Two Cases of Herpes Zoster in Multiple Adjacent Dermatomes

AUTHORS:
Nadine H. Ruth, MD
Naval Medical Center San Diego, California

Michael J. Scott III, DO, MPH
Seattle Dermatology Center, Seattle, Washington

DISCLAIMER:
The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, the Department of Defense, or the United States Government.

CITATION:
Ruth NH, Scott III MJ. Two cases of herpes zoster in multiple adjacent dermatomes. Consultant. 2016;56(12):1133-1134. 

It is very unusual to observe herpes zoster (shingles) involving multiple adjacent dermatomes as was seen in 2 otherwise healthy patients who presented to an outpatient dermatology clinic within 2 weeks of each other.

Case 1. The first patient was a 74-year-old woman who presented 6 days after the onset of multiple vesicular bullous lesions on the left side of her face, scalp, neck, shoulder, and thorax (Figures 1 and 2), which involved the mandibular division of cranial nerve V, cervical spinal nerves C1 through C8, and thoracic spinal nerves T1 through T3. She had mild overlying yellow crust in various areas of the rash. She complained of moderate pain of the involved areas.

The patient received a diagnosis of multiple dermatomal herpes zoster. Because of the extensive involvement and the presence of secondary bacterial infection, the patient was prescribed a regimen of oral famciclovir; oral prednisone, 20 mg, 3 times daily for 10 days; and oral amoxicillin, 20 mg, 4 times daily for 10 days.

On follow-up examination 6 days after her initial presentation, the patient had experienced significant improvement of her vesicular bullous lesions, the secondary infection had completely resolved, and she had no associated pain.

Case 2. The second patient was a 65-year-old man who presented 3 days after having developed a tender rash on the left side of his neck. Upon examination, the patient had some mild swelling with new developing lesions on the left side of his face, scalp, shoulder, and chest (Figure 3). As in the first patient’s case, the man’s lesions involved the mandibular division of cranial nerve V, cervical spinal nerves C1 through C8, and thoracic spinal nerves T1 through T3.

This patient also received a diagnosis of multiple dermatomal herpes zoster. He was treated with oral famciclovir and oral prednisone, both for 10 days. In addition, he was given an astringent cream with topical triamcinolone and aluminum acetate topical solution.

Discussion. Herpes zoster is caused by a reactivation of the varicella-zoster virus. Once a patient has had a primary infection or vaccination, the virus remains dormant in the dorsal root ganglia cells. Upon reactivation of the virus, the rash is generally distributed unilaterally along 1 dermatome, with some possible extension into an adjacent dermatome.

Rarely, herpes zoster involves more than 1 dermatome; these cases are classified into 3 types. Multidermatomal herpes zoster involves 2 or more adjacent dermatomes. When 2 noncontiguous dermatomes are involved, it is called herpes zoster multiplex. In contrast, disseminated herpes zoster involves having more than 20 vesicles outside of the primary or adjacent dermatome. The latter 2 types of herpes zoster are common in elderly, debilitated, or immunocompromised patients, such as those with an underlying lymphoreticular malignancy or HIV/AIDS. It is very rare to see any of these 3 herpes zoster types in healthy persons.

Very few cases of multidermatomal herpes zoster have been reported in the literature, and the cases that have been reported have occurred in patients who are immunocompromised.^1-3 Based on our extensive literature search, to date no cases of multidermatomal herpes zoster have been reported in healthy patients without an underlying cause for immunosuppression. Additionally, based on our personal observation of hundreds of patients with herpes zoster, we believe that oral prednisone therapy is more effective than antiviral therapy at decreasing the edema and inflammation associated with herpes zoster. Moreover, oral prednisone therapy also greatly reduces the chance of developing postherpetic neuralgia.

References:

1. Sundriyal D, Kapoor R, Kumar N, Walia M. Multidermatomal herpes zoster. BMJ Case Rep. June 4, 2014. doi:10.1136/bcr-2014-205024.
2. Gomez E, Chernev I. Disseminated cutaneous herpes zoster in an immunocompetent elderly patient. Infect Dis Rep. 2014;6(3):5513. doi:10.4081/idr.2014.5513.
3. Costello MJ, Scott MJ. Paralysis of cranial nerves complicating herpes zoster. Arch Derm Syphilol. 1949;60(4):558-569.