Case Presentation: A 37-year-old woman with no significant medical history initially presented to the Emergency Department (ED) with an itchy rash on her left thigh that developed over a week. The only preceding event was visiting a water park with her children two weeks prior. She denied other exposures, traumas, recent travel, or sick contacts. Initial exam of her thigh showed a small circular group of several erythematous papules with central umbilication. She was diagnosed with molluscum contagiosum and discharged from the ED with hydroxyzine.
After two days, she returned to the ED with a worsened rash that spread throughout her body and was more painful. Skin exam was notable for about 30 firm, grey, umbilicated vesicles on an erythematous base on her left thigh along the L3 dermatome, and over 50 vesicles, papules, and pustules on erythematous bases scattered bilaterally on her forehead, trunk, arms, and vagina.

Her laboratory workup was notable for a normal complete blood count, mildly elevated aspartate and alanine aminotransferases (127 U/L/128 U/L), positive varicella-zoster (VZV) IgG Ab (index 4.3) and a positive VZV IgM Ab (1.3). She underwent a punch biopsy of a left thigh lesion which isolated VZV on culture, and a swab of a vesicle on the right arm was positive for VZV DNA PCR. Her workup for possible immunodeficiency (HIV, quantitative IgA, IgG, IgM antibodies, CD4 and CD8 counts) was unrevealing.

With consultation from dermatology and infectious diseases, she was maintained on airborne and contact isolation, and treated with IV acyclovir for disseminated zoster. Her transaminitis resolved, her lesions crusted after a week, and she was discharged on oral acyclovir (total 14-day therapy). She presented to clinic a month later with complete resolution of symptoms.

Discussion: Following primary infection, VZV establishes a latent infection within the sensory dorsal root ganglia, suppressed by cell-mediated immunity. Age-related dermatomal VZV reactivation is common, but disseminated disease typically arises as a result of immunosuppression [1]. It is exceptionally rare to have disseminated zoster without immunosuppression; there are only a handful of case reports [2].

This case is notable for the patient’s young age, absence of comorbidities, and a negative workup for immunosuppression. A lesion on the left thigh was biopsied for VZV, but given the rarity of such a presentation, the medical team remained suspicious of alternative diagnoses and also tested a lesion on the right arm for VZV. The positive VZV culture and DNR PCR, as well as the resolution of disease with acyclovir, confirmed the diagnosis of disseminated zoster.

Conclusions: Although this patient was initially misdiagnosed, she fortunately did not suffer any complications. Because dissemination can lead to devastating multi-organ involvement, a high level of suspicion is required to diagnose zoster in a young healthy patient and promptly initiate treatment and isolation. Lastly, investigation for undiagnosed causes for immunosuppression in such cases is reasonable.

1. Arvin A. Aging, immunity, and the varicella-zoster virus. N Engl J Med. 2005 Jun 2; 352(22):2266-7.
2. Gomez E, Chernev I. Disseminated cutaneous herpes zoster in an immunocompetent elderly patient. Infect Dis Rep. 2014 Aug 26;6(3):5513.

IMAGE 1: Photos of thigh (A) and back (B)