Clicky

Herpes Zoster Duplex Bilateralis in a Patient with Breast Cancer

Cancer patients tend to have a higher incidence of herpes zoster (HZ), but little is known about their risk of HZ complications. We investigated the risk of cancer among patients with herpes zoster using a nationwide health registry in Taiwan. patients this year. Three human pancreatic cell lines, AsPC-1, MIA PaCa-2, and BxPC-3, were infected with G207 at different multiplicities of infection. Cases (n = 1,108,986) were people with first cancers identified in cancer registries (1992–2005). Humira also has a place on the FDA’s first list of drugs under investigation for “Potential Signals of Serious Risks,” newly published on a quarterly basis under a drug safety bill Congress passed last year. The phenomenon of zoster occurring on two non-contiguous, widely separated dermatomes has been referred to as zoster duplex unilateralis or bilateralis, depending on whether one half or both halves of the body are involved (3).

Herein, we report on a case of herpes zoster duplex bilateralis that occurred in an immunosuppressed patient who had previously received chemotherapy for breast cancer treatment. A 49-year-old female visited the authors’ hospital for an evaluation of the painful grouped erythematous vesicles on her left anterior chest and upper back, and this had developed about five days earlier and then rapidly spread. The lesions showed a band-like arrangement, and they were noted in the right T4 and left T4 non-contiguous dermatomes (). The company estimates one course of treatment will cost about $65,000, depending on the length of treatment. The MTS assay data indicated a dose-dependent cytotoxicity for G207 in the cell lines tested. Associations were strongest when HZ was diagnosed 13 to 35 months before cancer diagnosis/selection; they were significant for some cancers in the 36 to 59 months period, and 60+ months for lymphoplasmacytic lymphoma (OR = 1.99). Clinical trials in 2004 revealed allergic reactions including anaphylactoid in 1 percent of Humira patients as well as cytopenia, a serious hematologic event, and pancytopenia and aplastic anemia, bone marrow conditions.

There was no sign of recurrence or metastasis. The results of her complete blood count, serum chemistry, urinalysis and VDRL and chest PA tests were normal except for a decreased level of helper/inducer T-cells (CD4, 643/mm3) and suppressor/cytotoxic T-cells (CD8: 552/mm3). The Tzanck smear on her left anterior chest showed multinucleated giant cells with intranuclear inclusion bodies. Histologic examination of the vesicle lesions on her left anterior chest and upper back displayed intraepidermal blisters with ballooning degeneration, reticular degeneration, characteristic intranuclear inclusion bodies and acantholytic multinucleated giant cells (). For further evaluation and diagnostic confirmation, polymerase chain reaction (PCR) was performed for the varicella-zoster virus, and this consisted of a positive band of 208 bp (). Under the impression that herpes zoster duplex bilateralis had occurred in a breast cancer patient who had previously received chemotherapy and she had not suffered tumor recurrence, she was treated with oral administration of famciclovir 750 mg/day for seven days, and the skin lesions and pain subsided without complications. Herpes zoster is caused by the varicella zoster virus.

And Abbott has excelled at the two-step, removing references to the damning JAMA study from Wikipedia, according to a Brandweek blog, and paying $622 million in 2003 to settle an investigation into illegal sales of liquid foods to nursing homes. The clinical manifestations are characterized by several groups of painful vesicles situated unilaterally within the distribution of the cranial or spinal sensory nerve. Bilateral involvement and recurrence are rare, and zosters involving two widely separated regions at one time are even rarer (2). The phenomenon of zoster occurring in two non-contiguous, widely separated dermatomes has been referred to as zoster duplex unilateralis or bilateralis, depending on whether one half or both halves of the body are involved (3). The incidence of herpes zoster duplex bilateralis is below 0.5% (4). In a review of the medical English literature over the last three decades, only seven cases have been reported, two in immunocompetent persons, three in older persons on oral steroids for treating chronic illnesses and two in children with cancer (one with lymphoma and the other with leukemia) (4). Yet there is no previously reported case that occurred in an immunosuppressed patient who had previously received chemotherapy for breast cancer, as in the current case.

