Cristiano, Peter

Kim, Mira

Shaaban, Adnan

Tung, Robert

English

The University of Kansas: Journals@KU

KANSAS JOURNAL of  M E D I C I N EAn Unusual Presentation of Herpes Zoster Robert C. Tung, M.D.1, Adnan Shaaban, M.D.2, Mira Kim, ARNP3, Peter Cristiano, M.D.31Cedars-Sinai Medical Center, Department of Surgery, Los Angeles, CA2University of Minnesota Health, Department of Medicine, Minneapolis, MN3Leavenworth Lansing Family Health Center, Lansing, KSReceived April 24, 2019; Accepted for publication Aug. 14, 2019; Published online Jan. 31, 2020INTRODUCTIONHerpes zoster, commonly known as shingles, occurs after a primary infection from the varicella zoster virus.1 This virus remains latent in the ganglionic neurons derived from neural crest cells. During states of decreased cell-mediated immunity in the elderly and immunocom-promised, the varicella zoster virus reactivates and travels along nerve fibers peripherally.2 This results in a painful vesicular rash, usually involving a single dermatome that does not cross the midline.3Should herpes zoster present in unusual locations such as the genitals, it can be challenging to diagnose which can lead to a delay in treatment and complications. The most common complication of herpes zoster is post-herpetic neuralgia.4 Post-herpetic neuralgia is a debilitating complication because it is difficult to treat and is respon-sible for a large burden of the disease.5 Treatment of herpes zoster involves pain management and healing of the lesion. Antivirals (famciclovir, 500 mg orally 3 times daily or valacyclovir, 1 g 3 times daily for 7 - 10 days) speed up healing of the rash.6 Pregabalin (150 to 300 mg/day) typically is started and titrated (up to 600 mg/day) to relieve the pain of postherpetic neuralgia. Our case highlighted how herpes zoster should remain on the differ-ential diagnosis for elderly patients presenting with a new onset lesion of the genitals. Early diagnosis and treatment can speed recovery and prevent complications.CASE REPORTA 59-year-old male with no history of medical or medication related immunosuppression presented to the clinic with itching and burning around the head of his penis for the past few days. He was in a monogamous relationship with no exposure to sexually transmit-ted diseases. He denied urethral discharge, dysuria, hematuria, or tenderness. Vital signs were within normal limits. On physical exam, there was redness at the urethral opening without any skin lesions. The patient was diagnosed with balanitis and started on clotrimazol topical cream. He was directed to come back if his symptoms pro-gressed.Three days later, the patient returned with worsening discomfort around the site of presentation. He complained of severe sharp pain at his shaft and noticed new red spots on the head of his penis. Physi-cal exam showed a tender glans and shaft of the penis with newly noticed few red vesicles at the left aspect of the glans penis. HSV 1, HSV 2, and varicella-zoster titers were drawn. HSV 1 anti-body titers were positive at 26.2. HSV 2 antibody titers were negative at 0.54. Varicella-zoster virus antibody IgM was positive at 1.24 ISR.The patient was prescribed valacyclovir and gabapentin and asked to follow-up in one week. Upon follow-up, the patient described an improvement of his rash and pain. On physical exam, the left side of his glans penis appeared to be healing with a slight ulceration. He was to take acetaminophen as needed.DISCUSSIONHerpes zoster is a common medical condition with a lifetime risk of developing the condition between 25% and 30%.7 This risk increases to 50% in those individuals 80 years and older. This age-related increased incidence of herpes zoster is thought to be due to decreased cell-mediated immunity. Individuals that are immuno-compromised due to HIV or drug therapy are also at an increased risk.8   Birch et al.9 evaluated specimens obtained from the genital lesions