PAINLESS HERPES ZOSTER IN THE SETTING OF EOSINOPHILIA AND MARKEDLY ELEVATED IGE LEVELS

Abstract

<h3>Introduction</h3> Herpes zoster (HZ) is a common condition caused by varicella zoster virus (VZV) reactivation. Typical malaise, fever, and localized paresthesias are followed by a dermatomal maculopapular eruption with eventual vesicles. HZ has been associated with eosinophilia, but not with elevation of IgE. The conditions most often associated with IgE elevations are typically rare. Here we describe an atypical case of painless HZ with eosinophilia and elevated IgE. <h3>Case Description</h3> A 96-year-old healthy female presented to the hospital with weakness and an erythematous, pruritic rash extending from her right neck to her upper chest and back. The rash started three days prior with progressive blistering. She denied any associated symptoms, medications, or new exposures. With concern for shingles and cellulitis, valacyclovir, vancomycin, and cefazolin were started. However, the rash was not dermatomal or painful, making it inconsistent with HZ. Labwork revealed eosinophilia at 0.840 K/mcL which increased to 0.920 K/mcL and IgE at 27,071 IU/mL which increased to 27,567 IU/mL. Biopsies were obtained and corticosteroids were started. The eosinophilia resolved and IgE level decreased. She completed her antimicrobials and was discharged on a prednisone taper. Initial biopsy report noted drug eruption, however, family denied medication use. Further investigation confirmed positive staining for VZV. <h3>Discussion</h3> This case was convoluted by an atypical HZ presentation with absence of herpetic neuralgia and a mysteriously elevated IgE response. Such a robust IgE response would provoke suspicion for significantly rarer disease processes. For completeness, an outpatient evaluation for elevated IgE was recommended to our patient.