Gastrointestinal: Herpes vasculitis in an ulcerative colitis patient

Abstract

A 57-year-old man with ulcerative colitis of two years duration was hospitalized for an acute relapse of disease presenting with abdominal pain and bloody diarrhea. Methylprednisolone (intravenous 80 mg per day), in addition to mesalamine (oral 800 mg three times per day and 2 g/100 ml enema twice per day), were prescribed to induce remission. A purpuric rash developed over left thigh during the admission. The patient had not been prescribed anti-tumour necrosis factor alpha biological therapy. There was no known casual contact with any individuals harboring an acute viral infection or rash. Laboratory investigations revealed normal platelet count, prothrombin time, unremarkable fibrin degradation products, and normal D-dimer and fibrinogen levels. Compression ultrasonography showed no deep vein thrombosis. The purpura spread up to left lower trunk and down to the toes in the following days (Figure 1). As the lesion progressed, the affected skin was biopsied as recommended by the consulted dermatologist. The skin biopsy histopathology revealed focal epidermal erosions with acantholytic squamous cells, herpes virus infection with multinucleation, nuclear molding and chromatin margination (Figure 2). Along with this there was also lymphocytic vasculitis with red blood cell extravasation, endothelial cell swelling and frequent nuclear dust in the dermal venules (Figure 3). The diagnosis was of herpes zoster vasculitis. The patient received acyclovir (intravenous 10 mg/kg every 8 hours for 10 days) and the purpura vanished gradually over the next two weeks. Herpes zoster is caused by reactivation of the latent varicella zoster virus after a primary infection, more frequently in immunocompromised adults. It is quite common for this to be associated with inflammatory bowel disease immunosuppressive therapy. Herpes vasculitis, however, is quite rare, with only a single report occurring in a systemic lupus erythematosus patient. To our knowledge this is the first report of herpes vasculitis occurring in an ulcerative colitis patient. In patients on immunosuppressive agents, the possibility of infection with atypical presentation must always be kept in mind. Only clinical suspicion and appropriate diagnostic procedures, such as skin biopsy in this patient, will promptly enable correct diagnosis and management.