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Disseminated zoster in an adult patient with extensive burns: a case report.

Abstract

BACKGROUND

Shingles (localized zoster) and disseminated zoster are caused by the reactivation of latent varicella zoster virus (VZV). Reactivation of VZV is related to impaired cell-mediated immunity. Extensive burns affecting a patient result in burn-related immunosuppression and cytokine storm. Despite immunosuppression in burn patients, the reactivation of VZV is extremely rare, whereas eczema herpeticum, caused by reactivation of latent herpes simplex virus (HSV), is common. We have found only 1 published case of VZV reactivation during burn treatment in the literature.

CASE PRESENTATION

A 51-year-old man was burned in a fire, which affected 60% of his total body surface area (TBSA), and also received inhalation injury (day 0). Despite fluid resuscitation, he showed persistent renal failure. Continuous hemodialysis and filtration (CHDF) combined with polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP) therapy was used for cytokine modulation. Autologous and allogeneic skin grafting was performed. On day 15, multiple-drug-resistant Pseudomonas aeruginosa (MDRP) was detected from a blood specimen, and the patient developed multiple organ failure (MOF). On day 31, compact aggregations of small vesicles appeared on the intact skin of his left knee and left buttock. The vesicles were located within the 4th lumbar (L4) spinal dermatome. From day 32 to day 34, similar new vesicles arose on his intact skin and epithelializing skin-graft donor sites. We diagnosed disseminated zoster, based on the patient's age, the characteristic occurrence of the initial vesicles within a limited area of intact skin in the left L4 dermatome, and a positive Tzank smear. Serologic testing on day 36 showed a high level of anti-VZV immunoglobulin (Ig)G with low levels of anti-VZV IgM, anti-HSV IgG, and anti-HSV IgM. The patient was isolated in a negative-pressure room to avoid air-borne spread of VZV. On day 52, the patient died.

CONCLUSIONS

To the best of our knowledge, our patient is the second case of reactivation of VZV during burn treatment. It is unclear why reactivation of VZV is rare in patients with burn-related immunosuppression, whereas HSV reactivation is common. Cytokine modulation throughout the treatment period using CHDF combined with PMX-DHP might have been related to the rare reactivation of VZV in our patient. Our case provides an additional information on the relationship between the immune status of a patient with extensive burns and reactivation of latent VZV or HSV.

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  • Authors+Show Affiliations

    ,

    Department of Plastic Surgery, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba, #260-8677, Japan. kbkt@hospital.chiba-u.jp.

    ,

    Department of Plastic Surgery, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba, #260-8677, Japan.

    ,

    Department of Plastic Surgery, Imakiire General Hospital, 4-16, Shimotatsuo-cho, Kagoshima-city, Kagoshima, #892-0852, Japan.

    ,

    Department of Plastic Surgery, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba, #260-8677, Japan.

    ,

    Department of Plastic Surgery, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba, #260-8677, Japan.

    ,

    Department of Plastic Surgery, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba, #260-8677, Japan.

    ,

    Department of Plastic Surgery, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba, #260-8677, Japan.

    Department of Plastic Surgery, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba, #260-8677, Japan.

    Source

    Virology journal 16:1 2019 05 23 pg 68

    Pub Type(s)

    Journal Article

    Language

    eng

    PubMed ID

    31122255

    Citation

    Kubota, Yoshitaka, et al. "Disseminated Zoster in an Adult Patient With Extensive Burns: a Case Report." Virology Journal, vol. 16, no. 1, 2019, p. 68.
    Kubota Y, Kosaka K, Hokazono T, et al. Disseminated zoster in an adult patient with extensive burns: a case report. Virol J. 2019;16(1):68.
    Kubota, Y., Kosaka, K., Hokazono, T., Yamaji, Y., Tezuka, T., Akita, S., ... Mitsukawa, N. (2019). Disseminated zoster in an adult patient with extensive burns: a case report. Virology Journal, 16(1), p. 68. doi:10.1186/s12985-019-1179-8.
    Kubota Y, et al. Disseminated Zoster in an Adult Patient With Extensive Burns: a Case Report. Virol J. 2019 05 23;16(1):68. PubMed PMID: 31122255.
    * Article titles in AMA citation format should be in sentence-case
    TY - JOUR T1 - Disseminated zoster in an adult patient with extensive burns: a case report. AU - Kubota,Yoshitaka, AU - Kosaka,Kentaro, AU - Hokazono,Toshinori, AU - Yamaji,Yoshihisa, AU - Tezuka,Takafumi, AU - Akita,Shinsuke, AU - Kuriyama,Motone, AU - Mitsukawa,Nobuyuki, Y1 - 2019/05/23/ PY - 2019/03/21/received PY - 2019/05/16/accepted PY - 2019/5/25/entrez PY - 2019/5/28/pubmed PY - 2019/5/28/medline KW - Air-borne infection KW - Burn KW - Hemodialysis KW - Herpes simplex virus KW - Reactivation KW - Varicella zoster virus SP - 68 EP - 68 JF - Virology journal JO - Virol. J. VL - 16 IS - 1 N2 - BACKGROUND: Shingles (localized zoster) and disseminated zoster are caused by the reactivation of latent varicella zoster virus (VZV). Reactivation of VZV is related to impaired cell-mediated immunity. Extensive burns affecting a patient result in burn-related immunosuppression and cytokine storm. Despite immunosuppression in burn patients, the reactivation of VZV is extremely rare, whereas eczema herpeticum, caused by reactivation of latent herpes simplex virus (HSV), is common. We have found only 1 published case of VZV reactivation during burn treatment in the literature. CASE PRESENTATION: A 51-year-old man was burned in a fire, which affected 60% of his total body surface area (TBSA), and also received inhalation injury (day 0). Despite fluid resuscitation, he showed persistent renal failure. Continuous hemodialysis and filtration (CHDF) combined with polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP) therapy was used for cytokine modulation. Autologous and allogeneic skin grafting was performed. On day 15, multiple-drug-resistant Pseudomonas aeruginosa (MDRP) was detected from a blood specimen, and the patient developed multiple organ failure (MOF). On day 31, compact aggregations of small vesicles appeared on the intact skin of his left knee and left buttock. The vesicles were located within the 4th lumbar (L4) spinal dermatome. From day 32 to day 34, similar new vesicles arose on his intact skin and epithelializing skin-graft donor sites. We diagnosed disseminated zoster, based on the patient's age, the characteristic occurrence of the initial vesicles within a limited area of intact skin in the left L4 dermatome, and a positive Tzank smear. Serologic testing on day 36 showed a high level of anti-VZV immunoglobulin (Ig)G with low levels of anti-VZV IgM, anti-HSV IgG, and anti-HSV IgM. The patient was isolated in a negative-pressure room to avoid air-borne spread of VZV. On day 52, the patient died. CONCLUSIONS: To the best of our knowledge, our patient is the second case of reactivation of VZV during burn treatment. It is unclear why reactivation of VZV is rare in patients with burn-related immunosuppression, whereas HSV reactivation is common. Cytokine modulation throughout the treatment period using CHDF combined with PMX-DHP might have been related to the rare reactivation of VZV in our patient. Our case provides an additional information on the relationship between the immune status of a patient with extensive burns and reactivation of latent VZV or HSV. SN - 1743-422X UR - https://www.unboundmedicine.com/medline/citation/31122255/Disseminated_zoster_in_an_adult_patient_with_extensive_burns:_a_case_report L2 - https://virologyj.biomedcentral.com/articles/10.1186/s12985-019-1179-8 DB - PRIME DP - Unbound Medicine ER -