Vasculitis-Like Hemorrhagic Herpes Zoster and HIV Infections: An Intricate Association

Abstract

Herein, we report the case of a 69-year-old patient who presented to our dermatology clinic for a skin eruption characterized by grouped hemorrhagic vesicles and erosions covered by hemorrhagic crusts on an erythematous background located on the lower right limb. The lesions were small, clustered, and variable in size (diameters between one and 10 mm) and located at the level of the L4-L5 dermatomes. The rash had started three to five days after the complete COVID-19 vaccination scheme with the BNT162b2 Pfizer BioNTech vaccine and had been accompanied by a flu-like syndrome. The histopathological examination established the diagnosis of leukocytoclastic vasculitis potentially in the context of a cytopathic zoster phenomenon. The atypical aspect of the zosterian eruption required additional laboratory work-up to identify possible causes of immunosuppression, i.e., screening for the presence of the human immunodeficiency virus (HIV) infection, solid cancers, as well as measurement of serum immunoglobulin concentrations, which revealed that the subject was HIV-positive. Antiviral treatment was started, with a favorable evolution of the lesions, and the patient was referred to an infectious diseases clinic for initiation of antiretroviral therapy (ART).

Keywords: bnt162b2 (pfizer-biontech); covid 19; cutaneous vasculitis; herpes zoster virus; hiv.

Figure 1. Clinical aspects of the lesions

The clinical aspect of the lesion at the beginning (A) and at the moment of presentation in our clinic (B, C). Grouped, herpetiform lesions separated through apparently intact skin located mainly at the level of the L4 and L5 dermatomes of the right lower limb. The evolution toward erosions covered by hemorrhagic crusts of variable sizes (diameter of 1-10 mm) is observed.

Figure 2. Histological aspects of a 6-mm punch biopsy specimen at the level of the lesions. (A) x5, (B) x10.

Ulceratated lesion covered by fibrin-leukocyte and necrotic crust. Frequent neutrophilic and lymphocytic perivascular infiltrates with nuclear residues, extravasation of erythrocytes, and fibrinoid necrosis. Optical microscopy examination; hematoxylin-eosin stain.