Herpes zoster multiplex and bilateral in an immunocompetent child.

Abstract

To the Editors: A healthy 7-year-old Caucasian male child with a history of chickenpox caused by varicella zoster virus (VZV) 2 years earlier was referred to our outpatient department of Dermatology because of a painful vesico-papular eruption in the torso evolving for the previous 3 days. Erythematous papules and vesicles surrounded by erythema were observed clustered on the right shoulder (C4 dermatome), left scapula (T3-4 dermatomes) and left lumbar region (L2 dermatome), which had been preceded by local pain 2 days before (see Fig., Supplemental Digital Content 1, https://links.lww.com/INF/B1000). There were no other cutaneous or systemic abnormalities, such as fever, lymphadenopathies or headache. Blood tests were unremarkable, namely complete blood count with white blood cell differential, biochemistry panel including lactate dehydrogenase, HIV, HCV and HBV antibody tests, immunoglobulin values and immunophenotyping studies of peripheral blood. The presumed diagnosis of herpes zoster (HZ) multiplex bilateralis was confirmed by polymerase chain reaction of the vesicle content. Oral acyclovir (800 mg, 5 times per day) was started and maintained for 7 days, with resolution of skin lesions and symptoms in 10 days. No recurrent zosteriform lesions were noticed during a follow-up period of 6 months. Herpes zoster multiplex bilateralis is caused by the concurrent VZV reactivation in more than 2 noncontiguous dermatomes in both sides of the body, which had hitherto remained latent in sensory dorsal root ganglia after the episode of chickenpox.1 Childhood zoster is more likely if primary infection occurred within the first year of age including in utero. Multiple dermatome involvement in the lack of immune deficiency is rare or otherwise unreported in children.2 Most of the reported cases involving noncontiguous dermatomes have been limited to 2 dermatomes and are referred as HZ duplex.1,3 This rare clinical entity is almost exclusively associated with age-related decline in cellular immunity, primary or acquired immunodeficiencies and with the use of immunosuppressive drugs.1 According to recent studies,4,5 the simultaneous reactivation of VZV in multiple noncontiguous dermatomes usually requires an immunocompromised milieu, leading to the recommendation that these patients should undergo a complete status immune evaluation.5 It seems not to portend a poor prognosis.3 We present a rare case of HZ involving 3 noncontiguous dermatomes in both halves of the body, in the absence of an immunodeficiency background. To our knowledge, most of case reports of HZ duplex/multiplex bilateralis were related to older age and/or immunocompromised patients,1,3 and in the few cases reported in children, only 4 of them were confirmed to be immunocompetent.3,5 Ana Pedrosa, MD Maria João Cruz, MD Alberto Mota, MD, PhD Department of Dermatology and Venereology Centro Hospitalar São João EPE Porto, Portugal Faculty of Medicine University of Porto Teresa Baudrier, MD Filomena Azevedo, MD Department of Dermatology and Venereology Centro Hospitalar São João EPE Porto, Portugal