Ann Thorac Surg 2004;78:2159-2161
© 2004 The Society of Thoracic Surgeons
Case report
Acute Postoperative Shingles After Thoracic Sympathectomy for Hyperhidrosis
Malek G. Massad, MD*,a,
Rafael A. Navarro, MDa,
Helene Rubeiz, MDa,
Jacques Kpodonu, MDa,
Janet Karol, MSNa,
Mathew Blacha, MDa,
Alexander Evans, MDa
a Division of Cardiothoracic Surgery, Department of Surgery, The University of Illinois at Chicago, Chicago, Illinois, USA
Accepted for publication July 21, 2003.
* Address reprint requests to Dr Massad, University of Illinois at Chicago, 840 S. Wood St, MC 958, Chicago, IL 60612, USA
mmassad{at}uic.edu
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Abstract
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Shingles secondary to reactivation of a previous varicella-zoster virus infection has been reported to develop within surgical wounds and after trauma. We report the case of a 17-year-old girl with history of chicken pox in childhood who had acute postoperative shingles develop along the T3-T4 dermatomes after thoracic sympathectomy for hyperhidrosis. The possible causes and precipitating factors are discussed.
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Introduction
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Shingles secondary to reactivation of a previous varicella-zoster virus infection has been reported to develop within surgical wounds and after trauma [1, 2]. Shingles has also been described after breast reconstruction or radiation therapy to the breast [3, 4], after dental procedures or facial surgery [5], and after liver biopsy [6]. In this article we report the case of a 17-year-old girl with history of chicken pox in childhood who had acute postoperative shingles develop, characterized by painful dyesthesia and cutaneous vesicular eruptions, along the T3-T4 dermatomes after thoracic sympathectomy for hyperhidrosis. We believe this is the first case of reactivation of a latent varicella-zoster virus from childhood chicken pox to be reported after a thoracic sympathectomy.
A 17-year-old girl presented to our medical center with the chief complaint of bilateral axillary and palmar hyperhidrosis since childhood. The patient reported excessive sweating in her palms and axillae that was interfering with her daily activities, requiring her to change her clothes frequently. She had been in a perfect state of health with no significant medical or social history, except for a history of chicken pox at the age of 7. Three months before her presentation, she was seen in the dermatology clinic where she received botulinum toxin A (Botox, Allergan Inc, Irvine, CA) injections in both of her axillae. Fifty Units of Botox reconstituted in 5 mL of 0.9% normal saline were injected into both axillae with a 30-gauge needle using 30 injections, but this produced no notable improvement in her symptoms. Subsequently, a staged bilateral thoracoscopic sympathectomy was planned. The patient underwent a right thoracoscopic T2-T4 sympathectomy through two access ports over the third intercostal space (right anterior axillary line), and the fourth intercostal space (mid-axillary line). Each of the two port incisions measured about 2 cm in length. The patient was discharged home the next day after the procedure. However, she came back to the emergency department 24 hours later with severe pain, swelling, and erythema over the right breast area associated with tenderness and a warm sensation. The patient noted that the upper outer quadrant of her breast was itching and very sensitive to touch. Over the course of the night, a rash erupted over her entire right breast that soon progressed into multiple small blisters (Fig 1). Over the ensuing 5 to 7 days, these vesicles dried up and became crusted. She reported no fever or chills. Her peripheral white blood cell count and a plain chest roentgenogram were normal. A computerized tomographic scan of the chest was obtained to rule out a soft tissue abscess or collection, and this was also normal. Because of concern that her presentation could be secondary to an infectious process, she was admitted to the hospital and treated with intravenous antibiotics on empiric basis (initially cefazolin, then vancomycin and ceftriaxone for broader coverage). Gram stain and cultures of the skin lesions were obtained in addition to a blood culture, which were all negative. The patient did not show any signs of improvement in her skin manifestations after 48 hours of intravenous antibiotics. In view of her history of chicken pox at the age of 7 and because the skin lesions followed a right T3-T4 dermatomal pattern involving the right breast, and were consistent with those of "shingles," she was started on oral antiviral therapy (valacyclovir, 500 mg orally twice a day for 10 days; Valtrex; GlaxoSmithKline, Research Triangle Park, NC). With the initiation of valacylovir, the degree of erythema and the skin lesions that were initially noticed both improved in the patient. Because she did not demonstrate any signs or symptoms of a systemic infection, she was discharged home on a 10-day course of oral valacyclovir. On follow-up visits to the clinic, the lesions were noted to have gradually subsided. However, she continued to have pain in the area originally affected, consistent with post-herpetic neuralgia. The pain gradually subsided by 2 months from the time of diagnosis.
