Hemorrhagic Herpes Zoster with Contralateral Multidermatomal Distribution Associated with Rivaroxaban: An Unusual Presentation

Herpes zoster is an infection that develops when varicella-zoster virus reactivates from its latent state in a nerve ganglion. Symptoms typically begin with pain along the affected dermatome, followed within 2-3 days by a vesicular eruption, which is usually diagnostic. Herpes zoster eruption involving 2 disparate dermatomes on different sides of the body is referred to as herpes zoster duplex bilateralis, with a reported occurrence rate of < 0.5% when compared with general herpes zoster.1 Multidermatomal herpes zoster has been most commonly reported in immunocompromised individuals. In a comprehensive literature review by Vu. et al conducted between 1969 and 1999, 6 cases of multidermatomal herpes zoster were reported, with only one of these 6 cases presenting in an immunocompetent adult.2,3 Atypical herpes zoster has been reported in the immunocompetent elderly, suggesting a general immunocompromised state of advanced age with no evident underlying immunocompromised condition.4 The classic clinical presentation consists of clear vesicles in a dermatomal distribution; however, a hemorrhagic or purpuric presentation has been reported in association with anticoagulants, in particular clopidogrel.5