CASE PRESENTATION (CONT.) DISSEMINATED CUTANEOUS HERPES ZOSTER FOLLOWING PNEUMOCOCCAL VACCINATION Woo Cheal Cho, MD1, William A. Berger, BS2, Frank Santoro, MD3, Richard Cartun, PhD1, Zendee Elaba, MD1 1Department of Pathology and Laboratory Medicine, Hartford Hospital, Hartford, CT 2Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT 3Division of Dermatology, Hartford Hospital, Hartford, CT INTRODUCTION CASE PRESENTATION (CONT.) Herpes zoster (HZ) results from reactivation of latent varicella-zoster virus (VZV) from dorsal root ganglia, typically presenting as a localized, vesicular rash in a dermatomal distribution. Disseminated cutaneous HZ (DCHZ) rarely occurs in immunocompetent patients. Herein, we describe a case of a 78-year-old male who developed DCHZ following administration of pneumococcal vaccine. Laboratory studies were unremarkable without leukocytosis and chest X-ray was negative for acute findings. The patient was placed on Solu-Medrol for COPD exacerbation and antihistamines. However, the rash continued and dermatology was consulted on day 4 of admission. The patient was found to have cellulitis on the left frontal scalp (Figure 1) for which vancomycin was administered. He was also suspected to have possible hypersensitivity eruption, scabies or folliculitis. His cellulitis resolved after administration of vancomycin, but the rash continued to progress and became more localized over the face in a dermatomal fashion. Punch biopsy revealed a small intraepidermal blister with degenerated keratinocytes showing multinucleation and chromatin margination, which were highlighted by VZV immunostain (Figure 2). Tissue culture was also positive for VZV. The patient was immediately started on acyclovir for treatment of DCHZ, with discontinuation of steroids. CASE PRESENTATION A 78-year-old Hispanic male with a medical history of atrial fibrillation and chronic obstructive pulmonary disease (COPD) was admitted to the hospital for shortness of breath of 3 days’ duration secondary to COPD exacerbation. The patient reported that he had received pneumococcal vaccine on his right upper arm 2 weeks prior to admission and subsequently developed a rash 1 day after receiving the vaccine. The rash had initially developed over his right arm and had spread to involve other parts of his body, including chest, abdomen, back, groin, bilateral extremities, as well as scalp. He stated that the rash had been extremely pruritic and progressively worsening over the course of 2 weeks. He denied fever or recent sick contacts but reported chills shortly after the onset of rash. Physical examination revealed a diffuse erythematous, non-dermatomal papular rash involving the scalp, face, chest, back, abdomen, groin, and bilateral upper and lower extremities (Figure 1). Fluid-filled vesicles were not noted. A left periorbital edema along with mild conjunctival irritation was present. Figure 1. Diffuse erythematous, non-dermatomal papular rash, left periorbital edema (top left) and left frontal cellulitis (bottom right) CONCLUSION In immunocompetent patients, the classic painful, dermatomal rash of DCHZ may not be apparent. Thus, it is important to recognize various presentations that may lack the classic blistering and dermatomal pattern to ensure prompt treatment and minimize complications. In addition, post-vaccination DCHZ in immunocompetent patients is rare and mostly associated with live varicella vaccine administration. This case highlights an uncommon presentation of DCHZ which may have been triggered by pneumococcal vaccine administration. Figure 2. Punch biopsy showing an intraepidermal blister and multinucleated keratinocytes with intranuclear inclusions highlighted by VZV immunostain (right). REFERENCE Petrun B, Williams V, Brice S. Disseminated varicella-zoster virus in an immunocompetent adult. Dermatol Online J. 2015;21(3). pii: 13030/qt3cz2x99b. Gomez E, Chernev I. Disseminated cutaneous herpes zoster in an immunocompetent elderly patient. Infect Dis Rep. 2014;6(3):5513. DISCLOSURE NOTHING TO DISCLOSE