Tzanck Smear Research Articles

Varicella challenges: A case of respiratory tract complications in an elderly patient

Varicella, caused by the varicella-zoster virus (VZV), is rarely reported in the elderly but often complicates with pneumonia. In this case report, we present a case of varicella pneumonia in the elderly. A 60-year-old man presented to the emergency room with vesicles filled with clear fluid that had appeared all over the body for the past four days. The patient also reported fever, headache, pain when swallowing, and itching. Initially, the rash consisted of pink macules that progressed to papules, vesicles, pustules, and crusts. The patient experienced a cough and shortness of breath one day before the hospital visit but did not report any chest or abdominal pain. Notably, the patient’s two grandchildren had a history of chickenpox. The patient had been living with diabetes for five years and was undergoing treatment with insulin injections. The patient was also an active smoker for 40 years. On physical examination, several vesicles with varying degrees of redness were observed, along with yellow-black crusts, pustules, and erosions. Diagnostic tests revealed multinucleated giant cells on a Tzanck smear; pulmonary inflammation with thickening of the right hilum on a chest X-ray; extended-spectrum beta-lactamases Klebsiella pneumoniae in the sputum culture; and elevated hemoglobin A1c, blood sugar level, and liver and kidney function markers on laboratory examination. Based on the clinical findings, the patient was diagnosed with varicella, community-acquired pneumonia, diabetes, acute renal failure, and elevated transaminase enzymes. The patient was treated with acyclovir, paracetamol, salicylate 2% powder, fusidic acid 2% cream, moxifloxacin, N-acetylcysteine, curcuma, and insulin. The patient’s clinical condition improved, the complaint of dyspnea decreased, and the patient was discharged to outpatient care after eight days of hospitalization. This case highlights that while varicella is rare in the elderly, it often presents with severe varicella pneumonia, making early detection and comprehensive management essential to prevent complications and mortality.

Beyond dermatomes disseminated Herpes zoster in the immunocompetent: two rare cases

Herpes zoster is typically a localized reactivation of the varicella-zoster virus (VZV) that occurs in individuals following a primary varicella infection (chickenpox). Disseminated herpes zoster, characterized by widespread vesicular lesions beyond the primary dermatome, is uncommon and usually associated with immunocompromised states. Till date only 25 immunocompetent patients with disseminated HZ have been reported in literature. We report two such cases of disseminated HZ in immunocompetent individuals. The 1st patient is a 53-year-old woman with painful, itchy multiple grouped erythematous papules, vesicles, and bullae over right T8-T9 dermatome and multiple papules, crusted papules, and vesicles over face associated with fever and fatigue. The 2nd patient is an 8-year-old boy with multiple grouped clear vesicles and bullae with erythematous base involving the left S1-S5 dermatome. Multiple discrete erythematous papules and vesicles (active and crusted) were noted over trunk, right forearm, left arm, bilateral thigh and left mandibular area. Routine laboratory investigations were within normal limits. Tzanck smears were done, and multinucleated giant cells were seen in both cases. They were treated with antivirals and showed improvement. We have reported these two cases of disseminated HZ due to their occurrence in immunocompetent patients, which is a very rare phenomenon.

Pulse Therapy in Rituximab Era: A Retrospective Study of 124 Patients of Pemphigus from a Tertiary Care Center of South Rajasthan

Abstract Background: Pemphigus is a potentially life-threatening autoimmune blistering disease which characteristically affects skin and mucosae. Pulse therapy for the treatment of pemphigus has been in vogue for several years and considered better than conventional corticosteroids. Aims and objectives: This study was conducted to evaluate the efficacy and safety of pulse therapy in pemphigus patients treated over a period of 10 years. Materials and Methods: This retrospective study was based on medical records of Pemphigus patients treated at Department of Dermatology from January 2008 to December 2017. Diagnosis of pemphigus was made on clinical ground, Tzanck smear and histopathology of skin/mucous membrane lesions. Patients were put on DCP/DAP depending on the completion of family. Results: A total of 124 patients were included in the study. Age of patients ranged from 18 years to 72 years with mean of 41.21±12.71 years. Amongst 124 patients, 114 (92%) had pemphigus vulgaris and 10 (8%) had pemphigus foliaceous. 89 patients received DCP and 35 patients received DAP therapy. Number of pulses received by patients in phase I ranged from 4 to 27, average being 8.16±4.63. 106 patients completed the phase I of which 83 completed the phase II. 54 patients had successfully completed phase III of which 22 are currently in phase IV and 28 patients have completed their five year follow up period and considered as cured. Conclusion: Pulse therapy is a cheap and easily available mode of therapy in treatment of pemphigus in India even in the present era of modern molecules like Rituximab. With pulse therapy, it is now possible to induce and maintain remission, and achieve cure, provided the patients strictly adhere to the prescribed schedule.

