A case report of Herpes zoster with extended prodrome

Abstract

Introduction Herpes zoster (HZ), commonly known as shingles, is a neurocutaneous disorder caused by reactivation of varicella-zoster virus. It is characterized by a painful, unilateral vesicular rash limited to a single dermatome, usually starting with localized pain, itching or tingling sensation. HZ is traditionally associated with a prodrome of 1-5 days, however, in certain cases extended prodromal pain may occur before exhibiting clinically evident herpes zoster [1,2]. Aim An 81-year-old female was admitted to the hospital with severe lower lumbar pain radiating to the left lower limb, along with swelling and a burning sensation. The symptoms persisted for 10 days and did not show improvement with the previous analgesic treatment. Physical examination demonstrated hyperesthesia and slightly shinier skin on the left limb. No rash was noted. Neurological assessment showed hyperalgesia in the entire left limb. A case of intervertebral disc herniation was suspected, and conservative medical therapy was initiated, however the patient continued to experience persistent pain, burning sensation and swelling. Magnetic resonance imaging (MRI) of lumbar region revealed deforming spondylosis at Th11/Th12, L1/L2, L4-S1, intervertebral osteochondrosis at Th11/Th12 and L4-S1, Modic type II changes at L4/L5, and arthritic changes of the facet joints at L3-S1. On the fifth day of hospitalization, several vesicles were noted in the sacral region, some with rupture. The surrounding tissues showed mild erythema, with no signs of purulence or additional rash. A suspicion of herpes zoster arose and treatment with Acyclovir treatment was initiated. After antiviral therapy patients' symptoms regressed. Conclusion This case highlights the variable clinical presentation of herpes zoster. The delayed appearance of vesicles, especially in immunocompromised or elderly patients, can complicate diagnosis and delay antiviral treatment. Clinicians should consider HZ in patients presenting with unilateral pain or sensory disturbances even if the vesicular lesions have not yet manifested [2].