Adjei, Susuana

Mattia, Alexzandra

Miller, Austinn C

Temiz, Laurie A

Thompson, Anthony

Tyring, Stephen K

English

DigitalCommons@The Texas Medical Center

NOTES & COMMENTSHemorrhagic herpes zoster duplexunilateralis in a patient takingclopidogrelTo the Editor: We read with interest the publicationby Sowell et al1 on hemorrhagic herpes zoster (HHZ)in a contralateral, multidermatomal distribution in apatient taking rivaroxaban. To our knowledge, thiswas the first case reported to the literature impli-cating direct oral anticoagulants in the pathogenesisof this condition. Here, we present a case of HHZ inan ipsilateral, multidermatomal distribution in apatient who recently started clopidogrel.A 75-year-old man receiving clopidogrelstatusepost distant coronary artery bypass graftpresented with a vesicular rash. Two days prior, henoted simultaneous onset of dark vesicles on hischeek, buccal mucosa, lower abdomen, and back,consistent with a right-sided, ipsilateral distributionin the T10 and V3 dermatomes (Fig 1). Besides mildpain in the involved dermatomes, he denied anyother symptoms. The patient was not vaccinatedagainst varicella-zoster. Medical history was negativefor HIV, malignancy, transplant, diabetes mellitus,systemic corticosteroids, and immunosuppressivedrugs. The patient denied using any medicationsFig 1. A, The lateral view of the right side of theright side of the T10 dermatome. C, The lateral vieThe anterior view of the right side of the V3 dermª 2023 by the American Academy of Dermatology, Inc. Publishedby Elsevier, Inc. This is an open access article under the CC BYlicense (http://creativecommons.org/licenses/by/4.0/).54 JUNE 2023other than clopidogrel. No culture or PCR wasperformed based on a presumptive clinical diagnosisof HHZ duplex unilateralis. In support of thediagnosis, the patient had excellent clinical responseto valacyclovir 1 g three times a day for 7 days.Clopidogrel was continued without alteration ofdosage. The patient had no residual findings (ie,postherpetic neuralgia) at 3-week follow-up.Herpes zoster involving multiple noncontiguousdermatomes accounts for\0.1% of all herpes zostercases.2 HHZ is also very rare and has been attributedto anticoagulant use in several cases.1,3 Both arecommonly associated with immunodeficiency.Concomitant occurrence of both variants has onlybeen reported once in a contralateral distributioninvolving C2, C3, V3, and L3 in a patient takingrivaroxaban.1 To our knowledge, there have onlybeen 4 cases of HHZ secondary to clopidogrelreported in the literature.4 In all the cases, only 1dermatome was involved, all individuals wereimmunocompetent, and the average at presentationwas 70 years old (Table I).3,4 In 3 of 4 patients,clopidogrel was continued and treatment with vala-cyclovir or acyclovir was initiated with completeresolution of symptoms.T10 dermatome. B, The anterior view of thew of the right side of the V3 dermatome. D,atome.J AM ACAD DERMATOLTable I. Summary of all cases of hemorrhagic herpes zoster associated with clopidogrel3,4Previous cases Age, y Dermatome Clopidogrel status Immune statusPatient 1 49 T1 Discontinued ImmunocompetentPatient 2 74 T1 Continued ImmunocompetentPatient 3 78 L5 Continued ImmunocompetentPatient 4 74 L5 Continued ImmunocompetentPatient 5 (our case) 75 T10; V3 Continued ImmunocompetentJAAD CASE REPORTSVOLUME 36Notes & Comments 55Our case corroborates Sowell et al1 and theirsuggestion that multidermatomal involvementshould not deter providers from a diagnosis ofherpes zoster. In this rare manifestation of a commondisease, we reinforce clopidogrel as a potentialoffending agent in the pathogenesis of HHZ anddemonstrate the first case of HHZ in a multiple,noncontiguous ipsilateral dermatomal distribution.In addition, to our knowledge, this is the first casedescribing intraoral involvement of HHZ. DespiteHHZ demonstrating a predilection for immunocom-promised individuals, this case supports previousliterature describing the potential for HHZ in immu-nocompetent patients on anticoagulation.Austinn C. Miller, MD,a Anthony Thompson, BS,bAlexzandra Mattia, BS,b Laurie A. Temiz, BA,c,dSusuana Adjei, MD,c and Stephen K. Tyring, MD,PhD, MBAc,eFrom the Dermatology Associates of Tallahassee,Tallahassee, Floridaa; Florida State UniversityCollege of Medicine, Tallahassee, Floridab; Cen-ter for Clinical Studies, Webster, Texasc; MeharryMedical College, Nashville, Tennesseed; Depart-ment of Dermatology, University of Texas HealthScience Center, Houston, Texas.eDrs Miller, Adjei, and Tyring and Authors Temizand Mattia are coauthors.Funding sources: None.IRB approval status: Not applicable.Key words: clopidogrel; coronary artery bypassgraft; hemorrhagic herpes zoster; HHZ;multidermatomal.Correspondence to: Anthony Thompson, BS, Flor-ida State University College of Medicine, 1115West Call St, Tallahassee, FL 32308E-mail: ajt16b@med.fsu.eduConflicts of interestNone disclosed.REFERENCES1. Sowell J, Reynolds H, Sowell J. Hemorrhagic herpes zoster withcontralateral multidermatomal distribution associated withrivaroxaban: an unusual presentation. JAAD Case Rep. 2021;9:31-33.2. Rodrıguez-Lomba E, Sanchez-Herrero A, Suarez-Fernandez R,Pulido-Perez A. Herpes zoster duplex and multiplex: theexception that confirms the rule. Actas Dermosifiliogr (EnglEd). 2019;110(8):690-693.3. Veraldi S, Vaira F, Nazzaro G. Purpuric herpes zoster in patientsin therapy with clopidogrel. J Clin Virol. 2015;69:122-124.4. Ghosh S, Bandyopadhyay D. Haemorrhagic herpes zosterassociated with clopidogrel treatment. Clin Exp Dermatol.2009;34(3):409-410.https://doi.org/10.1016/j.jdcr.2023.04.014

Hemorrhagic Herpes Zoster Duplex Unilateralis in a Patient Taking Clopidogrel

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Hemorrhagic Herpes Zoster Duplex Unilateralis in a Patient Taking Clopidogrel

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