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E-IJD® - CORRESPONDENCE
Year : 2022  |  Volume : 67  |  Issue : 5  |  Page : 626
Herpes zoster associated with cutaneous small-vessel vasculitis: A rare case report with review of literature


1 Dermatology, Faculty of Medicine, Gazi University, Ankara, Turkey
2 Pathology, Faculty of Medicine, Gazi University, Ankara, Turkey

Date of Web Publication29-Dec-2022

Correspondence Address:
Elif Afacan
Dermatology, Faculty of Medicine, Gazi University, Ankara
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.ijd_1001_21

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How to cite this article:
Afacan E, Öğüt B, Erdem &, Adışen E. Herpes zoster associated with cutaneous small-vessel vasculitis: A rare case report with review of literature. Indian J Dermatol 2022;67:626

How to cite this URL:
Afacan E, Öğüt B, Erdem &, Adışen E. Herpes zoster associated with cutaneous small-vessel vasculitis: A rare case report with review of literature. Indian J Dermatol [serial online] 2022 [cited 2023 Feb 8];67:626. Available from: https://www.e-ijd.org/text.asp?2022/67/5/626/366085




Sir,

Herpes zoster (HZ) is a common disease caused by reactivation of varicella-zoster virus (VZV).[1] Besides the classical vesicular rash on the skin, VZV is known to cause extra-cutaneous manifestations, including vasculopathy of different sized vessels.[2],[3] VZV vasculopathy is a well-recognised entity in central nervous system (CNS); however, only few data have been published on cutaneous small-vessel vasculitis (CSVV) in HZ. Herein, we present a case of HZ with CSVV and a review of the literature.

A 53-year-old woman with a history of acute myeloid leukaemia and allogeneic stem cell transplantation was admitted to our department with complaints of painful lesions in left gluteal region and upper leg for 2 days. On examination, purpuric papules/plaques with central necrohaemorrhagic crusts were seen in dermatomal distribution [Figure 1]. Punch biopsy showed intraepidermal bulla with viral nuclear inclusions and giant cell formations, as well as perivascular mononuclear inflammation, leukocytoclasia and fibrinoid necrosis around superficial dermal capillaries [Figure 2]. To exclude the presence of herpes simplex virus (HSV), an immunohistochemical staining for HSV and plasma HSV-1/HSV-2 PCR were performed and resulted in negative. After routine laboratory screenings, systemic involvement of vasculitis was excluded. Based on these findings, the patient was diagnosed with HZ with CSVV. She was started on valacyclovir 3 × 1000 mg/day and analgesics. After 7 days, complete resolution of the cutaneous lesions was observed without sequelae and no additional systemic therapy was required for CSVV. She did not develop postherpetic neuralgia (PHN) or vasculopathy of CNS during 2 months of follow-up.
Figure 1: Purpuric papules and plaques on an erythematous base with occasional central black haemorrhagic and necrotic crusts on (a) left gluteal region and (b) left upper leg

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Figure 2: Skin biopsy, haematoxylin-eosin stain, (a) intraepidermal bulla formation, erythrocyte extravasation and perivascular inflammation in the superficial dermis (×40 original magnification), (b) viral nuclear inclusions and giant cell formations in the cells within the bulla (arrows) (×400 original magnification) and (c) superficial dermal vessel with leukocytoclastic vasculitis (arrows) (×200 original magnification)

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Vascular changes associated with VZV are vessel wall thickening, stenosis and inflammatory infiltrate with abundant neutrophils. VZV is suggested to spread transaxonally from neural ganglia to vessel walls.[4] It can infect endothelial cells directly from adjacent nerves and cause vascular damage including microthrombi formation and haemorrhage.[3],[5] In 1984, Cohen and Trapuckd[6] described the first case of CSVV associated with HZ. After a detailed literature review, we found 10 published cases.[6],[7],[8],[9],[10],[11],[12],[13],[14],[15] Clinicopathological features of present and reported cases are summarised in [Table 1]. The mean age was 57.18 ± 17.74 years, which can be explained by the fact that advanced age is a major risk factor for HZ.[1] Most cases, including ours, were immunocompromised individuals. Cutaneous findings were characterised by vesicles, palpable purpura and ulcerated nodules/plaques. The lesions were mostly on the lower extremities. Histopathological findings included intraepidermal blisters, multinucleated giant cells and leukocytoclastic vasculitis. In most cases, complete recovery was achieved with anti-viral agents and no patient required further systemic therapy for CSVV. It is estimated that PHN occurs in 5%–20% of patients with HZ; the absence of postherpetic neuralgia (PHN) in our patient can be explained by early treatment with valacyclovir.[16]
Table 1: Clinical and histopathological features of the present and reported cases in the literature

