Saudi Journal of Kidney Diseases and Transplantation

LETTER TO THE EDITOR
Year
: 2010  |  Volume : 21  |  Issue : 6  |  Page : 1155--1156

Disseminated "Shingles" in the nephrotic syndrome


Sunil Kumar, AP Jain 
 Dialysis Unit, Department of Medicine, MGIMS, Sewagram, India

Correspondence Address:
Sunil Kumar
Dialysis Unit, Department of Medicine, MGIMS, Sewagram
India




How to cite this article:
Kumar S, Jain A P. Disseminated "Shingles" in the nephrotic syndrome.Saudi J Kidney Dis Transpl 2010;21:1155-1156


How to cite this URL:
Kumar S, Jain A P. Disseminated "Shingles" in the nephrotic syndrome. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2021 Oct 18 ];21:1155-1156
Available from: https://www.sjkdt.org/text.asp?2010/21/6/1155/72316


Full Text

To the editor,

Disseminated shingles is a rare entity which has been defined as more than 20 vesicles out­side the area of the primary and adjacent der­matomes [1],[2] and is seen especially in the immu­nosuppressed patient. It is caused by the vari­cella zoster virus (VZV) due to reactivation of the virus from dorsal root or cranial nerve ganglia. Human immunodeficiency virus in­fection, chronic infections, and treatment with corticosteroids are important causes of disse­minated herpes zoster. We report one case of adult nephrotic syndrome on corticosteroids that developed shingles at multiple dermatomes.

A previously asymptomatic 39-year-old man presented with a 3-day history of severe pain and burning sensation over both thighs and buttocks followed a day later with develop­ment of vesicular eruptions. It was followed by the spread of vesicular eruption to involve the chest, back and abdominal wall over the next two days. The patient was a known case of the nephrotic syndrome and was on corticosteroids in a dose of 60 mg per day. The patient did not have a history of chickenpox during childhood or any recent exposure to it. There was no past history of diabetes, cardiac or pulmonary di­sease, or lymphoma. On examination, the pa­tient was afebrile (37.4ºC). He had vesicles and pustules, with crusting and swelling, in the distribution of the bilateral L-1, 2, 3 dermatomes. Vesicles, pustules and scabs in various stages were also present over the trunk and extremi­ties. The palms and soles were spared and there was no lymphadenopathy. Pulmonary, cardio­vascular and abdominal examinations were nor­mal. Complete blood count, peripheral smear, routine biochemistry, renal profile, and chest x-ray were normal. Liver function tests re­vealed hypoalbuminemia with serum protein of 2.5 mg/dL. Urine albumin was negative. Se­rology for Human Immunodeficiency Virus (HIV), Hepatitis B, and Hepatitis C were nega­tive. The blood and vesicle cultures for VZV were negative. The patient was started on oral acyclovir, 800 mg every 8 hours. In the next 24 hours, the eruption of new vesicles ceased, the rash started to resolve and his clinical status improved. The patient was discharged on oral acyclovir 800 mg, five times daily for 14 days and is doing well on follow-up.

Shingles, also called Herpes Zoster, is due to reactivation of latent VZV from the dorsal root ganglia. It is characterized by unilateral vesi­cular eruptions within a dermatome. This com­plication of zoster has been described in im­munocompromised persons (HIV, cancer, pa­tients on corticosteroid treatment) and reported to be as common as 10 to 40%. [3] Our patient presented with characteristic skin findings of disseminated cutaneous herpes zoster. Dissemi­nation occurred by second day of the eruption. In our patient, significant decrease in cellular immunity caused by treatment with steroids could have contributed to dissemination of her­pes zoster. Patients with cutaneous dissemina­tion of VZV are at risk of infection of visceral organs, particularly lungs, liver and brain. Other complications include corneal ulceration and post herpetic neuralgia. Therefore, early clinical diagnosis and aggressive treatment of disseminated herpes zoster infection in pa­tients on steroids is important. The treatment of choice for disseminated zoster is intrave­nous acyclovir 10 mg/kg every 8 hours for 5-7 days, though our patient responded well to oral acyclovir.

References

1Brown TJ, McCrary M, Tyring SK. Varicella­Zoster Virus (Herpes 3). J Am Acad Dermatol 2002;47(6):972-97.
2Thami GP, Kaur S. Varicella, herpes zoster and dissemination. Pediatr Infect Dis J 2003; 22:295.
3Merselis JG Jr, Kaye D, Hook EW. Disse­minated herpes zoster. Arch Intern Med 1964; 113:679-86.