A blade-free approach to the Tzanck smear

A blade-free approach to the Tzanck smear

Erosive-ulcerative blepharitis in a case of herpes labialis

A 41-year-old male presented to the outpatient department with complaints of redness and pain in the left lower eyelid for 3 days. Left lower eyelid showed ulcer present laterally on the intermarginal strip with the bare mucosal surface. There was mild edema and conjunctival injection adjacent to the ulcer. He had a history of fever and perioral rashes for last 5 days. Tzanck smear from perioral lesions showed multinucleated giant cells. He was diagnosed with herpes labialis (HL) with ocular involvement. We would like to highlight the presence of erosive-ulcerative blepharitis in association with HL.

A Case of Herpes Zoster Simulating Pemphigus Vulgaris Flare

Pemphigus vulgaris is an autoimmune bullous disorder caused by autoantibodies directed against desmogleins. There is an increased risk for developing herpes zoster in pemphigus vulgaris due to the prolonged and high doses immunosuppressant therapy. Here, we present a 52-year-old female patient with extensive pemphigus vulgaris who developed herpes zoster while on treatment which resulted in a diagnostic confusion and a Tzanck smear acted as a lifesaver revealing both multinucleated giant cells and acantholytic cells. Hence, a prompt decision of reducing the immunosuppressant and initiation of IV acyclovir helped the patient to recover faster. This case highlights the relevance of simple bedside investigation like Tzanck smear and reminds the clinician once again to be open to all possibilities.

Two Waves of Specific B Cell Memory Immunoreconstruction Observed in Anti-HHV1-3 IgG Kinetics after Hematopoietic Stem Cell Transplantation.

Humoral memory and specific antibody levels depend on the kind of antigen and individual immunofactors. The presence of IgM antibodies or a fourfold rise in specific IgG levels are generally accepted as diagnostic factors in the serology of acute viral infections. This basic model is not adequate for the herpes virome, especially after hematopoietic stem cell transplantation (HSCT), due to continuous, usually multifocal antigenic stimulation, various donor serostatuses, immunosuppression, and individual immunoreconstitution. A case-control study was conducted to identify active infection cases of human herpesvirus (HHV) (from 300 diagnosed immunocompromised patients) and to evaluate historically associated humoral factors to look at outcomes. We considered only the data of patients with meticulous differential diagnosis to exclude other causes, and thereby to observe pathways and temporal relationships, not the statistical ones usually collected in cohorts. Despite the small number, such data collection and analysis methods avoid a number of biases and indicate cause and effect. In this observational study, a retrospective analysis of data from 300 patients with clinical diagnosis of herpes simplex virus (HSV) and varicella zoster virus (VZV) reactivation showed a number of biases. Two well-differentiated cases (confirmed by a Tzanck test) with various diseases and conditioning evolutions of immune parameters showed an interesting pathway. Exponential decreases in specific IgGs after HSCT preceded virus replication were observed, with a cytopathic effect (shingles, VZV encephalitis and HSV-induced mucositis). The minima (lowest IgG levels) before herpesvirus reactivation were 234.23 mIU/mL and 94 RU/mL for VZV and HSV, respectively. This coincided with a low CD4 titer, but without other infectious processes. Other immune response parameters such as Treg, cytotoxic T cells, and complement and total IgG level were the same as they were before the transplant procedure. Interestingly, a second wave of immunoreconstitution with an anamnestic antibody response was not always observed. It coincided with prolonged herpes viral infection. A patient with lymphocyte depletion in conditioning showed an earlier second wave of immunoreconstitution (6th vs. 14th month). As is typical for infancy, the kinetics of the IgG level is unique after HSCT (the decline phase is first). Host microbiome factors (e.g., HHV1-3-serostatus) should be taken into account to predict risk of non-relapse mortality and survival after HSCT. The levels of specific antibodies help in predicting prognoses and improve disease management. A lack of differentiation and the confusing bias of the assessor (i.e., observer selection bias) are the main obstacles in statistical HHV1-3 research. Such time-lapse case studies may be the first to build evidence of a pathway and an association between immune parameters and HHV disease.

