A middle-aged female clinical doctor with no previous data of serious ill conditions had got over the chicken pox in early childhood (when she was five years old). She had no feeling of any health disorder but these days in the beginning of November of 2015 year she had too much work in her workplace in the hospital: in a short time several nights on duty with big number of seriously ill patients. In her private life she had a very big emotional stress-some financial problems of buying new apartment with neglecting proper nutrition in that period.
Around 10th of November she began to feel fatigue, anorexia, general weakness, irritability, mild depression, which she explained that she was overworked. On the 12th of November when she went to sleep she felt the discomfort and mild pain beside the spine in the level of right scapula. She had difficulties in falling asleep with a number of awakenings during the night with feeling of discomfort and mild pain in the right shoulder, upper arm and right elbow. In the morning 13th of November she noticed the red skin indurated papules the size of a few millimeters to half a centimeter in diameter in the palmar side in the root of ring finger. During the day a few indurated papules appeared in the border between the palmary and dorsal side of the right hand in the area of innervations of the ulnar nerve. On the 14th of November a couple of the same indurations appeared in the palmary side of right hand in the root of forearm, and in the region of pinkie finger. In the next few days (4 to 5 days) skin of the ulnary side of the palm of the right hand became erythematous and grouped herpetiform vesicles developed hour by hour, day after day and almost complete clinical picture was developed on the 17th of November. The vesicles were cloudy, some of them with red border, some of them merged in blisters more than 2 centimeters in diameter. That day she went to doctor dermatologist who characterized the appearance as hemorrhagic form of herpes zoster and therapy was prescribed: Acyclovir tbl 5x 800mg two days and 5x600 mg 4 days four days, broad-spectrum antibiotic, vitamins B12 and B1, B6, analgesics and Acyclovir cream locally several times on day. The entire time patient felt fatigue, general weakness, discomfort and pain in most expressed in elbow and in ulnar side of forearm, ulnaro-carpal joint and in the palmary and dorsal side of the right hand all in projection of the branching of ulnar nerve. The vesicles were staggered and grouped also in the projection of ulnar nerve innervations. The pain may be described as burning but no narcotics were needed. It might be reduced by no steroidal anti-inflammatory drugs (ibuprofen) 3 to 4 tablets per day. During the first three days of therapy some new vesicles erupted. About 10 days after first eruption some vesicles started converting into crusts with no new vesicle eruption. After vesicular involution, there was slow resolution of the remaining erythematous plaques, but with visible squeals. On the control examination (10 day after first examination) the dermatologist characterized illness as gangrenous form of herpes zoster with recommendation to patient to examine her immune system and to use panthenol ointment-for epithelialization and skin regeneration long time and eozine (antiseptics) locally for five to six days. She has done blood testing (ESR-erythrocyte sedimentation rate, FBC-whole blood count, liver and kidney laboratory tests, rheumatic tests, OraQUICK HIV test, urine examinations, chest x- ray, ultrasound examination of abdomen and pelvis. All examinations were in normal rate. From day to day she felt better and better but 30 days after the begging of illness she still have crusts in the places of vesicles, the largest one on the ulnar side of the palm of right hand with mild pain in involved area. Two months after first vesicular eruption there are sequels in the form of the pink stains in the places of previous vesicles with mild hyperesthesia in involved area and very mild occasional pain in there especially in the evening.
The appearance of skin manifestations in first seven days is presented in the figures 1, 2, 3.