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Fig 1. An anterior view of the right and left breasts, which was taken after the right thoracoscopic T2-T4 sympathectomy, demonstrates the severe swelling and erythema involving the right breast and T4 dermatome. Crusted vesicular papules were scattered over the lateral aspect of the right breast following a dermatomal pattern.
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Comment
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The differential diagnosis of a patient with the acute postoperative skin manifestations described earlier include conditions such as bacterial skin infection, mastitis, and lymphangitis. None of these conditions follow a dermatomal distribution and none are associated with vesicular eruptions that later dry up and crust. More rarely, the differential diagnosis includes reflex sympathetic dystrophy, also called complex regional pain syndrome that has been reported to involve the ipsilateral breast area after breast augmentation or mastectomy [7–9]. In this patient, the gross appearance and progression of the postoperative skin lesions were consistent with those of shingles and followed the pattern of the T3-T4 dermatomes that include the breast. The skin manifestations did involve the two recent thoracoscopic port scars, as both sites were along the T3 and T4 dermatome distribution. The skin lesions did not respond to antibacterial therapy and did not show signs of improvement until the antiviral therapy was initiated. In those circumstances of latent reactivation, the zoster virus, which is quite labile, may not be isolated or confirmed by swab culture of the vesicular skin lesions, and the diagnosis had to be made on clinical grounds. Finally, the patient continued to have pain, consistent with post-herpetic neuralgia in the described areas for weeks after her skin lesions subsided. It is likely that the herpes varicella-zoster virus may have remained dormant in the dorsal root ganglia after her chicken pox infection and was reactivated in the recent surgical scars of her thoracoscopic ports. Other possible explanations for the development of shingles in this patient include (1) the reactivation of the old varicella-zoster virus in the dorsal root ganglia by manipulation of the sympathetic chain through preoperative and postoperative ganglionic axonal connections between the denervated sympathetic ganglia and the T3 and T4 dorsal root ganglia, or (2) reactivation of the virus by direct pressure of the thoracoscopic instruments on the third and fourth intercostal nerve bundles.
The patient had presented with previous botulinum toxin injections in the right axilla 3 months before her operative procedure. A review of the world literature between 1966 and the present using Medline showed no reported link or association between botulinum toxin and the reactivation of varicella zoster. Thus it is the current opinion of the authors that this particular patient had shingles develop that we believe had no relation with the previous botulinum toxin injections she had received, and that any such association or observation at this time is considered purely coincidental.
In this patient, we believe that the shingles was causally related to the surgical procedure. It acutely followed the thoracic sympathectomy and the location of the lesions corresponded to the T3-T4 dermatomes. We believe this is the first such case of shingles to be reported after sympathectomy. We would like to bring this complication to the attention of the readers, because early recognition of this postoperative problem is important for prompt and appropriate therapy to begin.
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References
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- Nikkels AF, Pierard GE. Shingles developing within recent surgical scars. J AM Acad Derm 1999;41:309–11
- Foye PM, Stitik TP, Nadler SF, Chen B. A study of post-traumatic shingles as a work related injury. Am J Ind Med. 2000;38(1):108–111[Medline]
- Skoll PJ, Hudson DA. Zoster following immediate transverse rectus abdominis myocutaneous breast reconstruction. Plast Reconstr Surg. 2000;106(5):1218–1219[Medline]
- Dunst J, Steil B, Furch S, Fach A, Bormann G, Marsch W. Herpes zoster in breast cancer patients after radiotherapy. Strahlenther Onkol. 2000;176(11):513–516[Medline]
- Furuta Y, Ohtani F, Fukuda S, Inuyama Y, Nagashima K. Reactivation of Varicella-Zoster virus in delayed facial palsy after dental treatment and oro-facial surgery. J Med Virol. 2000;62(1):42–45[Medline]
- Levy JM, Smyth SH. Reactivation of herpes after liver biopsy. J Vasc Interv Radiol. 2002;13(2 Pt 1):209–210[Medline]
- Graham LE, McGuigan C, Kerr S, Taggart AJ. Complex regional pain syndrome post mastectomy. Rheumatol Int. 2002;21(4):165–166[Medline]
- Papay FA, Verghese A, Stanton-Hicks M, Zins J. Complex regional pain syndrome of the breast in a patient after breast reduction. Ann Plast Surg. 1997;39(4):347–352[Medline]
- Saddison DK, Vanek VW. Reflex sympathetic dystrophy after modified radical mastectomy: a case report. Surgery. 1994;115(3):409–410
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Abstract
Introduction