Eponyms that honor Jewish dermatologists: A celebration and a remembrance, Part three: Jewish physicians who practiced during the Holocaust and in its aftermath

Part III of this contribution continues to celebrate the many contributions that Jewish physicians have made to advance the specialty of dermatology, as reflected by eponyms that honor their names. Part I covered the years before 1933, a highly productive period of creativity by Jewish dermatologists, especially in Germany and Austria. The lives of 17 Jewish physicians and their eponyms were described in Part I. Part II focused on the years of 1933 to 1945, when the Nazis rose to power in Europe, and how their anti-Semitic genocidal policies affected leading Jewish dermatologists caught within the Third Reich. Fourteen Jewish physicians and their eponyms are discussed in Part II. Part III continues the remembrance of the Holocaust era by looking at the careers and eponyms of an additional 13 Jewish physicians who contributed to dermatology during the period of 1933 to 1945. Two of these 13 physicians, pathologist Ludwig Pick (1868-1944) and neurologist Arthur Simons (1877-1942), perished in the Holocaust. They are remembered by the following eponyms of interest to dermatologists: Lubarsch-Pick syndrome, Niemann-Pick disease, and Barraquer-Simons syndrome. Four of the 13 Jewish physicians escaped the Nazis: Felix Pinkus (1868-1947), Herman Pinkus (1905-1985), Arnault Tzanck (1886-1954), and Erich Urbach (1893-1946). Eponyms that honor their names include nitidus Pinkus, fibroepithelioma of Pinkus, Tzanck test, Urbach-Wiethe disease, Urbach-Koningstein technique, Oppenheim-Urbach disease, and extracellular cholesterinosis of Karl-Urbach. The other seven Jewish physicians lived outside the reach of the Nazis, in either Canada, the United States, or Israel. Their eponyms are discussed in this contribution. Part III also discusses eponyms that honor seven contemporary Jewish dermatologists who practiced dermatology after 1945 and who continue the nearly 200 years of Jewish contribution to the development of the specialty. They are A. Bernard Ackerman (1936-2008), Irwin M. Braverman, Sarah Brenner, Israel Chanarin, Maurice L. Dorfman, Dan Lipsker, and Ronni Wolf. Their eponyms are Ackerman syndrome, Braverman sign, Brenner sign, Chanarin-Dorfman syndrome, Lipsker criteria of the Schnitzler syndrome, and Wolf's isotopic response.

Unusual Localization of Eczema Herpeticum to Tinea Corporis and Cruris

Abstract Eczema herpeticum (EH), known as Kaposi varicelliform eruption presents with multiple vesiculopustular lesions localized to areas of preexisting eczematous or erosive dermatoses. Most commonly seen in atopic dermatitis but colocalization with tinea cruris and corporis is atypical. In our case, multiple vesicles, pustules, and small crusted erosions associated with pain were seen confined to the areas of dermatophytosis. Tzanck smear from vesicles showed multiple multinucleated giant cells and acantholytic cells. In view of strong clinical suspicion and the presence of multinucleated giant cells, she was prescribed oral acyclovir 400 mg thrice a day for 7 days. She was reviewed after a week with complete clearance of the vesicles and crusting.

Kaposi Varicelliform Eruption in a Chronic Kidney Disease Individual Under Tacrolimus: A Case Report

Background: “Kaposi varicelliform eruption” (KVE), also known as “eczema herpeticum,” refers to a rare widespread skin infection. The primary causal agent is thought to be the herpes simplex virus (HSV). Though common in patients with underlying skin dermatosis, systemic immunosuppression can at times lead to KVE.Case Presentation: A 27‐years male, a renal transplant recipient, under systemic immunosuppressants, presented with lesions over the whole body for 2 weeks and fever for 10 days. Skin examination revealed multiple flaccid vesicles with hemorrhagic fluid over the face, trunk, and bilateral extremities. Multiple erythematous erosions over the chest and abdomen, multiple petechiae and purpura over bilateral legs, palms, soles, and abdomen, erosions over the hard palate along with thick crusts over the scalp. A tzanck smear showed plenty of acantholytic cells. With a diagnosis of KVE, he was managed with an injection of acyclovir that led to resolution of his symptoms.Conclusion: KVE is a serious condition that may have fatal outcomes. Early diagnosis and appropriate treatment of patients at risk for viral complications are very important medical considerations.