of adults presenting with presumed genital herpes infection. They discovered that about 3% of the herpes simplex virus positive speci-mens also were positive for varicella virus. It is possible that genital herpes zoster is underdiagnosed because of the atypical location of the rash. When patients present with vesicular lesions of the genitals, most clinicians include herpes simplex virus on the differential diagno-sis. Herpes simplex virus is a sexually transmitted disease caused by HSV-1 or HSV-2 that manifests as vesicles on the genitals, perineum, perianal, and buttocks during an outbreak.10  The classic presentation during primary infection is malaise, fever, or localized adenopathy; however, these symptoms are absent most of the time.11 Clinicians also include other infectious (e.g., herpes simplex virus, herpes zoster, syphilis, and chancroid) and noninfectious (e.g., Bechet’s syndrome, fixed drug eruption, psoriasis, and sexual trauma) causes of genital lesions on their differential diagnosis.12 Diagnosing herpes zoster can be difficult when presenting in unusual areas, such as the genitals. It can be difficult to distinguish genital herpes zoster from other genital lesions due to varying clini-cal presentation or possible co-infection. Our case highlighted how herpes zoster should remain on the differential diagnosis for elderly patients presenting with a new onset lesion of the genitals. Early diag-nosis and treatment can speed recovery and prevent complications.REFERENCES1 Badani H, White T, Schulick N, et al. Frequency of varicella zoster virus DNA in human adrenal glands. J Neurovirol 2016; 22(3):400-402. PMID: 26843382.2 Nagel MA, Jones D, Wyborny A. Varicella zoster virus vasculopathy: The expanding clinical spectrum and pathogenesis. J Neuroimmunol 2017; 308:112-117. PMID: 28335992.3 Dayan RR, Peleg R. Herpes zoster – typical and atypical presentations. Postgrad Med 2017; 129(6):567-571. PMID: 28540752.4 Sampathkumar P, Drage LA, Martin DP. Herpes zoster (shingles) and postherpetic neuralgia. Mayo Clinic Proc 2009; 84(3):274-280. PMID: 19252116.5 Johnson R, Rice A. Clinical practice. Postherpetic neuralgia. N Engl J Med 2014; 371(16):1526-1533. PMID: 25317872.6 Gilden D, Nagel MA, Mahalingam R, et al. Clinical and molecular aspects of varicella zoster virus infection. Future Neurol 2009; 4(1):103-117. PMID: 19946620.19 This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (by-nc-nd) License. (CC-BY-NC-ND 4.0: https://creativecommons.org/licenses/by-nc-nd/4.0/)KANSAS JOURNAL of  M E D I C I N E207 Burke BL, Steele RW, Beard OW, Wood JS, Cain TD, Marmer DJ. Immune responses to varicella-zoster in the aged. Arch Intern Med 1982; 142(2):291-293. PMID: 6277260.8 Johnson RW, Alvarez-Pasquin MJ, Bijl M, et al. Herpes zoster epide-miology, management, and disease and economic burden in Europe: A multidisciplinary perspective. Ther Adv Vaccines 2015; 3(4):109-120. PMID: 26478818.9 Birch CJ, Druce JD, Catton MC, MacGregor L, Read T. Detection of vari-cella zoster virus in genital specimens using a multiplex polymerase chain reaction. Sex Transm Infect 2003; 79(4):298-300. PMID: 12902579.10 Groves MJ. Genital herpes: A review. Am Fam Physician 2016; 93(11):928-934. PMID: 27281837.11 Bernstein DI, Bellamy AR, Hook EW 3rd, et al. Epidemiology, clinical pre-sentation, and antibody response to primary infection with herpes simplex virus type 1 and type 2 in young women. Clin Infect Dis 2013; 56(3):344-351. PMID: 2307395.12 Roett M, Mayor M, Uduhiri K. Diagnosis and management of genital ulcers. Am Fam Physician 2012; 85(3):254-262. PMID: 22335265.Keywords: herpes zoster, postherpetic neuralgia, male genital diseases                            HERPES ZOSTER             continued. 

An Unusual Presentation of Herpes Zoster

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An Unusual Presentation of Herpes Zoster

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