HPI: This 39 yo man developed a dermatomal vesicular eruption 2 months ago. He was seen by his GP and treated with valcyclovir and it cleared somewhat but not completely. The eruption continues to evolve. He complains of pain and pruritus. Feels well otherwise. No underlying diseases known of.
O/E: There is a dermatomal process extending from T-10 to L 2 on the right side. The lesions are scaly patches. There are no vesicles. The lesions do not cross the mid-line. Area biopsied today is only a couple of days old, by history.
Photos:
Diagnosis: Atypical Herpes Zoster. H.z. progressing over a two month period (especially after valcyclovir) is quite unusual in a healthy, immunocompetent person.
Plan: I did a biopsy and checked his chemistries and CBC. I have seen patients with HIV/AIDS and a patient with angioimmunoblastic lymphadenopathy with atypical HSV and HZ; but never a patient like this. Perhaps, this is something I am not thinking about. I will post a photomic when path is reported and lab results. For the time being, I prescribed acyclovir 800 mg 5 times a day.
Addendum: Fran Storrs felt this was an eczematous process, possibly a contact dermatitis. The pathology showed no multinucleated giant cells and had features of a "dermatitis." So, was this a dermatitis secondary to H.Z., an atypical contact dermatitis, or factitial (the patient did ask for pain meds when first seen, which were not given)? He is now being treated with a topical corticosteroid now and we'll see how he does. When seen for suture removal sight days after biopsy, the eruption looked a bit better, was less symptomatic and had not spread beyond the dermatomes first involved.
Many thanks for presenting the case.It is very unusual for herpes zoster to have such presentation;involvement of several dermatomes of such duration in immunocompetent patient.On the other hand it is not uncommon to see what I can name; post herpes zoster dermatitis, subacute or chronic scaly, pruritic dermatitis,may be neurotic or self inflicted in part.I think,this case is an ipsilateral rather than dermatomal presentation. Good history to exclude contact dermatitis and biopsy may show the exact diagnosis,keeping in mind; diseases with generalized distribution may present locally.
ReplyDeleteGood luck
Abbas Naji Alshammari MD
Qatar Armed Forces Clinic
From Fran Storrs: looks eczematous to me. Itch? Top steroids help? WEars something over that area,,,?? a gun maybe or holster.? May well be chrome pos. does he carry wet cement on his side? Chrome often presents with a chronic nummular poattern. confess that unilateral is weird. Maybe it will move.
ReplyDeleteIn my humble opinion it could be POST HERPETIC itch /neuralgia,as persisting pain and itch favors PHI --> dermatitis.
ReplyDeleteu should try
gabapentin /pregabalin,
topical steroid and oral antihistamine.