Widespread necrotic vesicles with genital involvement.

We present a clinicopathological challenge consisting of disseminated herpes zoster that simulated mpox. We emphasize the utility of diagnosis with the Tzanck test and skin biopsy, as well as the importance of understanding the clinical picture, owing to its potential severity

Tzanck smear: revisiting the basics.

Tzanck smear: revisiting the basics.

Unusual herpetic reactivation in a young female following botox injection: a case report study

BackgroundBotox injections are commonly used for cosmetic and therapeutic purposes because they temporarily paralyze muscles, reduce wrinkles, and alleviate certain medical conditions. Although generally considered safe and effective, Botox injections may cause potential complications. While herpes reactivation is more commonly associated with immunosuppressive therapies, such as chemotherapy or corticosteroid use, its association with Botox injection is poorly documented.Case PresentationA 33-year-old woman presented with progressive painful rashes and vesicles on her forehead, scalp, and right upper eyelid, accompanied by fever and malaise following a Botox injection to treat wrinkles. A positive Tzanck smear test result confirmed the diagnosis of herpes infection. The patient was treated with antiviral medication, and her symptoms gradually regressed over several days.ConclusionsAlthough herpes reactivation is more commonly associated with immunosuppressive therapies, few cases of herpes zoster and herpes simplex following Botox injection have been reported. The pathogenesis of herpes reactivation following Botox injection is unclear; however, it has been hypothesized that the Botox protein is a potent antigen that may activate the cellular immune system, making it easier for the virus to reactivate. Healthcare providers should be aware of this potential complication and consider it when evaluating patients who present with painful rashes following Botox injections. In addition, individuals who want to receive Botox injections should be informed of this complication. The diagnosis of herpetic infection should be made promptly, and antiviral therapy should be initiated to minimize the risk of complications. Further research is needed to better understand the pathogenesis and risk factors for herpes following Botox injection and to develop strategies for preventing and managing this complication.

A-181 Comparison of POCT Accreditation Between TJC and CAP: Which Way to Go?

Abstract Background Point-of-care testing (POCT) at UW Health University Hospital is accredited by the Joint Commission (TJC) while the main laboratory is accredited by the College of American Pathologists (CAP). Consolidating to a single accrediting agency would eliminate the burden of maintaining two separate accreditation programs, and reduce related expenses. In consideration of consolidation, we compared the accreditation requirements between the two agencies for POCT. Methods CAP standards in the All Common (n = 84), POC (n = 62), and Lab General checklists (n = 98) were evaluated for non-waived testing requirements in accordance to the POC test menu. The POC test menu includes the following non-waived tests: activated clotting time, blood gases, urine specific gravity by refractometry, and Tzanck smear; and provider performed microscopy (PPM): wet mount (skin or hair), wet prep, and fern test. A gap analysis was conducted to distinguish differences between CAP and TJC standards and further investigation was initiated when needed. Results The majority of CAP checklist standards aligned with the current processes under TJC. From the CAP All Common checklist, 5 out of 84 standards flagged as a potential gap. One notable difference was found for CAP COM.04250Comparability of Instruments and Methods—Nonwaived testing where comparison studies are required only for instruments and methods under the same CAP number. In contrast, the TJC requires instrument and method comparisons across the entire organization, regardless of separate CLIA certificates or sites. Shifting POC nonwaived tests to CAP would eliminate the need to perform comparisons across different sites, which in our hands has been labor intensive and of little clinical value. From CAP POC checklist, 10 out of 62 standards flagged as potential gaps. Specifically, CAP POC.03800Problem Resolution where the ability to provide prompt resolution for POC issues for all shifts in which POC testing is performed is demonstrated. From the CAP Lab General checklist, 4 out of 98 standards flagged as a potential gap. Specifically, CAP GEN.40470Specimen Collection Training where additional discussion with nursing education would be needed to assess collection training records. The other key difference was with CAP GEN.23584Interim Self-Inspection where self-inspection is required during the interim year. Conclusion Overall, our assessment is that moving non-waived POC testing to CAP will align the requirements for this set of largely hospital based POC tests, where the considerable effort saved from eliminating organization wide instrument/method comparisons could be more effectively applied to expanding our existing CAP mandated interim self-inspections to include nonwaived POCT. Because the vast majority of the waived testing performed at our organization occurs at ambulatory sites under CMS oversight, leaving waived POC tests under TJC oversight was felt to align better. Overall, the POCT requirements under CAP checklists were similar to TJC with minor, but potentially impactful, differences. In our situation, moving nonwaived POC testing to CAP accreditation and keeping waived POC testing under TJC accreditation provided the best balance between quality/patient safety and regulatory administrative effort.

