A 52-year-old black woman presented to our dermatology clinic for evaluation of a generalized pruritic rash of 5 days’ duration. The eruption had started on the trunk and subsequently spread to the face, legs, and arms, including the dorsal surfaces of the hands (Figure 1). The patient reported that she had developed a similar rash 4 years prior. She recalled no sick contacts but had occupational exposure to many people as a food service worker. Two days prior, the referring physician had initiated treatment with oral acyclovir 400 mg every 6 hours. The patient was in otherwise good health and reported no fever, chills, diaphoresis, or fatigue. She did not recall any recent insect bites, and a review of systems was negative.
The patient’s medical history was remarkable for 2 cases of varicella: the first, which occurred at 5 years of age, was diagnosed by a pediatrician and manifested as diffuse papules, vesicles, and crusts with concurrent mild fever. The infection followed a typical clinical course and resolved without complications after 1 week. The second case of varicella was diagnosed clinically at our dermatology clinic approximately 4 years prior to the current presentation and manifested as widespread pruritic lesions that were too numerous to count. Given her history of varicella in childhood, a punch biopsy specimen was taken from a lesion on the left trunk and a dermatopathologist confirmed the diagnosis of a herpesvirus infection. The second infection also resolved without sequelae after 12 days. Her medical history was otherwise unremarkable, revealing no exceptional sinopulmonary or gastrointestinal infections. The patient was not currently taking any medications or supplements and reported no known drug allergies.
Physical examination at the current presentation revealed a well-nourished, afebrile woman with vesicles and papules on the hands, arms, and legs along with vesicular and crusted papules in various stages of healing distributed on the chest, abdomen, and back. Lesions on the legs and feet were present but scant. The eruption was not confined to a single dermatome. No lesions were noted on the palms, soles, or oral mucosa and no epitrochlear, axillary, or supraclavicular lymphadenopathy was noted.
Initial laboratory values were obtained. A complete blood count demonstrated a normal leukocyte number of 5700 cells/μL (reference range, 4500–11,000 cells/μL) and mild anemia with a hemoglobin level of 10.3 g/dL (reference range, 14.0–17.5 g/dL). Monocytes were mildly elevated at 11% (reference range, 1%–9%). Serologic tests showed positive titers for varicella-zoster virus (VZV) IgM at 1.64 (negative, <0.91) and VZV IgG at 1.72 (negative, <0.91), indicating current and past VZV infection, respectively. Antibodies against herpes simplex virus (HSV) types 1 and 2 were negative for IgM and positive for IgG at >5.00 (negative, <0.90), indicating a remote HSV infection. Furthermore, results from a culture of a lesion on the left hand were negative for HSV.
After consultation with the Department of Infectious Diseases, further laboratory studies were performed. The absolute lymphocyte number was within normal range at 1600 cells/μL (reference range, 850–3900 cells/μL). Likewise, CD4+ T lymphocytes were normal at 618 cells/μL (reference range, 490–1740 cells/μL) or 39% of total lymphocytes (reference range, 30%–61%). Screening results were negative for human immunodeficiency virus types 1 and 2. Immunoglobulin subtype analysis revealed slightly elevated IgG at 1709 mg/dL (reference range, 723–1685 mg/dL), elevated IgA at 487 mg/dL (reference range, 65–382 mg/dL), and normal IgM at 238 mg/dL (reference range, 63–277 mg/dL).
Consistent with the clinical presentation and serologic studies, recurrent varicella was accepted as the most plausible diagnosis. Over the next 2 weeks, the eruption resolved with postinflammatory hyperpigmentation (Figure 2). The patient returned to work without further incident.