Disseminated Herpes Zoster in an Immunocompetent Elderly Patient
A 75 year old male patient visited the pain clinic at our hospital complaining of stabbing pain and grouped erythematous vesicles in the external auricle and the C2 dermatome of the ipsilateral temporal region, which started approximately 10 days before (). At the initial occurrence of the symptoms, the patient had been diagnosed with an acute herpes zoster infection at the local ENT and dermatology hospital, so was taking oral antiviral agents for more than a week with no improvements in the symptoms. According to his premedical history, the patient had been undergoing treatment for diabetes mellitus and angina, while taking aspirin, 100 mg/day, and cilostazol, 200 mg/day, (pletaal@). At the time of the hospital visit, the visual analogue scale was 7/10, so the patient was hospitalized. Aspirin and cilostazol were temporarily discontinued and oral drug treatment was started with pregabalin, 150 mg/day, nortriptyline, 10 mg/day, and acetaminophen, 750 mg/day. For the relief of sympathetic mediated pain, a stellate ganglion block was performed daily using 0.375% ropivacaine 6 cc with a paratracheal approach technique on the left C6 level. According to the routine blood tests taken at the time of hospitalization, there were no abnormal observations other than an erythrocyte sedimentation rate (ESR) of 39 mm/hr and a high sensitive C-reactive protein (hs-CRP) of 5.81 mg/dl.\nOn the morning of the second day of hospitalization, skin eruptions began to appear in numerous areas along the bilateral scalp, posterior neck, shoulder, upper arm, and post upper back (, ). The patient complained of an itching sensation, but no pain in the newly blistered areas. At the same time, there were symptoms of left facial palsy, hearing impairment, otalgia, and tinnitus, and the patient was unable to walk independently due to vertigo with accompanying mild cognitive disability (). His vital signs showed that his blood pressure, heart rate, and respiration rate were normal, but the temperature had risen to a maximum of 38.0℃, while there were no headaches, nausea, or Kernig's signs. Hence, a disseminated herpes zoster infection with accompanying Ramsay Hunt syndrome in the left facial area was suspected, so a blood culture, urine culture, tumor marker (CEA, CA 19-9, PSA), serum test for anti-HIV antibody (ELISA) and anti-VZV IgM antibody (ELISA), and chest x-ray were performed first to differentiate the cause of infection and immune suppression. Immediately after the above symptoms were observed, nephrologists, neurologists, dermatologists, and otolaryngologists were consulted, with the resulting diagnosis being a disseminated herpes zoster infection. In concern for renal injury from old age, the BUN and creatinine figures were observed every 2 days, and acyclovir, 1,500 mg/day, was IV administered for a week. Pregabalin was stopped, as it may have caused the cognitive disability and vertigo, and was replaced with neurontin, 900 mg/day. The stellate ganglion block was continued. Considering the possibility of cerebrovascular disease or myelopathy, a brain stroke MRI was taken on the 3rd day of hospitalization, followed by a T2 sagittal whole body spine MRI on the 5th day of hospitalization, but no abnormalities were observed. The possibility of meningitis from the virus was also suspected, so a CSF culture (body fluid examination, gram stain, fungus, acid fast bacilli smear) was performed, but again no abnormalities were observed. The administration of steroids was considered for the Ramsay Hunt syndrome, but it was not attempted due to concerns of immune suppression. No abnormalities were observed in the additionally performed cultures (blood, urine, CSF), tumor markers, anti-HIV antibodies, and anti-VZV IgM antibody tests. The hs-CRP was high at 2.44 mg/dl, but it was lower than at the time of hospitalization, so there was a gradually decreasing trend that recovered to normal figures before discharge from the hospital. While maintaining drug therapy and observing the progress, all vital signs returned to normal on the 4th day and the skin lesions did not develop further after the 6th day of hospitalization. Gradually, the vertigo and tinnitus symptoms also improved, so by the 10th day the patient recovered enough to walk independently. The patient began to recover from the facial palsy and hearing impairment from the 9th day, so the patient was discharged according to his wishes on the 12th day while maintaining outpatient treatment at the clinic. The patient visited the clinic every week for two months after his discharge, and there were nearly no complications.