Disseminated cutaneous herpes zoster and multiple cerebral infarcts in an adult with diabetes mellitus

  • Chun-Fu Lin
  • Chien-Tai Hong
  • Wei-Hwa Lee
  • Dean Wu
  • Chaur-Jong Hu
  • Chen-Chih ChungEmail author
Case Report


Ischemic stroke is a rare complication of varicella-zoster virus (VZV) infection. We present the case of a patient with a medical history of type 2 diabetes mellitus (DM) who experienced disseminated cutaneous VZV infection followed by multiple cerebral infarcts associated with VZV vasculopathy. Brain magnetic resonance imaging revealed multiple hyperintense lesions over the bilateral deep white matter and basal ganglia. A skin biopsy revealed small-vessel leukocytoclastic vasculitis with neutrophilic, lymphocytic, and eosinophilic infiltration. This case report describes the rare finding of cutaneous leukocytoclastic vasculitis in VZV infection and highlights that VZV infection is an uncommon but critical etiology of cryptogenic stroke in patients with DM.


Diabetes mellitus Varicella-zoster virus Vasculitis Vasculopathy Stroke 



Varicella zoster virus


Diabetes mellitus


Immunoglobulin M


Magnetic resonance imaging


Fluid-attenuated inversion recovery


Diffusion-weighted imaging


Cerebrospinal fluid



This manuscript was edited by Wallace Academic Editing.

Compliance with ethical standards

The study was approved by the Taipei Medical University Joint Institutional Review Board (No. N20190387).

Conflict of interest

The authors declare that they have no conflict of interest.


  1. Amlie-Lefond C, Gilden D (2016) Varicella zoster virus: a common cause of stroke in children and adults. J Stroke Cerebrovasc Dis 25:1561–1569CrossRefGoogle Scholar
  2. Cohen C, Trapuckd S (1984) Leukocytoclastic vasculitis associated with cutaneous infection by herpesvirus. Am J Dermatopathol 6:561–565CrossRefGoogle Scholar
  3. Gilden D, Cohrs RJ, Mahalingam R, Nagel MA (2009) Varicella zoster virus vasculopathies: diverse clinical manifestations, laboratory features, pathogenesis, and treatment. Lancet Neurol 8:731–740CrossRefGoogle Scholar
  4. Gilden DH, Lipton HL, Wolf JS, Akenbrandt W, Smith JE, Mahalingam R, Forghani B (2002) Two patients with unusual forms of varicella-zoster virus vasculopathy. N Engl J Med 347:1500–1503CrossRefGoogle Scholar
  5. Kawai K, Yawn BP (2017) Risk factors for herpes zoster: a systematic review and meta-analysis. Mayo Clin Proc 92:1806–1821CrossRefGoogle Scholar
  6. Ke CC, Lai HC, Lin CH, Hung CJ, Chen DY, Sheu WH, Lui PW (2016) Increased risk of herpes zoster in diabetic patients comorbid with coronary artery disease and microvascular disorders: a population-based study in Taiwan. PLoS One 11:e0146750CrossRefGoogle Scholar
  7. Min SW, Kim YS, Nahm FS, Yoo d H, Choi E, Lee PB, Choo H, Park ZY, Yang CS (2016) The positive duration of varicella zoster immunoglobulin M antibody test in herpes zoster. Medicine (Baltimore) 95:e4616CrossRefGoogle Scholar
  8. Nagel MA, Cohrs RJ, Mahalingam R, Wellish MC, Forghani B, Schiller A, Safdieh JE, Kamenkovich E, Ostrow LW, Levy M, Greenberg B, Russman AN, Katzan I, Gardner CJ, Hausler M, Nau R, Saraya T, Wada H, Goto H, de Martino M, Ueno M, Brown WD, Terborg C, Gilden DH (2008) The varicella zoster virus vasculopathies: clinical, CSF, imaging, and virologic features. Neurology 70:853–860CrossRefGoogle Scholar
  9. Nagel MA, Khmeleva N, Choe A, Gutierrez J, Gilden D (2014) Varicella zoster virus (VZV) in cerebral arteries of subjects at high risk for VZV reactivation. J Neurol Sci 339:32–34CrossRefGoogle Scholar
  10. Okamoto S, Hata A, Sadaoka K, Yamanishi K, Mori Y (2009) Comparison of varicella-zoster virus-specific immunity of patients with diabetes mellitus and healthy individuals. J Infect Dis 200:1606–1610CrossRefGoogle Scholar
  11. Papagianni M, Metallidis S, Tziomalos K (2018) Herpes zoster and diabetes mellitus: a review. Diabetes Ther 9:545–550CrossRefGoogle Scholar
  12. Sauerbrei A, Eichhorn U, Schacke M, Wutzler P (1999) Laboratory diagnosis of herpes zoster. J Clin Virol 14:31–36CrossRefGoogle Scholar
  13. Snow JL, el-Azhary RA, Gibson LE, Estes SA, Espy MJ, Smith TF (1997) Granulomatous vasculitis associated with herpes virus: a persistent, painful, postherpetic papular eruption. Mayo Clin Proc 72:851–853CrossRefGoogle Scholar

Copyright information

© Journal of NeuroVirology, Inc. 2020

Authors and Affiliations

  1. 1.Department of Neurology, Shuang Ho HospitalTaipei Medical UniversityNew Taipei CityTaiwan
  2. 2.Taipei Neuroscience InstituteTaipei Medical UniversityTaipeiTaiwan
  3. 3.Department of Neurology, School of Medicine, College of MedicineTaipei Medical UniversityTaipeiTaiwan
  4. 4.Department of pathology, Shuang Ho Hospital, TaipeiMedical UniversityTaipeiTaiwan
  5. 5.Graduate Institute of Biomedical Informatics, College of Medical Science and TechnologyTaipei Medical UniversityTaipeiTaiwan

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