Eczema exacerbation following herpes zoster infection in an immunocompetent patient: A case report

Abstract

This case report highlights a severe eczematous rash manifesting broadly across the scalp, face, and neck of a 54-year-old female following a resolved herpes zoster infection. Notably, such cutaneous reactions post-varicella zoster virus infection, which may present weeks to years after the acute phase, have been documented but remain poorly understood in their pathogenesis. This patient exhibited a blistering rash diagnosed as shingles with overlying cellulitis, initially treated with valacyclovir and cefalexin. Upon returning with a diffuse rash post-treatment, further examination and tests led to a differential diagnosis that most closely aligned with eczema exacerbation with superimposed bacterial infection, confirmed by the presence of methicillin-resistant Staphylococcus aureus. Treatment encompassed intravenous vancomycin, ciprofloxacin eye drops, topical hydrocortisone, betamethasone lotion, and gabapentin, leading to substantial improvement. This case underscores the complexity of diagnosing and managing cutaneous reactions post-varicella zoster virus infection and suggests a multimodal treatment approach may yield favorable outcomes.

Introduction

Numerous cutaneous reactions have been documented to arise at the sites of resolved varicella-zoster virus (VZV) infection, manifesting weeks to years after the acute phase of the disease.^1,2 While the pathogenesis of these cutaneous reactions remains unclear, the presence of VZV DNA in lesions devoid of viral cytopathic changes suggests that the virus triggers an unconventional delayed hypersensitivity reaction that is typically unresponsive to antiviral therapy. ² Herein, we report a rare case of a 54-year-old female presenting with a widely distributed severe eczematous rash following a resolved herpes zoster infection.

Case report

A 54-year-old female with a past medical history of hypertension, chronic obstructive pulmonary disease, asthma, ovarian and cervical cancer, heart murmur, and recent shingles infection presented to the emergency department with a severe bilateral rash over the scalp, face, and neck. One week prior to presentation, the patient arrived at the emergency department for evaluation of a blistering rash that presented in a dermatomal distribution on the left side of her face, chills, blurry vision in the left eye, and generalized paresthesia. At that time, the patient was diagnosed with shingles with overlying cellulitis, and promptly received treatment with valacyclovir and cefalexin. Fortunately, she did not require admission and was discharged from the emergency department. Following completion of the medication course, the patient returned with a diffuse rash on the scalp, face, ears, and neck. On examination, ill-defined eczematous lesions with crusting, minimal scaling, and some erosions were noted on the scalp, face, bilateral ears, neck, and the inframammary folds (Figure 1). The patient additionally exhibited watery discharge from bilateral eyes, accompanied by mild periorbital edema. Her antinuclear antibody, rheumatoid factor, and C-reactive protein were within normal limits. The erythrocyte sedimentation rate showed a slight elevation at 37 mm/h (normal range: 0–29 mm/h). HIV testing was negative. In addition, a wound culture was obtained, which tested positive for methicillin-resistant Staphylococcus aureus.

Figure 1.

Ill-defined eczematous lesions with crusting, minimal scaling, and some erosions.

The differential diagnosis included dermatitis herpetiformis, eczema exacerbation with superimposed infection, and allergic contact dermatitis. The clinical and laboratory findings were most consistent with eczema exacerbation with superimposed bacterial infection. Comprehensive treatment was given, including a 7-day course of intravenous vancomycin for the bacterial infection, ciprofloxacin eye drops for ocular symptoms, topical hydrocortisone for the eczematous rash, and betamethasone lotion for scalp management. Furthermore, gabapentin was administered to alleviate the discomfort and pain associated with the rash. Overall, this approach of intravenous, topical, and oral medications yielded remarkable improvement, successfully ameliorating the rash, and alleviating the patient’s distressing symptoms.

Discussion

This report presents an uncommon manifestation of cutaneous reactions following a resolved VZV infection. While cutaneous reactions have been documented after VZV infections, such as granuloma annulare, sarcoidal granulomas, tuberculoid granulomas, lymphoma, pseudolymphoma, granulomatous vasculitis, and Kaposi’s sarcoma, these occurrences have been infrequently reported in both immunocompetent and immunocompromised individuals.^3–7 Among these reactions, granuloma annulare stands out as one of the most frequently described responses following a VZV outbreak. ²

Polymerase chain reaction (PCR) has been a useful investigative tool in detecting VZV in lesions associated with secondary cutaneous sequelae. However, the detection of VZV in such lesions has shown inconsistent results. Ideally, the incorporation of PCR and biopsy studies could have provided valuable information in confirming the presence of VZV in the cutaneous lesions, enhancing diagnostic accuracy, and informing the treatment decisions. PCR and biopsy of similar presentations could contribute to a deeper comprehension of the mechanisms underlying secondary cutaneous sequelae following VZV infections.

Corticosteroids, administered through various routes, have been attempted in the management of these lesions, but the outcomes have been variable. Previous studies have explored the use of antiviral medications like acyclovir in managing cutaneous reactions following VZV infections, but the outcomes have been variable and unpredictable. ² In our patient’s case, valacyclovir was included as part of her multimodal treatment approach and demonstrated favorable results in ameliorating her condition.

Langenberg et al. ⁴ emphasize that many of these eruptions follow a self-limited course; however, they advocate for a biopsy of these lesions due to the potential for neoplastic changes. Conversely, the recognition of mere post-herpetic changes on skin biopsy holds equal significance, especially in patients with underlying conditions like chronic lymphocytic leukemia. In such cases, the emergence of an unusual eruption raises concerns about leukemia cutis and its associated high mortality rates. Given the complexities surrounding the pathogenesis and treatment of these lesions, further research and investigations are warranted to advance our knowledge and optimize therapeutic strategies.