Atypical presentation of bullous herpes zoster and necrotizing fasciitis in immunocompromised patients

Herpes zoster infection represents a localized reactivation state of latent varicella-zoster virus. Zoster presents as a grouped vesicular rash on an erythematous base distributed over sensory dermatomes. Disseminated zoster is defined as the presence of >20 vesicles outside the primary area or adjacent dermatomes. Atypical manifestations of zoster infection, especially in immunocompromised patients, may lead to delayed diagnosis, infection dissemination, and potentially life-threatening systemic complications. Bacterial superinfection of zoster lesions is a common complication; however, more serious deep soft-tissue infection is not. Here, we present two atypical cases of zoster infection, which needed a high index of suspicion to avoid misdiagnosis and inappropriate treatment. Our first patient is a 30-year-old Saudi male, with systemic lupus erythematosus on oral steroids who presented with a tense vesiculobullous eruption over two adjacent dermatomes. Biopsy revealed herpes infection. The second case is for a 58-year-old diabetic female who presented to the emergency department for evaluation of an extremely painful eruption in a dermatomal distribution 1 week after zoster resolution. Clinical and radiologic evaluation of the lesions identified necrotizing fasciitis. Although zoster commonly affects immunocompromised individuals, the atypical presentation of the initial lesions in our two patients was challenging. A high index of suspicion is required for early detection, with special consideration of the painful lesion in a cropped configuration.