INTRODUCTION
Cutaneous granulomatous dermatoses are uncommon sequelae of herpes zoster (HZ) infection that have been documented in the literature,1 with granulomatous vasculitis described in rare cases. Here, we report a patient with HZ ophthalmicus who developed edematous plaques with central scarring in a V1 dermatomal distribution with histopathological changes of a granulomatous dermatitis including features of granulomatous vasculitis.
CASE
A 72-year-old rheumatoid factor-positive female with a family history of scleroderma and systemic lupus erythematosus presented to her ophthalmologist with vesicles in a V1 distribution with associated pain (Figure 1). She was diagnosed with HZ ophthalmicus and treated with 1-gram valacyclovir 3 times daily for 7 days, erythromycin ophthalmic ointment, and ophthalmic prednisolone drops. The patient was subsequently referred to dermatology for evaluation of persistent HZ lesions. Physical examination revealed red to purple edematous papulonodules with central erosions in a V1 distribution. A PCR swab of an erosion failed to reveal herpes simplex virus 1 and 2 (HSV-1, HSV-2) or varicella zoster virus (VZV).
After a second course of valacyclovir without improvement, a 4-mm punch biopsy was performed and revealed a pan-dermal infiltrate comprised of mono- and multinucleated histocytes palisading around areas of necrobiosis (Figure 2A). Perivascular granulomatous inflammation and fibrin deposition within the walls of small- to medium-sized vessels within the deeper dermis were also present (Figure 2B). Special stains for spirochetes, routine bacteria, fungi, and acid-fast bacilli were negative.
She was referred to rheumatology for further workup of a potential underlying autoimmune disorder. Laboratory evaluation revealed a positive result on an antinuclear antibody test (1:160) and elevated rheumatoid factor, anti-smooth muscle Immunoglobulin G (IgG), thyroid peroxidase, and C-reactive protein. However, antineutrophil cytoplasmic antibodies, Myeloperoxidase, proteinase 3, in addition to anti-Ro/La, anti-double standard DNA, anti-Smith, and RNA polymerase III IgG were negative. QuantiFERON-TB Gold, HIV, and Hepatitis C were negative. A chest x-ray was normal. She otherwise denied any other signs or systems of autoimmune disease. Based on these findings, her cutaneous findings were attributed to a reactive granulomatous dermatitis and vasculitis in resolving HZ ophthalmicus infection.
After a second course of valacyclovir without improvement, a 4-mm punch biopsy was performed and revealed a pan-dermal infiltrate comprised of mono- and multinucleated histocytes palisading around areas of necrobiosis (Figure 2A). Perivascular granulomatous inflammation and fibrin deposition within the walls of small- to medium-sized vessels within the deeper dermis were also present (Figure 2B). Special stains for spirochetes, routine bacteria, fungi, and acid-fast bacilli were negative.
She was referred to rheumatology for further workup of a potential underlying autoimmune disorder. Laboratory evaluation revealed a positive result on an antinuclear antibody test (1:160) and elevated rheumatoid factor, anti-smooth muscle Immunoglobulin G (IgG), thyroid peroxidase, and C-reactive protein. However, antineutrophil cytoplasmic antibodies, Myeloperoxidase, proteinase 3, in addition to anti-Ro/La, anti-double standard DNA, anti-Smith, and RNA polymerase III IgG were negative. QuantiFERON-TB Gold, HIV, and Hepatitis C were negative. A chest x-ray was normal. She otherwise denied any other signs or systems of autoimmune disease. Based on these findings, her cutaneous findings were attributed to a reactive granulomatous dermatitis and vasculitis in resolving HZ ophthalmicus infection.
