|Year : 2021 | Volume
| Issue : 1 | Page : 47-48
Atypical herpes zoster reactivation in an elderly gentleman with advanced oral cancer
Divya Kukreja1, Deep Chakrabarti1, Abigail Veravolu Resu2, Mranalini Verma1, Madan Lal Brahma Bhatt1
1 Department of Radiotherapy, King George’s Medical University, Lucknow, Uttar Pradesh, India
2 Department of Radiation Oncology, Super Speciality Cancer Institute and Hospital, Lucknow, Uttar Pradesh, India
|Date of Submission||08-Jul-2021|
|Date of Acceptance||16-Nov-2021|
|Date of Web Publication||06-Jan-2022|
Dr. Deep Chakrabarti
Department of Radiotherapy, King George’s Medical University, Shah Mina Road, Lucknow 226003, Uttar Pradesh.
Source of Support: None, Conflict of Interest: None
Background: Varicella-zoster virus (VZV) causes varicella in children and reactivation zoster in adults. A 79-year-old gentleman with an old history of varicella infection receiving methotrexate for advanced tongue cancer presented with multiple vesiculo-papular lesions in axillae and chest wall. The lesions were multidermatomal in distribution, painless, indurated, and nontender. A Tzanck smear confirmed the diagnosis of herpes zoster. His lesions resolved on antiviral therapy. Dermatologic side effects of methotrexate are otherwise rare and occur in 1%–10% of patients. Nevertheless, advanced cancer or cancer chemotherapy may cause immunosuppression leading to reactivation of VZV in some patients.
Keywords: Head and neck cancer, head and neck squamous cell carcinoma, methotrexate, herpes zoster, palliative care
|How to cite this article:|
Kukreja D, Chakrabarti D, Resu AV, Verma M, Bhatt ML. Atypical herpes zoster reactivation in an elderly gentleman with advanced oral cancer. Bengal J Cancer 2021;1:47-8
|How to cite this URL:|
Kukreja D, Chakrabarti D, Resu AV, Verma M, Bhatt ML. Atypical herpes zoster reactivation in an elderly gentleman with advanced oral cancer. Bengal J Cancer [serial online] 2021 [cited 2022 Aug 18];1:47-8. Available from: http://www.bengaljcancer.org/text.asp?2021/1/1/47/335055
| Background|| |
Herpes zoster is an infectious manifestation caused by the varicella-zoster virus (VZV), which usually presents as a reactivation sequel to childhood varicella in immunocompromised adults.
| Case Presentation|| |
A 79-year-old gentleman was started on palliative chemotherapy with weekly intravenous methotrexate for advanced carcinoma tongue (Union for International Cancer Control 8th TNM cT4aN3b). He had no known current medical risk factors; however, he gave a history of varicella (chickenpox) at the age of 10 years. Two days after receiving the first dose, he developed multiple erythematous conglomerated vesicular and papular lesions in bilateral axilla (more on the right side) Figure 1]A and left anterior chest wall [Figure 1]B associated with pruritus. There was no pain, fever, or malaise. On examination, the lesions were multidermatomal in distribution, indurated, nontender, and without any axillary lymphadenopathy. Tzanck smear confirmed the diagnosis of herpes zoster infection. The patient was started on acyclovir, hydroxyzine, and topical mupirocin. After 10 days, there was a significant improvement in the lesions (right axilla [Figure 2]A, left axilla, and chest wall [Figure 2]B). Thus, it was concluded that the advanced oral cancer and subsequently the administration of methotrexate led to suppression in the patient’s immunity and caused reactivation of the VZV leading to atypical herpes zoster.
|Figure 1: Photograph showing vesicular and papular lesions in right axilla (A), left axilla, and chest wall (B)|
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|Figure 2: Resolution of lesions in right axilla (A), left axilla, and chest wall (B) post-antiviral therapy|
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| Discussion|| |
VZV presents as two distinct clinical entities. As a primary infection, it causes the highly contagious varicella, especially in children, presenting as a generalized vesicular rash. VZV remains latent in neural tissues. Later in life, if a person becomes immunocompromised, there is a reactivation of the latent VZV from the dorsal root ganglion resulting in shingles (herpes zoster) which typically presents as severe neuralgic pain associated with vesicular lesions in one or occasionally two dermatomes with a cut-off at the midline. In immunocompromised individuals, it may have an atypical presentation with irregular dermatomal involvement in the absence of pain. Patients with advanced cancer or those receiving corticosteroids or chemotherapeutic drugs have a decrease in the number and activity of T lymphocytes which explains the decreased immunity and reactivation of the virus. Other atypical causes of zoster include zoster sine herpete (acute neuralgic pain without rash), pain and rash in varicella vaccinated children, or reactivation of VZV in space travelers residing at the International Space Station (ISS) for prolonged periods.
Methotrexate is an age-old chemotherapeutic agent that is often used in advanced head and neck cancer. For palliation, it can still be considered a standard of care, relatively at par with targeted or newer agents in terms of overall survival. Dermatologic side effects of methotrexate occur in 1%–10% of the population and include acne, alopecia, dermatitis, erythema multiforme, folliculitis, furunculosis, photosensitivity, pigmentary changes, pruritus, rash, erythema, skin necrosis, telangiectasia and urticaria. Given the nature of cutaneous lesions, the possibility of reactivation of VZV must be kept in mind when treating patients with advanced cancer who have a history of varicella infection.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gnann JW Jr, Whitley RJ Clinical practice: Herpes zoster. N Engl J Med 2002;347:340-6.
McCrary ML, Severson J, Tyring SK Varicella zoster virus. J Am Acad Dermatol 1999;41:1-14; quiz 15–6.
Sterling JC Viral infections. In: Griffiths C, Barker J, Bleiker T, Chalmers R, Creamer D, editors. Rook’s Textbook of Dermatology. 9th ed. Chichester: Wiley Blackwell;2016.
Thomas SL, Hall AJ What does epidemiology tell us about risk factors for herpes zoster? Lancet Infect Dis 2004;4:26-33.
Woods RL, Fox RM, Tattersall MH Methotrexate treatment of squamous-cell head and neck cancers: Dose-response evaluation. Br Med J (Clin Res Ed) 1981;282:600-2.
Patil V, Noronha V, Dhumal SB, Joshi A, Menon N, Bhattacharjee A, et al
. Low-cost oral metronomic chemotherapy versus intravenous cisplatin in patients with recurrent, metastatic, inoperable head and neck carcinoma: An open-label, parallel-group, non-inferiority, randomised, phase 3 trial. Lancet Glob Health 2020;8:e1213-22.
BC Cancer Agency. Methotrexate; n.d. Available from: http://www.bccancer.bc.ca/drug-database-site/Drug Index/Methotrexate_monograph.pdf. [Last accessed on 2021 June 26].
[Figure 1], [Figure 2]