Abstract

Introduction: Herpes zoster (HZ) is the prototypical cause of zosteriform dermatoses. Additionally, many infectious, inflammatory, 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 significant improvement in symptoms and healing of ulcers. Conclusion: Atypical morphologies of herpes zoster, such as ecthymatous and that mirroring RPC, should be considered in immunosuppressed patients. Misdiagnosis as ecthyma or perforating dermatosis can delay appropriate antiviral treatment. Histopathology plays a crucial role in distinguishing HZ from its mimickers. This case underscores the need for heightened clinical suspicion while diagnosing atypical zoster and early intervention to prevent further complications in CKD patients.

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