm x 1 cm maculopapular patches on the right side of the abdomen, bilateral chest wall, and bilateral upper back are seen. There is also a 3 cm x 3 cm maculopapular rash on the right cheek.
CBC: WBC 14.7 K/mcL; Neutrophil 74.5%; Lymphocyte 20.6%
CSF: Clear color; WBC 161 per mm3; Lymphocytes 13%; Segmential neutrophils 57%
Viral CSF panel: Positive
CT head: Unremakrable
Disseminated herpes zoster (shingles)
Immunocompromised individuals are vulnerable to contracting disseminated herpes zoster. Unlike traditional herpes zoster, the disseminated version should involve 3 or more dermatomes. Although often the skin is the only involved structure, herpes zoster can disseminate to other organs such as the liver, the lungs, and the brain. In this patient’s case, it had disseminated to the brain and caused meningitis, as evidenced by the CSF positive with varicella zoster virus.
The patient often first notices itching or pain in a dermatomal distribution that does not cross midline. Then the area develops a maculopapular rash that soon becomes vesicular in nature.
It is best to start antivirals within 72 hours of the onset of the rash or if new vesicles are still developing. If the patient is immunocompromised, start antivirals at any time. Antivirals are effective for reducing the development of new lesions, reducing viral shedding, speeding up resolution of the rash, and decrease acute pain; however, they are not effective in treating postherpetic neuralgia once it has developed.
In an immunocompromised patient: IV acyclovir at 10-15 mg/kg every 8 hours should be used until there are no new vesicles formed, and the patient is clinically improving. Subsequently the patient can be transitioned to oral valacyclovir. The total oral plus IV course should be 7-14 days. Disseminated zoster requires airborne precautions.
Take Home Points
- Herpes zoster causes a maculopapular rash that soon becomes vesicular in nature.
- Disseminated herpes zoster of the skin should involved 3 or more dermatomes.
- Herpes zoster can disseminate to other organs such as the liver, the lungs, and the brain.
- For immunocompetent patients, start antivirals within 72 hours of the onset of the rash.
- In immunocompromised patients, start antivirals regardless of the onset time of the rash.