Herpes Zoster Infections in Solid-Organ Transplant Recipients.

Herpes zoster infections can be complicated and mortal in solid-organ transplant recipients. In our study, we investigated herpes zoster infections in solid-organ transplant recipients. UntilJune 2022, our center has performed 3342 kidney, 708 liver, and 148 heart transplants.Herpes zosterinfections were investigated in 1050 adult solid-organ transplant recipients from January 1, 2011, to June 31, 2022. We studied 44 patients diagnosed with herpes zoster infections. Of the 44 patients with herpes zoster, 32 had kidney, 7 had heart, and 5 had liver transplant procedures. Crude incidence rate was 5.2%.,with 9.7% being heart, 5.1% being kidney, and 3.9% being liver transplant recipients; 72.7% were male patients. The median age was 47.5 years, and 61% of patients were aged >45 years. Postherpetic neuralgia was significantly higher in patients older than 45 years (P = .006). The median duration to infection posttransplant was 16.5 months. The dermatomes of patients were 43.2% thoracic. Sacral dermatome involvement was significantly higher in heart transplant patients than in other transplant recipients (P = .015). We reviewed specific findings of the Tzanck test in 36.4% of the patients. There was concomitant infection in 15.9% of the patients, and 6.8% had pneumonia. Acute neuritis was more common in kidney transplant recipients (65.6%). The mean duration of acute neuritis/neuralgia was longest in liver transplant recipients (13.5 months; P = .047). Postherpetic neuralgia was detected as high as 24%. Early specific and supportive treatmentis important for transplant recipients with herpes zoster infections. Appropriate antiviral prophylaxis regimens and vaccination strategies for varicella zoster (chickenpox) and herpes zoster infections should be implemented in the vaccination schedule of solidorgan transplant candidates to prevent herpes zoster infections and complications.

Laryngeal carcinoma with hemorraghic varicella : a rare case report

Background : Hemorrhagic varicella is a complication that usually occurs in patients with immune disorders or those on immunosuppressive therapy or hematologic malignancies such as leukemia. Purpose: This case report aimed to further examine the complications of a rarely found hemorrhagic varicella in neck head malignancies / laryngeal carcioma. Case report : This is a case report of laryngeal carcinoma with hemorrhagic varicella in a 44-year-old man. Examination of dermatological status revealed hemorrhagic, polymorphic vesicles, generalized pustular psoriasis, erosion and, crusting. Tzanck test of the scrapes of the base of lesion of the vesicles is helpful in establishing the diagnosis of varicella and discovered multinucleated giant cells (MGCs) and epithelial cells with acidophilic intranuclear inclusion bodies The patient died after 3 days of treatment in the isolation room. A previous study also reported cases of hemorrhagic varicella in a 3-year-old girl with the main complaint of pus-filled red spots throughout the body. A previous history of chickenpox was denied. The physical examination showed dark red, polymorphic lession, generalized pustular psoriasis, erosion and crusting. Hemorrhagic varicella in the head and neck malignancy is a very rare form of varicella. Clinical question: In patient with immunocompromised during chemotheraphy suffer from varicella, is it necessary to have a comprehensive diagnostic examination panel, and therapy? Review methods: Evidence-based literature search with keywords “immunocompromised” AND “Hemorrhagic varicella” was performed through Cochrane, PubMed and Medline database. Result : The literature search obtained 318 articles in PubMed, 11 articles in Medline,and none in Cochrane, which were relevant with the topic. Only 1 article screened with inclusion and exclusion criteria. A research was conducted by Elizabeth et al in Philipina (2011) on Pediatric Infectious Disease and Hematology-Oncology Services. Out of 26 immunocompromised patients who developed varicella during the study period, only 22 charts were available for review. Of these patients, 13 were male and 9 were female. The highest incidence occurred from 0 to 5 years old (41%). Twenty patients had an underlying malignancy in the form of leukemia (14%) and solid organ tumors (6%) including nasopharyngeal cancer. Diagnosis based on the characteristic generalized papulovesicular rashConclusion : This requires a comprehensive diagnostic panel test for the delivery of appropriate therapy and improved outcome.

