Abstract

Introduction: Herpes zoster (HZ) is the prototypical cause of zosteriform   dermatoses. Additionally, many infectious, inammatory, and neoplastic   conditions may mimic this distribution pattern. Immuno compromised patients, such as those with end-stage renal disease (ESRD), are predisposed to both  infectious and reactive skin conditions. In these cases, HZ may present with  atypical morphologies, leading to diagnostic challenges. This report presents a case   of atypical herpes zoster in a patient with chronic kidney disease (CKD) showing   dimorphic ulcerative ecthymatous lesions and crusted umbilicated papulonodules   mimicking reactive perforating collagenosis (RPC). This report highlights the  importance of histopathology in distinguishing these conditions.  Case Report: A 48-year-old male with stage - VCKD on haemodialysis, presented  with acute onset of unilateral, multiple painful papulonodules culminating into ulcers over the right lower back and abdomen. The lesions were diverse ranging  from punched out ulcersto umbilicated papules with central keratotic crusting.  This evoked the differentials of ecthyma or segmental RPC. None of the past or  present lesions were vesicular. Investigations revealed anaemia, deranged sugar  levels and renal function parameters. Bacterial cultures showed no growth, while  Tzanck smear demonstrated multinucleated giant cells. Skin biopsy revealed viral   cytopathic changes and follicular involvement typifying herpes viral infection.  The patient responded well to renal-adjusted acyclovir therapy, with signicant   improvement in symptoms and healing of ulcers. 

• 1.   Hayderi L., Libon F., Nikkels-Tassoudji N., Rübben A., Dezfoulian B., Nikkels A.F. Zosteriform dermatoses—A review. Glob Dermatol. 2015; 2(4): 163-173. doi:10.15761/ GOD.1000146.
• 2.   Yamauchi Y., Oyama N., Hasegawa M. A case of segmental acquired reactive perforating collagenosis: case report and literature review of the unique presentation. An Bras Dermatol. 2025; 100(1): 169-172. doi:10.1016/j. abd.2024.03.010
• 3.   Mueller N.H., Gilden D.H., Cohrs R.J., Mahalingam R., Nagel M.A. Varicella-zoster virus infection: clinical features, molecular pathogenesis of disease, and latency. NeurolClin. 2008; 26(3): 675-97, viii.
• 4.   Kroth J., Tischer J., Samtleben W., Weiss C., Ruzicka T., et al. Isotopic response, Köbner phenomenon and Renbök phenomenon following herpes zoster. J Dermatol. 2011; 38(11): 1058-61.
• 5.   Omidian M., Mapar M.A. Chronic zosteriform cutaneous leishmaniasis. Indian J Dermatol Venereol Leprol. 2006; 72(1): 41-42. doi:10.4103/0378-6323.19717
• 6.   Nakanishi G., Tsunemitsu R., Akagi O. Reactive perforating collagenosis occurring in a zosteriform distribution. Br J Dermatol. 1999; 141(2): 367-9.
• 7.   Bang S.W., Kim Y.K., Whang K.U. Acquired reactive perforating collagenosis: unilateral umbilicated papules along the lesions of herpes zoster. J Am Acad Dermatol. 1997;36:778-9.
• 8.   Lee H.N., Lee D.W., Lee J.Y., Cho B.K. Two cases of reactive perforating collagenosis arising at the site of healed herpes zoster. Int J Dermatol. 2001; 40(3): 191-2. doi:10.1046/ j.1365-4362.2001.01138.x.
• 9.   Böer A., Herder N., Blödorn-Schlicht N., Steinkraus V., Falk T.M. Refining criteria for diagnosis of cutaneous infections caused by herpes viruses through correlation of morphology with molecular pathology. Indian J Dermatol Venereol Leprol. 2006; 72(4): 270-5. doi:10.4103/0378-6323.26717.
• 10.   Seront E., Kidd F., Metz T., Van Ruyssevelt P. Atypical case of ecthyma gangrenosum mimicking a breast cancer recurrence. BMJ Case Rep. 2016 Mar 30;2016:bcr2016214349. doi:10.1136/bcr-2016-214349
• 11.   Seshadri D., Kumaran M.S., Kanwar A.J.Acantholysis revisited: Back to basics. IndianJ Dermatol Venereol Leprol. 2013;79(1):120-6.doi:10.4103/0378-6323.104688.
• 12.   Gilson I.H., Barnett J.H., Conant M.A., Laskin OL, Williams J., Jones P.G. Disseminated ecthymatous herpes varicella-zoster virus infection in patients with acquired immunodeficiency syndrome. J Am Acad Dermatol. 1989; 20(4): 637-42. doi:10.1016/ S0190-9622(89)70076-1.
• 13.   Schneiderman H., Robert N.J., Walker S., et al. Herpes without vesicles: limited, recurrent genital lesions in an immuno debilitated host. South Med J. 1986; 79(3): 368-70.
• 14.   Williamson B.C. Disseminated herpes zoster in a human immunodeficiency virus-positive homosexual man without complications. Cutis. 1987; 40(6): 485-6.
• 15.   Walsh N., Boutilier R., Shaffelburg M. Exclusive involvement of folliculosebaceous units by herpes: A reflection of early herpes zoster. Am J Dermatopathol. 2005; 27(3): 189-94.
• 16.   Sadjadi S.A., Regmi S., Chau T. Acyclovir neurotoxicity in a peritoneal dialysis patient: report of a case and review of the pharmacokinetics of acyclovir. Am J Case Rep. 2018; 19: 1459-1462. doi:10.12659/AJCR.911520.

Data Sharing Statement

Funding