Post Herpes Zoster Granulomatous Dermatitis with Vasculitis

Without any clinical information, I hesitate to make this diagnosis.  The dermatologist said this elderly patient presented with a cluster of erythematous slighlty indurated lesions in a unilateral dermatomal distribution on the right flank.  He said if there were vesicles, it would be perfect for herpes zoster/shingles.  The patient was otherwise healthy. This biopsy had a superficial and mid-dermal granulomatous infiltrate, with multinucleate histiocytes and lymphocytes predominating.  Some areas looked granuloma annulare-like, although without increased mucin.  Special stains were negative for fungal and acid fast organisms and I did not identify herpes viral cytopathic changes.  Focusing on the dermal changes, I almost brushed past the vasculitis in the subcutis, which appears primarily lymphocytic.  I did not see any vasculitis in the dermis.   Carlson noted one case of lymphocytic vasculitis in a post-herpes infection case, but typically the vasculitis is more often reported to be granulomatous in post-herpes zoster infection. The vessel went away on deeper levels so I couldn’t evaluate it further.  I think it’s important to rule out other possible causes of vasculitis and other sources of infection, but I think given the clinical presentation and the histology, this was a nice case of post herpes zoster granulomatous dermatitis with vasculitis.

Reference
Cutaneous Vasculitis Update: Neutrophilic Muscular Vessel and Eosinophilic, Granulomatous, and Lymphocytic Vasculitis Syndromes J. Andrew Carlson and Ko-Ron Chen, MD, PhD. Am J Dermatopathol 2007;29:32–43

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2 responses to “Post Herpes Zoster Granulomatous Dermatitis with Vasculitis

  1. We sometimes see granuloma annulare like lesions in healed herpes zoster scars but it is a late phenomenon. This granulomatous vasculitis like picture must be a more acute response to the herpes zoster virus. I have had a patient with a generalised vasculitis from herpes zoster but it was not a granulomatous picture. Would pcr studies show up herpes virus in these lesions?

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