PATTERN OF NON-VENEREAL GENITAL DERMATOSES IN ADULT MALE- A CLINICAL STUDY IN A TERTIARY CARE CENTRE

Objectives: Non-venereal genital dermatoses are genital dermatoses that are not sexually transmitted. It causes extreme anxiety in patients because venereal disease is often their primary concern. The aim was to study the clinical pattern of various non-venereal genital dermatoses in males aged 18–60 years. Methods: A cross-sectional clinical study was done among male patients between 18 and 60 years of age with non-venereal genital dermatoses attending the dermatology outpatient department of a tertiary care hospital in Eastern India. Patients clinically diagnosed with non-venereal genital dermatoses were included in the study after signing the informed consent thorough examination of the genital lesion was done with special relevance to the morphology, number, tenderness, regional lymph node involvement, etc. A complete physical and systemic examination was done. Associated skin lesions were noted. Investigations such as blood sugar, Tzanck smear, KOH mount, Gram stain, and histopathological examination were done in relevant cases. At the Venereal Diseases Research Laboratory, HIV tests were done to rule out STDs. Statistical analysis was done using the necessary software. Results: A total of 133 patients were included in the study. The commonest age group was 18–30 years. The most common [35%] disease was Candidal Balano-Posthitis. Married people were more affected. Diseases predominant in rural areas were LSA. Non-STD genital dermatoses are less more common in Muslims. Diabetes is common in both personal and family histories. Conclusion: For the differentiation of non-venereal genital dermatoses, apart from history and investigations, the clinical study such as age, residence, religion, and morphology of the lesions are very important. A clinician should have an unbiased approach towards genital conditions.

TZANCK SMEAR: A USEFUL DIAGNOSTIC TOOL IN SPECTRUM OF VESICULOBULLOUS DISEASES OF SKIN.

Introduction: The pemphigus group of autoimmune bullous disorders and mucocutaneous herpesvirus infections are generally diagnosed with the Tzanck smear. Only a few research have looked into its diagnostic value in the literature. To evaluate tzanck smear ndings in patients Objectives: with vesiculobullous skin lesions and histopathological correlation. All recei Material and Methods: ved Samples received between 01/08/2021 to 31/01/2022 were stained with May-Grunwald-Giemsa. In some patients, methylene blue staining and ZN staining were done. Tzanck Results: smear was performed on a total of 25 patients with skin lesions. The sensitivities of multinucleated giant cells and acantholytic cells in herpetic infections, dyskeratotic acantholytic cells,inammatory cells and cocci in bullous impetigo, acantholytic cells with neutrophils and lymphocytes in pemphigus foliaceous, acantholytic cells and plenty of neutrophils in drug-induced pemphigus, no acantholytic cells with neutrophils and lymphocytes in IgA pemphigus, cluster of acantholytic cells in pemphigus vulgaris, only lymphocytes with no acantholytic cells in bullous pemphigoid and dyskeratotic acantholytic cells without inammation in staphylococcal scalded skin syndrome, intracytoplasmic HendersonPatterson bodies and anucleated squamous cells in molluscum contagiosum and broblast, leucocytes with necrotic basal cells in Toxic epidermal necrolysis. The tzanck smear test is an inexpensive, useful, quick, reliable Conclusion: and an easy diagnostic tool for certain vesiculobullous skin diseases.

