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Int J Dermatol. 1998 Jun;37(6):476-7.
Zosteriform skin metastases from breast carcinoma in association with herpes zoster.
Cecchi R, Brunetti L, Bartoli L, Pavesi M, Giomi A.
A 78-year-old woman was admitted to our department with a painful, erythematous, and vesicular eruption over the left side of the chest and back, in a typical dermatomal distribution. The clinical picture strongly suggested herpes zoster. Careful examination also revealed groups of confluent, translucent, pseudovesicular papules and nodules, some of which were eroded and covered with hemorrhagic crusts, intermingled with herpetic vesicles on the same dermatomal segments. The rest of the physical examination was negative.
The patient had first noted these changes 5 weeks before admission. Her general practitioner had diagnosed herpes zoster and prescribed oral acyclovir (800 mg five times daily for 10 days), with no improvement. Four weeks later, a painful, rapidly increasing, vesicular eruption suddenly developed over the same dermatomes.
The patient had had a ductal carcinoma of the left breast 6 years previously, treated by quadrantectomy and irradiation.
A biopsy specimen of a nodule showed a dermal infiltration from breast carcinoma, while the cytologic examination of the content of a vesicle confirmed the clinical diagnosis of herpes zoster. Laboratory studies showed mild anemia and an erythrocyte sedimentation rate of 40. Further investigations failed to disclose internal metastases.
Herpes zoster was successfully treated with intravenous acyclovir, 250 mg three times daily for 7 days. The metastatic lesions became more and more evident with the gradual healing of the herpetic eruption. Subsequently, the patient underwent radiation therapy, but she developed widespread bone and parenchymal metastases and died 6 months later.
Discussion
This is a case of association between zosteriform skin metastases, secondary to breast carcinoma, and herpes zoster. At first, the patient presented with cutaneous metastases, mimicking herpes zoster, on the left side of the chest. Three weeks later, she developed a typical herpes zoster eruption over the same cutaneous segments.
The skin is not a common site of metastases from internal malignancies. The overall reported incidence varies from approximately 0.7% to 9.0% of patients with malignant diseases. Although every tumor may occasionally cause cutaneous metastases, some do so more frequently; however, the incidence of metastatic skin disease correlates well with the frequency of the primary malignant tumors in each sex. In women, breast cancer accounts for the majority of skin metastases, and their clinical appearance varies over a wide morphologic spectrum.
Eight distinct clinicopathologic types of metastatic skin involvement occur in breast carcinoma and, sometimes, different forms may develop in the same patient. A zosteriform arrangement of metastatic breast carcinoma has been rarely reported. The pathogenic mechanism of dissemination often remains unknown. The possibility of surgical implantation of metastases has been hypothesized. A Koebner-like reaction at the site of a previous herpes zoster eruption, as has been reported in cases of leukemia cutis, is unlikely in our patients, because metastatic spread anticipated herpes zoster infection. Alternatively, it has been suggested that a zosteriform pattern may take place through a perineural lymphatic spread, or via the fenestrated vessels of the dorsal root ganglion. Brownstein and Helwig first noted the peculiar behavior of certain tumors to produce skin metastases. Breast cancer causes cutaneous metastases largely through the lymphatic route. More recently, Williams et al. have hypothesized that a zosteriform arrangement may occur as a result of both a lymphatic and neural invasion. Similar mechanisms are also likely in our patient.
As dermatomal metastases can mimic herpes zoster very well, many of the reported cases were initially diagnosed and treated as herpetic diseases. 5 Furthermore, varicella-zoster infection is common in patients with impaired cellular immunity and neoplasms. Owing to the personal history of cancer, the disease appeared likely in our patient. A dermatomal distribution does not necessarily indicate herpes zoster, because several cutaneous lesions, including primary and metastatic tumors, may present a zosteriform arrangement. Skin biopsy is necessary for a correct diagnosis.
