MYSTERIOUS RASH NOTICED IN HEMODIALYSIS PATIENT: HERPES ZOSTER OPHTHALMICUS

Introduction:

Zoster is of particular concern in end-stage renal disease (ESRD) patients due to their older age (48% are >65 years old) and relatively immunosuppressed state.  Herpes zoster (HZ), which is caused by the reactivation of a latent varicella-zoster virus (VZV) infection within the cranial or dorsal root ganglia, typically manifests as a characteristic vesicular rash with a unilateral distribution limited to a single dermatome. Using iron preparations and 1α-hydroxylated vitamin D was potentially associated with less risk of developing HZ reactivation in maintenance hemodialysis patients (Chao et al).

Methods:

An 82-year-old female patient, known to have congestive heart failure, chronic hypercapnic respiratory failure on long-term oxygen, dyslipidemia, osteoporosis with a history of left neck of femur fracture, and end-stage renal disease requiring initiation of hemodialysis. She came to the outpatient dialysis unit for her second scheduled session following hospital discharge with a vesicular rash on her right forehead involving the right eyelid and redness, there was no discharge. The patient did not sleep last night and was complaining of pain she is also tachypnoeic with a respiratory rate of 22 breaths per minute, her blood pressure was 151/79 mmHg and oxygen saturation was 95% on room air. Eye examination showed reactive pupils bilaterally, right upper lid edema, erythema, and ruptured vesicles, involving the right side of the forehead. There are no vesicles on the lid margin, the cornea is clear in both eyes, no pseudo-dendritic ulcer. A diagnosis of Herpes Zoster Ophthalmicus was made and she was started on an intravenous renal dose of acyclovir and a topical acyclovir ointment. 

Results:

She developed septic shock with high inflammatory markers. Her chest x-ray showed an enlarged cardiac silhouette, left-sided blunting of costophrenic angle representing pleural effusion, and increased Hazy opacification of both lung fields more prominent in the inferior zones. Abdominal x-ray showed gas-filled distended loops of bowel noted in 4 quadrants of the abdomen with no transition or significant air-fluid levels, in a picture of pseudo-obstruction. She was started on intravenous antibiotics to cover the possibility of meningitis and encephalitis including ampicillin, cefepem, and vancomycin. She had high inflammatory markers and the graph below shows her cell counts during her hospitalization. Unfortunately, the patient passed away due to comorbid conditions that were complicated with sepsis. 

Conclusions:

Mortality in ESRD patients with an inpatient zoster diagnosis is increased with older age and higher severity of clinical comorbidities. The role of zoster vaccination on mortality in this population remains to be defined.

I have no potential conflict of interest to disclose.

I did not use generative AI and AI-assisted technologies in the writing process.