Patients with malignancy, and especially patients with Hodgkin’s disease and leukemia, are five times more likely to develop zoster than others of the same age (5). The other patients who have a higher incidence of zoster include those with deficient immune systems, such as the individuals who are immunosuppressed for organ transplantation, the individuals with connective tissue disease and those who take agents such as corticosteroids (6). The patient reported on in this paper had a history of breast cancer and she had been previously treated with chemotherapy that included 5-fluorouracil, methotrexate and adriamycinskin. We can speculate that she was under an immunosuppressed state because of her previous chemotherapy and not because of tumor recurrence, and the previous chemotherapy led to her defective cellular immune response and the development of zoster duplex bilateralis. The clinical appearance of these patients is usually identical to that of typical zoster, but the lesions may be more ulcerative and necrotic and they may scar more severely (7). Our patient, however, revealed typical zoster lesions and she healed without complications such as scars and pain. This is the first case reported in the English medical literature in which herpes zoster duplex bilateralis occurred in an immunosuppressed patient who had previously received chemotherapy for breast cancer treatment.

Our case illustrates that herpes zoster can present with bilateral involvement, which is referred to as zoster duplex bilateralis, in an immunosuppressed patient. 1. Straus SE, Schmader KE, Oxman MN. Varicella and herpes zoster. In: Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, editors. Dermatology in general medicine. 6th ed.

New York: McGrow-Hill; 2003. pp. 2070–2085.

Herpes Zoster Duplex Bilateralis in a Patient with Breast Cancer

A HIV infected patirent with recurrent herpes zoster has been presented. It is characterized by unilateral radicular pain and vesicular eruptions limited to a single dermatome innervated by a single spinal or cranial sensory ganglion.[1] Multi-dermatomal involvement is rare in immunocompetent patients.[2] We report an unusual case of involvement of ophthalmic, mandibular and maxillary branches of the trigeminal nerve in an immunocompetent male, which is extremely rare. Ogilvie’s syndrome due to herpes zoster infection is a rare manifestation of VZV reactivation. The lesions, which ranged from macular to vesicular, resolved with no scarring or postherpetic neuralgia following 10 days of therapy with oral acyclovir and intramuscular injections of γ-globulin. A variable degree of partial desensitisation of herpes-affected skin was found in 15 patients with post-herpetic neuralgia before capsaicin treatment where the mean threshold elevation for warm detection was 1.19 degrees C and 0.7 degrees C for cold detection, compared with the corresponding normal skin. The second case was a 65-year-old male diabetic who presented with right wrist drop of 3 days duration. The phenomenon of zoster occurring on two non-contiguous, widely separated dermatomes has been referred to as zoster duplex unilateralis or bilateralis, depending on whether one half or both halves of the body are involved (3).

Examination revealed localized, multiple, grouped vesicles, erosions, ulcers over erythematous base with oozing and crusting over the right side of the abdomen corresponding to T-10 dermatome. Multiple grouped vesicles on an erythematous base were seen over left upper lip, tip of nose, left temporal region, left cheek, and left side of the hard palate []. The patient had an uneventful recovery and was later discharged. Another unusual case of herpes zoster is depicted in Figure 3. Generally, it was found that those patients with less initial desensitisation to warm detection as a consequence of post-herpetic neuralgia experienced better pain relief after capsaicin was applied. In all the three cases, power of the involved group of muscles was markedly decreased compared to other groups of muscles. Her chemotherapy regimen included 5-fluorouracil, methotrexate and adriamycin.

She had recently visited the Department of General Surgery for a follow-up evaluation for the breast cancer. His laboratory investigations such as random blood glucose levels and complete hemogram were within normal limits. He also had a single band of skin eruptions on the right side of the abdomen for 6 days that was associated with itching and burning sensation in the region of their appearance. The Tzanck smear on her left anterior chest showed multinucleated giant cells with intranuclear inclusion bodies. Histologic examination of the vesicle lesions on her left anterior chest and upper back displayed intraepidermal blisters with ballooning degeneration, reticular degeneration, characteristic intranuclear inclusion bodies and acantholytic multinucleated giant cells (Fig. Nerve conduction studies were carried out in all these cases, which showed involvement of the left common peroneal and posterior tibial nerves in the first case, right radial and ulnar nerves in the second case and right axillary nerve in the third case [Table – 1]. For further evaluation and diagnostic confirmation, polymerase chain reaction (PCR) was performed for the varicella-zoster virus, and this consisted of a positive band of 208 bp (Fig.

