Image 53: This 61 year old patient presented with 4 skin lesions on her legs that had developed in the month after her return from 4 months in Burkina Faso (same region as Image 45). Four months after the lesions appeared a biopsy revealed loose granulomas but no amastigotes. A PCR on the biopsy material was positive for Leishmania spp. Response to a 6 week trial of itraconizole was minimal, so she was started on Pentostam IV 20mg/kg. On day 14 of the pentostam she developed a painful papulo-vesicular herpes zoster over her left L1 dermatome. Why did she get herpes zoster?

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Image 53: For as yet unknown reasons the incidence of herpes zoster during  intravenous Pentostam treatment of cutaneous Leishmaniasis is increased 10 fold or more relative to the incidence in the normal population. Cases of cutaneous leishmaniasis not treated with antimony do not have an increased incidence of zoster. Visceral leishmaniasis cases, almost always immunocompromized, are associated with opportunistic infections whether on antimony or not. The patient was treated with Valacyclovir and improved  quickly. The Pentostam was continued till the end of the 20 day course, and she did well.

(1) Wortmann GW et al Herpes zoster and lymphopenia associated with sodium stibogluconate therapy for cutaneous leishmaniasis. CID 27: 509-12; 1998
(2) Hartzell JA eta al. Varicella zoster virus meningitis complicating sodium stibogluconate treatment for cutaneous Leishmaniasis. AJTMH 74: 591-2: 2006