[CIS PIDD] [cis-pidd] Recurrent Zoster

[Seppänen Mikko]

Dear Richard,

Never seen VZV this active, these all usually turn out to be HSV, if virus at all. If indeed VZV, agree totally with Kate. 

Never seen E. fixum with blistering, but E multiforme (e.g. NSAIDs?) can be this active, recurrent, staying in one place and blistering, seen two in about 10 last years. They do not have the characteristic prodromal and early neuropathic pain. About 90% of patients with very recurrent EM have herpes-associated EM, HAEM, and lesions appear delayedly, 5-20 days after recurrence. Rophylaxis helps them as well. No use if for example NSAIDs.

If HSV, if this active often becomes chronic sensory neuropathy without high dose valaciclovir long-term. Hsv is extremely active in a subset (MBL2deficiency and HSV-2, see Seppanen M et al, nabout 50 with >10 recurrences/year), we were unable to collect enough patients with HSV1, so unproven for it. MBL2 recognizes HSV. Oral HSV1 that is extermely active seems to have to do with MHC homozygosity (again Seppanen M et al), but n=3. Usually patients have other inciting factors as well, sunshine, menses, and especially strong negative long-lasting stressas wel. Has this girl experienced somethig extremely traumatizing?

In Finland, I would order herpes virus (VZV+HSV) spin Ag test, unlike culture sensitively detects VZV as well. PCR is an option, if the lab has a certified method for it...

Hope this helps a bit further, let us know what it turns out to be.

Mikko Seppänen, MD
HUCH, Finland
________________________________________
Lähettäjä: Jason Raasch [jraasch at midwestimmunology.com]
Lähetetty: 23. marraskuuta 2013 17:54
Vastaanottaja: CIS-PIDD
Aihe: Re: [cis-pidd] Recurrent Zoster

Richard,

1.  is this patient atopic?

2.  Agree regarding biopsy.  Pemphigus foliaceus?  Wouldn't explain consistent dermatome distribution though.

Tom, if this patient is going to have a biopsy anyway, can one use DFA on a biopsy specimen?  Do you know if this would be of any benefit over PCR (e.g. in the event insufficient fluid is obtained from lesion)?

-J




Jason Raasch, MD

Midwest Immunology Clinic
15700 37th Ave N, Ste 110
Plymouth, MN 55446

TEL: (763) 577-0008
FAX: (763) 577-0192







On 11/22/13 2:44 PM, Richard Wasserman wrote:

I am seeing a 13 yo otherwise healthy girl who had her first episode of apparent herpes zoster four years ago in the distribution of the ophthalmic branch of the trigeminal nerve without involvement of the globe. Since the first episode there have been 15 additional episodes until the last two that appear to involve a limited area of the C2 distribution. That is, the rash is about 2x4 cm over the sternocleidomastoid muscle about 3 cm caudal to the mastoid. I saw the last episode, it looked like zoster. Culture obtained on the first day of blistering failed to grow either herpes zoster or herpes simplex. There may have been a response to high dose valacyclovir.

CBC, CD3,4,8,19, and 16/56 were all normal. IgG anti-herpes zoster was present, IgA, IgG and IgM were normal as was the response to PHA, PWM and ConA.

I think she needs a biopsy of the next recurrence in a cosmetically acceptable location. Suggestions?

Thanks,
Richard Wasserman
Dallas

--
Richard L. Wasserman, MD, PhD
DallasAllergyImmunology
7777 Forest Lane, Suite B-332
Dallas, Texas 75230
Office (972) 566-7788
Fax (972) 566-8837
Cell (214) 697-7211

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