Clinical Image

Late diagnosis of extensive herpes zoster infection in a patient with granulomatosis with polyangiitis

Running title: herpes zoster in an immunosuppressed GPA patient

Nektarios Marios Liapis, Ioannis Alexiou, Dimitrios P. Bogdanos*

Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, University General Hospital of Larissa, 40110 Larissa, Greece

Corresponding Author’s e-mail: bogdanos@med.uth.gr

Keywords– ANCA; immunosuppression; infection; vasculitis; virus; Wegener’s granulomatosis

(submitted 18 August 2022; accepted 22 August 2022)

Image. Herpes zoster in a drug-induced immunosuppressed patient with c-ANCA positive vasculitis. This is the case of a 79-year-old man with a two-year history of granulomatosis with polyangiitis (formerly known as Wegener’s disease) with both renal and lung involvement. At diagnosis, the patient presented with low grade fever, arthralgias, lung nodules and necrotizing glomerulonephritis. Laboratory tests revealed increased inflammation markers and the presence of c-ANCA and anti-PR3 antibodies at high titre. The patient

received methylprednisolone and cyclophosphamide pulses with sufficient response. Prior to his current admission, he was successfully treated with azathioprine. Last week, he presented to our department with significant erythematous rash with crusted vesicles extending

to a great area along the right T4 dermotome. The clinical image was firstly attributed to neglected herpes zoster infection in an immunosuppressed patient. Although the rash was typical of herpes zoster virus, the patient mentioned no excruciating pain or neuralgia. Analgesics, which he received for joint pain and arthralgia for the last 2 weeks, probably obscured pain and early diagnosis. Herpes zoster is usually self-limited. However, risk of serious infection increases with age, and with any condition or treatment causing severe immunosuppression. Our patient was treated with iv acyclovir (10 mg/kg) for ten days. With the initiation of treatment, the rash was significantly reduced and gradually receded without any complications.

AUTHORS CONTRIBUTION

The authors prepared the manuscript and the artwork. All authors approved the final version of the manuscript.

CONFLICT OF INTEREST

The Authors declare no conflict of interest