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Limited skin lesions in a haemodialysis patient

Published:December 31, 2019DOI:https://doi.org/10.1016/j.ejim.2019.12.025

      Keywords

      An 82-year old hemodialysis patient presented with a painful rash on his left arm. His-dialysis access was on this arm for more than ten years (synthetic PTFE graft). Within a week there was a non-palpable erythematous, sharply defined cutaneous lesions which were painful upon palpation (Fig 1). Proximal the lesions resembled purpura, more distal there were flat vesicles, partially confluent to larger lesions. The cutaneous abnormalities were limited exclusively to the left arm. The patient had been treated with radiotherapy for larynx carcinoma 3 months earlier. He recently suffered from oral candida infection. The patient had no fever. There were no skin lesions on any other parts of the body.

      1. What is the cause of the skin lesions?

      Diagnosis–We performed a PCR to herpes viruses on the skin defects which revealed the presence of varicella zoster virus (VZV). Hemodialysis patients have a twofold risk of herpes zoster compared to nondialysis control patient (OR 1.98 95%CI 1.72–2.27). Reactivation of herpes zoster virus is a consequence of reduced efficiency of the patients’ immune system [
      • Kuo C.C.
      • Lee C.T.
      • Lee I.M.
      • Ho S.C.
      • Yang C.Y
      Risk of herpes zoster in patients treated with long-term hemodialysis: a matched cohort study.
      ]. Risk factors for the reactivation of varicella zoster in hemodialysis patients are older age, and increased comorbidity (diabetes). Uremia is associated with impaired lymphocyte function. In patients with ESRD, cytokines and uremic toxins are important factors that cause inflammation and the relatively immunosuppressed state. In our patient the immunosuppressed state can be attributed to radiotherapy in treating his larynx carcinoma.
      Interestingly, herpes zoster reactivation may be an indication of severity of ESRD and comorbidity. Ahn et al. found that 51% of patients with ESRD who developed shingles died within 2 years after diagnosis with a mean time to death of 8.1 months [
      • Ahn J.H.
      • Waller J.L.
      • Baer S.L.
      • Colombo R.E.
      • Kheda M.F.
      • Nahman Jr., N.S.
      • et al.
      Mortality risk after herpes zoster infection in end-stage renal disease patients.
      ].
      Herpes zoster is treated with valacyclovir. One of the side effects is neurotoxicity, which is almost exclusively seen in patients with either chronic or acute kidney injury [
      • Asahi T.
      • Tsutsui M.
      • Wakasugi M.
      • Tange D.
      • Takahashi C.
      • Tokui K.
      • et al.
      Valacyclovir neurotoxicity: clinical experience and review of the literature.
      ]. This case emphasizes that the clinical presentation of herpes zoster may be atypical. Delay in the diagnosis may cause prolongation of pain. Our patient was treated with valacyclovir, the painful rash diminished and finally completely disappeared.

      References

        • Kuo C.C.
        • Lee C.T.
        • Lee I.M.
        • Ho S.C.
        • Yang C.Y
        Risk of herpes zoster in patients treated with long-term hemodialysis: a matched cohort study.
        Am J Kidney Dis. 2012; 59: 428-433
        • Ahn J.H.
        • Waller J.L.
        • Baer S.L.
        • Colombo R.E.
        • Kheda M.F.
        • Nahman Jr., N.S.
        • et al.
        Mortality risk after herpes zoster infection in end-stage renal disease patients.
        Clin Kidney J. 2019; 12: 101-105
        • Asahi T.
        • Tsutsui M.
        • Wakasugi M.
        • Tange D.
        • Takahashi C.
        • Tokui K.
        • et al.
        Valacyclovir neurotoxicity: clinical experience and review of the literature.
        Eur. J. Neurol. 2009; 16: 457-460