An 85-year-old male with a past medical history of hypertension, hyperlipidemia, sciatica, prostate cancer (status post radiation therapy, on leuprolide), and pulmonary fibrosis was admitted to the hospital by his PCP after developed bladder and bowel incontinence in the setting of weakness and unsteadiness. Ten days prior to his admission he reported a mechanical fall with head trauma during a racquetball match without loss of consciousness. Computed tomography (CT) of his head and magnetic resonance imaging (MRI) of his hips were negative for acute injuries.
He subsequently developed a prodrome of sharp right leg pain and numbness, followed by a zosteriform, linear, vesiculopustular eruption initially distal to the knee and progressed to involve the medial and posterior region of his right lower extremity and groin area (Fig. 1). Additionally, he developed discrete lesions of the face, trunk, and remaining extremities. Polymerase chain reaction (PCR) test was positive for VZV, confirming herpes zoster. Valacyclovir at 1 g three times a day (TID) was started for treatment of disseminated shingles. Patient at that time was also noted to be up to date on immunizations, with the exception of live zoster vaccine.
A few days later, he developed bladder and bowel incontinence in the setting of weakness and unsteadiness. Review of systems was otherwise negative. No history of immunosuppressive pharmaceutical drug use. He was seen by his PCP, who directly admitted him at the hospital.
Physical exam was significant for a vesiculopustular rash on the patient's face, trunk, and extremities, worse on the right lower extremity. More than 20 lesions were appreciated beyond the initial dermatome. Neurologic exam was significant for diminished right hip flexion and abduction strength, decreased pinprick and proprioception sensation on the right lower leg medially, without saddle involvement; and diminished right patellar and Achilles reflexes.
Initial labs were significant for a leukocytosis of 13,400/muL, with left shift. Imaging studies included a CT of the abdomen/pelvis that was significant for a dilated bladder and a MRI of the lumbar spine that was significant for diffuse abnormal enhancement of the cauda equina nerve root and right lumbosacral plexus.
The patient was diagnosed with disseminated herpes zoster, predominantly along the L3-S2 dermatomes with lumbosacral plexopathy, manifesting as cauda equina syndrome. He was started on intravenous (IV) acyclovir 10 mg/kg TID for 14 days, followed by valacyclovir 1000 mg for 7 days as well as gabapentin for associated neuropathic pain. He continued to have bowel incontinence and was found to have a coinfection with Clostridioides difficile. Leukocytosis and frequency of bowel movement improved after initiation of metronidazole 500 mg TID. An indwelling Foley catheter was placed for overflow incontinence.
After the lesions crusted over, the patient was discharged from the hospital. He continued to have bladder and bowel incontinence; however, he had marked improvement in motor function. He was followed closely by the Departments of Urology and Neurology. At a 10-week follow-up phone interview patient reported significant improvements in ambulating, resolution of neuropathic pain, and complete resolution of prior incontinence.