3). Zoster of the maxillary division produces vesicles on the uvula and tonsillar area. An ultrasound abdomen showed findings characteristic of paralytic ileus. Following a patient’s natural infection or immunization, the virus remains latent in his/her sensory dorsal root ganglion cells and it replicates later, traveling down the sensory nerve into the skin (1). The clinical manifestations are characterized by several groups of painful vesicles situated unilaterally within the distribution of the cranial or spinal sensory nerve. Bilateral involvement and recurrence are rare, and zosters involving two widely separated regions at one time are even rarer (2). The phenomenon of zoster occurring in two non-contiguous, widely separated dermatomes has been referred to as zoster duplex unilateralis or bilateralis, depending on whether one half or both halves of the body are involved (3).


The incidence of herpes zoster duplex bilateralis is below 0.5% (4). In a review of the medical English literature over the last three decades, only seven cases have been reported, two in immunocompetent persons, three in older persons on oral steroids for treating chronic illnesses and two in children with cancer (one with lymphoma and the other with leukemia) (4). Primary infection with varicella zoster virus (VZV) causes varicella (chickenpox), characterized by diffuse intensely pruritic rash and viremia. Patients with malignancy, and especially patients with Hodgkin’s disease and leukemia, are five times more likely to develop zoster than others of the same age (5). The other patients who have a higher incidence of zoster include those with deficient immune systems, such as the individuals who are immunosuppressed for organ transplantation, the individuals with connective tissue disease and those who take agents such as corticosteroids (6). The patient reported on in this paper had a history of breast cancer and she had been previously treated with chemotherapy that included 5-fluorouracil, methotrexate and adriamycinskin. We can speculate that she was under an immunosuppressed state because of her previous chemotherapy and not because of tumor recurrence, and the previous chemotherapy led to her defective cellular immune response and the development of zoster duplex bilateralis.

The clinical appearance of these patients is usually identical to that of typical zoster, but the lesions may be more ulcerative and necrotic and they may scar more severely (7). Our patient, however, revealed typical zoster lesions and she healed without complications such as scars and pain. Predisposing factors for reactivation are old age, stress, malnutrition, menstruation, and immunosuppression such as malignancy, posttransplant, and chemotherapy. Our case illustrates that herpes zoster can present with bilateral involvement, which is referred to as zoster duplex bilateralis, in an immunosuppressed patient. 1. Straus SE, Schmader KE, Oxman MN. In : Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, editors.

Varicella and herpes zoster. Dermatology in general medicine. It is clinically indistinguishable from mechanical bowel obstruction, presenting with abdominal pain, distention, and constipation and with or without nausea and vomiting. 6th ed. New York: McGrow-Hill; p. 2070–2085. 2.

Gilden DH, Kleinschmidt-DeMasters BK, LaGuardia JJ, Mahalingam R, Cohrs RJ. Neurologic complications of the reactivation of varicella-zoster virus. The most accurate test for diagnosing herpes zoster is PCR for VZV DNA in vesicle specimens with a sensitivity and specificity of 95% and 100%, respectively. 2000;342:635–645. PMID: 10699164. 3. Odom RB, James WD, Berger TG.

Viral diseases. Andrews’ diseases of the skin. Cecal perforation is the most feared complication of Ogilvie’s syndrome. 9th ed. Philadelphia: W.B. Saunders Co.; p. 486–491.

4. Vu AQ, Radonich MA, Heald PW. Decompression provides additional benefit of colonic assessment to exclude any mechanical obstruction. J Am Acad Dermatol. 1999;40:868–869. PMID: 10321638.