Multiple granuloma annulare lesions presenting simultaneously with herpes zoster infection: Wolf's isotopic response

To the Editor: We read with great interest the case reported by Storer et al1Storer M. Nazarian R.M. Kourosh A.S. Nonphoto-exposed initial cutaneous manifestation of lupus after zoster: A case of Wolf's isotopic reaction.JAAD Case Rep. 2016; 2: 425-427Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar in the November 2016 issue of JAAD Case Reports that described a 56-year-old white woman with a 20-year history of systemic lupus erythematosus who had non–photo-exposed initial cutaneous manifestation of lupus within a dermatome previously affected by zoster. In this patient, the cutaneous lupus lesions appeared 1 year after herpes zoster infection. The occurrence of new distinct skin disease within a dermatome previously affected by zoster infection supported the interesting phenomenon of Wolf's isotopic reaction in this case. All reported cases with Wolf's isotopic reaction occurred after resolution of the primary skin dermatosis, mainly herpes zoster infection. Here we share an interesting case we evaluated in our dermatology clinic, and we still believe it fits under Wolf's isotopic reaction, although the occurrence of both dermatosis occurred simultaneously, which makes it a rare presentation. Our patient was a 54-year-old woman with a history of right breast cancer treated with mastectomy and chemotherapy. She presented with progressive multiple slightly pruritic annular lesions on the left side of the abdominal wall. Painful grouped vesicles developed in the center of the initial annular lesions within a few days. Some vesicles were hemorrhagic (Fig 1, A and B). The patient had a history of herpes zoster at the site of right breast mastectomy scar a year ago. It resolved with a 7-day course of valacyclovir without scarring. On the latest presentation, her annular lesions were diagnosed as granuloma annulare (GA). The patient's concern and the reason for presentation to our clinic was the evolution of the vesicular eruption that was restricted to the center of some of the annular lesions. Based on clinical and laboratory evaluation with Tzanck smear with features suggestive of herpes-type virus infection (Fig 2) and positive direct fluorescent antibody for varicella zoster virus, atypical presentation of herpes zoster infection restricted to the center of GA lesions was diagnosed. She responded well to a course of valacyclovir with complete resolution of vesicles within 7 to 10 days. GA lesions healed with no residual scarring within 3 to 4 weeks without additional treatment.Fig 2Tzanck smear shows multinucleate giant cells.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Development of a skin disease at the site of another distinctly different and healed skin disease is known as Wolf's isotopic response.2Wolf R. Brenner S. Ruocco V. Filioli F.G. Isotopic response.Int J Dermatol. 1995; 34: 341-348Crossref PubMed Scopus (254) Google Scholar This phenomenon was first described by Wolf et al3Wolf R. Wolf D. Ruocco E. Brunetti G. Ruocco V. Wolf's isotopic response.Clin Dermatol. 2011; 29: 161-168Abstract Full Text Full Text PDF Scopus (59) Google Scholar in 1995. Most reported cases of Wolf's isotopic response have occurred after herpes zoster or herpes simplex infection.4Ruocco V. Brunetti G. Puca R.V. Ruocco E. The immunocompromised district: a unifying concept for lymphoedematous, herpes-infected and otherwise damaged sites.J Eur Acad Dermatol Venereol. 2009; 23: 1364-1373Crossref PubMed Scopus (176) Google Scholar Various skin diseases have developed after herpes zoster infection was reported, with the granulomatous reactions being the largest category—within this group, GA was the most common.4Ruocco V. Brunetti G. Puca R.V. Ruocco E. The immunocompromised district: a unifying concept for lymphoedematous, herpes-infected and otherwise damaged sites.J Eur Acad Dermatol Venereol. 2009; 23: 1364-1373Crossref PubMed Scopus (176) Google Scholar Other skin diseases reported include leukemic infiltrate, lymphoma, lichen planus, morphea, reactive perforating collagenosis, infections, and others.4Ruocco V. Brunetti G. Puca R.V. Ruocco E. The immunocompromised district: a unifying concept for lymphoedematous, herpes-infected and otherwise damaged sites.J Eur Acad Dermatol Venereol. 2009; 23: 1364-1373Crossref PubMed Scopus (176) Google Scholar The exact mechanism of development of an isotopic response is still unknown, but different hypotheses are postulated in the literature. One hypothesis suggested by Ruocco et al5Ruocco V. Ruocco E. Ghersetich I. Bianchi B. Lotti T. Isotopic response after herpesvirus infection: an update.J Am Acad Dermatol. 2002; 46: 90-94Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar, 6Ruocco E. Genital warts at the site of healed herpes progenitalis: the isotopic response.Int J Dermatol. 2000; 39: 705-706Crossref PubMed Scopus (11) Google Scholar is that herpes virus targets the sensory nerve fibers, resulting in the release of neuropeptides that modulate the immune and angiogenic responses locally. Another report suggests that the development of granulomatous reactions within healed herpes zoster scars is not caused by the persistence of viral DNA within the lesions, but could represent a delayed-type hypersensitivity reaction to incompletely degraded varicella zoster envelope glycoproteins.7Nikkels A.F. Pierard G.E. Are granulomatous reactions in old zoster lesions due to an immune response to varicella zoster virus envelope glycoproteins?.Clin Exp Dermatol. 1998; 23: 237-238Crossref PubMed Scopus (17) Google Scholar Recognition of Wolf's isotopic response is important for accurate diagnosis and appropriate management of patients presenting with this phenomenon. To our knowledge, our case is the first report of a multiple GA lesions presenting with simultaneous active herpes zoster infection. This case also highlights the importance of simple and rapid bedside diagnostic tests such as Tzanck smear, which is easy to perform and non invasive in confirming the suspected diagnosis. We thank the authors for giving us the chance to discuss this unique and interesting topic. Nonphoto-exposed initial cutaneous manifestation of lupus after zoster: A case of Wolf's isotopic reactionJAAD Case ReportsVol. 2Issue 6PreviewAn isotopic reaction describes a novel cutaneous condition occurring in a distribution previously affected by another disease, a dermatologic example of locus minoris resistentiae (LMR). LMR represents a physiologic Achilles heel in the skin in which a congenital or acquired altered defense capacity causes a certain region of skin to be more vulnerable and easily affected by a trigger or new disease than others. Since its initial description in 1995, Wolf's isotopic reaction has been characterized as a type of isotopic reaction in which a classically nondermatomal skin reaction presents in the same dermatome after an initial pathologic insult of a herpes zoster infection (or other herpes viruses). Full-Text PDF Open AccessConcurrent presentation of tumid lupus with herpes zoster infection: A variant of Wolf isotopic response?JAAD Case ReportsVol. 5Issue 7PreviewTo the Editor: We read with special interest the case discussed by Ali et al1 in the August 2018 issue of JAAD Case Reports that reported a 54-year-old woman with a history of varicella zoster infection (VZV) on the breast, who presented with annular lesions with central vesicles on her abdomen. Based on her clinical presentation, granuloma annulare was diagnosed, whereas Tzanck smear and direct fluorescent antibody confirmed VZV infection. The authors posited that simultaneous occurrence of both dermatoses should still be considered a presentation of Wolf isotopic response. Full-Text PDF Open Access

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