Death Caused by Disseminated Herpes Zoster in a Patient with Multiple Myeloma: A Case Report and Literature Review

Figures & data

Figure 1 The patient develops a blister-like rash all over the body with widespread itching.

Figure 2 Histopathologic images of the patient’s skin lesions (HE × 100). (a) Microscopic evaluation revealed the presence of blister-like formations beneath the stratum corneum, characterized by the presence of loosened spinous cells. There was a mild disintegration observed at the base of these structures, coupled with a discernible lymphocytic infiltration encircling the periphery. (b) Disintegration of blisters and balloon-like degeneration of cells with a little inflammatory cell infiltration are seen under the stratum corneum. The arrows in the figure indicate cellular balloon-like degeneration.

Table 1 Results of the Patient’s Blood Tests

Parameters	Result				Unit	Reference Range
Dates	May 23rd	May 28th	June 5th	July 7th	–	–
White blood cell count	9.82	12.47	8.62	24.99	10^9/L	3.5–9.5
Neutrophils	8.64	11.6	8.48	22.39	10^9/L	1.8–6.3
Lymphocytes	0.7	0.5	0.12	0.69	10^9/L	1.1–3.2
Red blood cell count	3.63	3.37	2.91	2.15	10^12/L	4.3–5.8
Hemoglobin	120	113	95	67	g/L	130–175
Platelets	120	121	42	4	10^9/L	100–300
C-reactive protein	38.73	80.43	293.87	216.89	mg/L	0–5
Procalcitonin	–	0.45	>50	>50	ng/mL	0–0.05
Blood nitrogen urea	46.48	–	47.7	8.05	mmo/L	3.1–8.0
Creatinine	324.4	–	419.9	135.0	μmol/L	57–97
Total protein	55.3	–	48.9	56.0	g/L	65–85
Albumin	34.1	–	26.3	22.2	g/L	40–55
Brain natriuretic peptide	4365.4	–	14,527.3	13,896.8	pg/mL	0–125
Aspergillus galactomannan	1.32				ug/L	0–0.5
Fungal D-glucan	932.62				pg/mL	<60

Table 2 Laboratory Test Results in the Patient

Microbiological
Blood culture	Klebsiella pneumoniae infection
Bacterial culture and identification	Multidrug resistant bacterium Klebsiella pneumoniae, sensitive only to tigecycline.
Sputum culture	Infection of multidrug-resistant strains of Acinetobacter baumannii, sensitive only to tigecycline.
NGS of alveolar lavage fluid	Klebsiella pneumoniae and Acinetobacter baumannii; Aspergillus fumigatus and Candida albicans.
PCR of alveolar lavage fluid	Cytomegalovirus: positive (+), EB virus: positive (+).
COVID-19 nucleic acid test	Negative
Nucleic acid testing for 13 respiratory pathogens	Negative

Abbreviations: NGS, Next-Generation Sequencing; PCR, Polymerase Chain Reaction.

Table 3 Prophylactic Medication in Special Situations

Drug(s)	Usage and Dosage	Duration of Prophylaxis	Efficacy	Reference
Acyclovir	400 mg 3 times daily.	Bortezomib dosing full course of drug administration.	Incidence of shingles reduced from 13% to 6.6%	Mateos MV et al^Citation36
Acyclovir	400 mg thrice daily, 400 mg once daily.	Duration of administration covers the entire course of bortezomib dosing.	No recurrence of herpes zoster was observed in either acyclovir prophylaxis group.	Pour L et al^Citation37
Acyclovir/ Valaciclovir/ Famciclovir	Acyclovir 400mg daily, alternatives are 200 mg acyclovir, 250 / 500 mg valacyclovir or 500 mg famciclovir given daily.	Continuing from the beginning of the treatment of the disease to the end of the entire course of treatment.	In myeloma patients treated with bortezomib, daily acyclovir (or a suitable alternative) appeared to be effective in preventing herpes zoster virus, with 100% prophylactic efficiency against herpes zoster, with or without corticosteroids.	Vickrey E et al^Citation32
Acyclovir	Sixty-one patients took 400 mg of acyclovir per day and 19 patients took 200 mg of acyclovir per day.	–	Seven cases of herpes zoster were observed in 80 patients; two patients with herpes zoster received 400 mg for a limited period of time from cycle 1 to cycle 4, and five others received 200 mg (incidence 26.3%).	Kim SJ et al^Citation28
Acyclovir	200 mg daily	Acyclovir prophylactic administration should cover the entire course of bortezomib dosing.	The incidence of herpes zoster was 27% (21/78) in the group that did not receive acyclovir prophylaxis and 1% (1/92) in the group that took acyclovir 200 mg daily prophylactically.	Minarik J et al^Citation38
Acyclovir	400 mg twice daily.	Started prior to initiating treatment with bortezomib and discontinued 4 weeks after bortezomib treatment.	None of the 100 MM patients who received acyclovir prophylaxis developed herpes zoster during bortezomib treatment, regardless of the patient’s receipt of multiple concomitant antimyeloma therapies or response to bortezomib-based therapy.	Swaika A et al^Citation33
Valaciclovir	500 mg daily	During bortezomib treatment.	Thirty-two patients with MM treated with a bortezomib-containing regimen were included, and it was found that only one case of herpes zoster occurred in the group of continuous oral prophylactic administration of valacyclovir (500 mg/d).	Fukushima T et al^Citation34
Valaciclovir	300 mg twice daily.	Discontinue after 3–4 courses of bortezomib chemotherapy.	All 26 patients receiving valaciclovir prophylaxis were protected against herpes zoster, in contrast to a control group where 5 out of 27 individuals developed the condition.	Tian Ying et al^Citation35
Famciclovir	250 mg twice daily.	After completion of the last dose of bortezomib treatment in each cycle for 9 days.	The investigation delineated a VZV reactivation rate of 13.4%, with distinct incidences across different prophylaxis strategies: 8.4% in the intermittent famciclovir cohort (21/250), 7.9% in the continuous famciclovir group (17/216), and 22.9% within the non-prophylaxis assembly (58/253).	Zheng G et al^Citation11

Abbreviation: VZV, Varicella-Zoster Virus.

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