Herpes zoster infection occurs owing to reactivation of varicella zoster virus and classically manifests as a vesicular eruption involving a single dermatome. Disseminated herpes zoster - defined as having greater than twenty vesicles outside the primary or adjacent dermatome - is uncommon and typically occurs in immunocompromised individuals. Central nervous system complications during or following a zoster outbreak are exceedingly rare. Encephalitis is reported to affect only 0.1-0.2% of patients and occurs more often in disseminated cases and in outbreaks involving those dermatomes in close proximity to the central nervous system. We present an elderly woman with disseminated herpes zoster and altered mental status who was subsequently diagnosed with varicella zoster virus encephalitis and describe the characteristics of patients with disseminated zoster who developed varicella zoster virus encephalitis.

Disseminated herpes zoster is defined as the presence of more than 20 lesions outside the dermatome. This unusual presentation is more common in immunosuppressed patients. Complications such as hepatitis, encephalitis, and pneumonitis are more likely in individuals with disseminated varicella zoster virus infection.

A 63-year-old woman being treated for breast cancer developed multiple pustules and vesicles days after starting doxorubicin and cyclophosphamide chemotherapy. Ten individual lesions appeared on her chest, abdomen, back, and leg. Non-dermatomal disseminated herpes zoster was suspected. She was treated with oral antiviral therapy, as well as with oral and topical antibiotics. Varicella zoster virus infection was confirmed by direct fluorescent antibody staining. After one month, her skin lesions had resolved and she resumed chemotherapy.

In a setting of immunosuppression, the rare presentation of disseminated herpes zoster without dermatome should be considered. Appropriate antiviral therapy should be administered while waiting for confirmation of the diagnosis, so as to reduce the risk of visceral dissemination of the varicella zoster virus infection.

Herpes zoster is uncommon in the pediatric population. We report a case of herpes zoster in a 2-year-old boy who received the live attenuated varicella zoster virus vaccination at his 12-month pediatric visit. The child was treated with acyclovir and recovered without complications.

Varicella-zoster is the virus that causes varicella (chicken pox), herpes zoster (shingles), and rarely, severe disseminated disease including diffuse rash, encephalitis, hepatitis, and pneumonitis. Disseminated disease is most often seen in immunocompromised patients. We describe a case of disseminated zoster in an immunocompentent patient who had previously been immune to VZV. This case is also unusual in that his clinical presentation was most consistent with varicella while his laboratory data was most consistent with herpes zoster. For the purpose of rapid diagnosis and initiation of appropriate therapy, clinicians should be aware of these more atypical presentations of VZV infection.

Case Report: Presented here is the case of an evolving sacral wound in a 70-year-old, immunocompromised woman that was eventually found to be localized herpes zoster and later became disseminated.

Conclusion: This case demonstrates the need for a broad differential diagnosis for sacral wounds that include atypical presentations for herpes zoster or herpes simplex virus. We discuss the guidelines for treatment and the classification of localized vs disseminated herpes zoster.