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In conclusion, all previously reported cases and our case had a clinically distinctive appearance that prompted dermatologists to obtain a biopsy. Nevertheless, given the well-known vasculopathic effects of VZV, it is possible that this phenomenon is more common than reported. Although the clinical picture is alarming, this association appears quite benign and has no further complications. However, future studies are needed to elucidate the clinical implications of HZ with CSSV.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Kennedy PG, Gershon AA. Clinical features of varicella-zoster virus infection. Viruses 2018;10:609.  Back to cited text no. 1
    
2.
Mueller NH, Gilden DH, Cohrs RJ, Mahalingam R, Nagel MA. Varicella zoster virus ınfection: Clinical features, molecular pathogenesis of disease, and latency. Neurol Clin 2008;26:675-97.  Back to cited text no. 2
    
3.
Xu X, Yun SJ, Erickson L, Chen L. Diseases caused by viruses. In: Elder DE, Elenitsas R, Rosenbach M, Murphy GF, Rubin AI, Xu X, editors. Lever's Histopathology of the Skin. Philadelphia, PA: Wolters Kluwer; 2015. p. 1692-710.  Back to cited text no. 3
    
4.
Nagel MA, Gilden D. Update on varicella zoster virus vasculopathy. Curr İnfect Dis Rep 2014;16:407.  Back to cited text no. 4
    
5.
Keller TT, Mairuhu AT, de Kruif MD, Klein SK, Gerdes VE, ten Cate H, et al. Infections and endothelial cells. Cardiovasc Res 2003;60:40-8.  Back to cited text no. 5
    
6.
Cohen C, Trapuckd S. Leukocytoclastic vasculitis associated with cutaneous infection by herpesvirus. Am J Dermatopathol 1984;6:561-5.  Back to cited text no. 6
    
7.
Erhard H, Rünger TM, Kreienkamp M, Müller J, Müller-Hermelink HK, Bröcker EB. Atypical varicella-zoster virus infection in an immunocompromised patient: Result of a virus-induced vasculitis. J Am Acad Dermatol 1995;32:908-11.  Back to cited text no. 7
    
8.
Uhoda I, Piérard-Franchimont C, Piérard GE. Varicella-zoster virus vasculitis: A case of recurrent varicella without epidermal involvement. Dermatology 2000;200:173-5.  Back to cited text no. 8
    
9.
Wollina U, Schönlebe J. Segmental leukocytoclastic vasculitis in herpes zoster. Int J Dermatol 2012;51:1351-2.  Back to cited text no. 9
    
10.
Wong J-M, Huang P-H, Wei S-C. Gastrointestinal: Herpes vasculitis in an ulcerative colitis patient. J Gastroenterol Hepatol 2013;28:586.  Back to cited text no. 10
    
11.
Tanaka A, Hayaishi N, Kondo Y, Kurachi K, Tanemura A, Katayama I. Severe gangrene accompanied by varicella zoster virus-related vasculitis mimicking rheumatoid vasculitis. Case Rep Dermatol 2014;6:103-7.  Back to cited text no. 11
    
12.
Burgard B, Smola S, Vogt T, Müller CS. Small vessel vasculitis in herpes zoster-Discussion of current aspects of varicella zoster virus vasculopathy. Am J Dermatopathol 2018;40:602-4.  Back to cited text no. 12
    
13.
Clark AK, Dhossche J, Korcheva VB, Keller JJ. Herpes zoster presenting as unilateral vasculitis. Dermatol Online J 2018;24:13030/qt5dd717sw.  Back to cited text no. 13
    
14.
Cury-Martins J, Bellesso M, Sotto MN, Sanches JA. Atypical herpes vasculitis in a leukemic patient: An unusual presentation. Hematol Transfus Cell Ther 2019;41:95-8.  Back to cited text no. 14
    
15.
Alvarez-Salafranca M, Garcés-Horna V, García-García M, Ara-Martin M. Atypical vasculopathic varicella-zoster infection mimicking cutaneous small-vessel vasculitis. Int J Dermatol 2020;59:e214-6.  Back to cited text no. 15
    
16.
Mallick-Searle T, Snodgrass B, Brant JM. Postherpetic neuralgia: Epidemiology, pathophysiology, and pain management pharmacology. J Multidiscip Healthc 2016;9:447-54.  Back to cited text no. 16
    


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