Granulomatous reaction as a postherpetic isotopic response after primary varicella infection in a healthy adult

We report the first case of post-herpetic isotopic reaction (PHIR) after primary varicella infection in a healthy adult. PHIR refers to the development of new skin lesions at sites where prior herpetic skin lesions have been resolved. Herpes zoster is the most common cause of PHIR; however, only a few cases of PHIR due to primary varicella infections have been reported. Postherpetic isotopic reaction (PHIR) refers to the development of new skin lesions at sites where prior herpetic skin lesions have been resolved. Herpes zoster (HZ) is the most common cause of PHIR; however, only a few cases of PHIR due to primary varicella infections have been reported. A 22-year-old Japanese man with no relevant medical history presented with multiple vesicles throughout the body. The patient was diagnosed with primary varicella infection based on a positive Tzanck test. Three weeks after onset, new skin eruptions appeared in the regions affected by the primary rash. He had multiple nodules of 5–8 mm size and hues ranging from red to normal skin on his face, trunk, and limbs (Figure 1A,B). He had been vaccinated against varicella during childhood. No abnormal findings were observed except for slightly low immunoglobulin (Ig) A and IgG (IgM: 37 mg/dL, IgA: 63 mg/dL, IgG: 734 mg/dL) in blood tests. Viral antibody examination revealed varicella-zoster virus (VZV)-IgM enzyme-linked immunosorbent assay (EIA) and VZV-IgG EIA titers of 0.03 and 6.8, respectively (both tests are positive at ≥4.0), indicating a previous infection. Histological findings showed epithelioid cells and granulomatous foreign body giant cells within the upper dermis, surrounded by marked neutrophilic and lymphocytic infiltration. No caseous necrosis, inclusion bodies, or residual viral particles were observed (Figure 1C,D). The patient was diagnosed with granulomatous reaction as PHIR after primary varicella infection. The nodules gradually improved with topical steroid, and no recurrence was noted. Postherpetic isotopic reaction is a type of Wolf's isotope reaction (WIR), and some argue that WIRs are Koebner reactions.1 However, Koebner reactions generally indicate the appearance of the same preexisting dermatosis on the injured skin. In the present case, a completely different eruption appeared after the primary rash. Thus, it was appropriate to describe it as a PHIR. Various skin manifestations have been reported in PHIR, with granulomatous dermatitis being the most common. According to Wang et al., the pathogenesis of granulomatous reaction as PHIR possibly encompasses post-infection nerve damage and residual virus particles, which may induce secretion of interleukin-4 and other chemokines, promote infiltration of inflammatory cells, and locally modulate immune and angiogenic responses.2 Less nerve damage associated with primary varicella compared to that associated with HZ may be a reason for the infrequent PHIR phenomenon following primary varicella infection. Several pediatric cases of granulomatous reactions as PHIR after primary varicella have been reported previously.3-6 Two PHIR cases in adults were previously reported, but the patients were immunosuppressed hosts with myelogenous leukemia. Immunocompromised patients are susceptible to greater nerve damage by VZV.7 This is the first case of PHIR after varicella infection in a healthy adult. Histological findings supported the possibility of a hyperimmune response to residual viral particles, resulting in granulomatous dermatitis. Blood samples showed a slightly low level of immunoglobulins, but no other abnormalities were observed. Although the cause is unclear, the patient should be followed carefully for the future development of immune system diseases. Further studies are required to understand the mechanisms underlying PHIR after varicella infection. The authors declare no conflict of interest. Informed consent: Informed consent was provided by the patient, and approval was received. Approval of the research protocol: N/A. Registration No. of the study/trial: N/A. Animal studies: N/A. The data that support the findings of this study are available from the corresponding author, Y. W., upon reasonable request.

Herpes Zoster: a case series with different manifestations

Background: The incidence of herpes zoster appears to correlate inversely with the host's ability to mount a cellular immune response. The disease is characterized clinically by an acute rash with herpetiform blisters on the skin and mucous membranes. This case series presented the different clinical presentations of herpes zoster infection in three patients with different underlying diseases in the ophthalmic, trigeminal, cervical, and thoracic dermatomes. Case Presentation: Three cases of herpes zoster were observed in this case series. The first case involved the ophthalmic division of the trigeminal nerve. The second case involved the cervical nerve, and the last case involved the thoracic nerve. All had undergone varicella infection in childhood and suffered from various states leading to immunosuppression. Tzanck smears were performed in all cases, which showed multinucleated giant cells. After treatment following the herpes zoster protocol, all cases healed without complications. Conclusion: Reactivation of the varicella-zoster virus may occur spontaneously or when host immunity is weakened. Increasing age, a physical trauma (including dental procedures), psychological stress, malignancy, and immunocompromised conditions, including transplant recipients, pregnancy, and HIV infection, are predisposing factors for varicella-zoster virus reactivation.