Zoster sine herpete: An atypical presentation of herpes zoster without rash

Introduction

The reactivation of Varicella-Zoster Virus (VZV) in the form of herpes zoster (HZ, commonly known as “shingles”) is a common cause of neuropathic pain.1,2 HZ generally presents with a vesicular rash in a dermatomal distribution that does not cross the midline, often preceded by pain and paresthesias. Zoster sine herpete (ZSH) is a less common clinical presentation of HZ without the characteristic dermatomal rash.3,4,5 We present a patient with signs and symptoms consistent with ZSH.

Methods

This paper is devoid of patient identifiable information and, therefore, exempt from IRB review requirements per institutional policy. Informed consent was obtained from the patient discussed in this case report.

Case Report

70-year-old patient presenting with right-sided pain in a thoracic dermatomal distribution without rash, starting just a few days before their clinic visit. They described a constant stabbing, burning sensation that initially started on their back to the right of their thoracic spine and gradually progressed in a straight line around their side to the underside of their right breast. They denied left-sided pain and had received their herpes zoster vaccine. Of note, they were recently diagnosed with pneumonitis concomitant with severe persistent asthma by a pulmonologist and were on week four of a prednisone taper and trimethoprim-sulfamethoxazole regimen. Relevant past medical history includes fibromyalgia and thoracic radiculitis. 

After consulting their pulmonologist and primary care physician alongside chest imaging, the presumptive diagnosis of ZSH was made. The patient started a 10-day course of valacyclovir 1000 mg three times per day. They were also prescribed lidocaine 5% ointment and advised to continue their chronic pain regimen consisting of tapentadol extended-release 50 mg two times daily to provide neuropathic and nociceptive pain control in addition to acetaminophen, celecoxib, 1% diclofenac gel, and cyclobenzaprine. On follow-up, the patient reported their acute pain had substantially improved to a tolerable level shortly after starting valacyclovir.

Discussion

ZSH is an important diagnosis to consider for immunocompromised patients presenting with acute, localized, dermatomal pain without skin changes or a clear, identifiable source. Similar to HZ, ZSH treatment includes antivirals like valacyclovir or acyclovir alongside analgesics.2,4,5 Prevention also plays an important role with the herpes zoster vaccine given as a two-dose series.1,4 While rare, prompt diagnosis and timely treatment of ZSH are crucial to avoid progression of the disease, intractable pain, and long-term sequelae.

References