Reply to Dado et al.

We read with great interest the comment of Drs Dado and Chernev related to our case report on gastrointestinal herpes zoster in an apparently immunocompetent patient [1].

As they suggest, it would be important to know whether varicella zoster virus (VZV) infection in the reported case was due to a primary infection or reactivation of latent VZV, as it is not clear whether primary VZV infection affects the gastrointestinal mucosa similarly to the skin. However, VZV IgM was negative in the serum of our patient, whereas VZV IgG was elevated (titer 1: > 320; normal cut-off 1:60), which supports reactivation of latent VZV and makes a primary infection less likely. As stated by Dado and Chernev, VZV might commonly establish latency in the enteric nervous system, which could consequently be a primary site of reactivation [2] [3] [4], and gastrointestinal involvement in herpes zoster may be the rule rather than the exception. We appreciate their suggestions that our case does not meet the exact definition of a disseminated cutaneous herpes zoster, which is defined by more than 20 vesicular lesions outside the primary and immediately adjacent dermatomes [5]. At the time of endoscopy, our patient presented with only a few vesicular eruptions over the head and trunk, and nearly all of the vesicles were already encrusted. Unfortunately we had no information about the initial appearance of the rash. Interestingly, it has been reported that abdominal symptoms related to visceral reactivation may even occur in the absence of skin lesions or may precede the rash by 1 to 10 days [5] [6] [7] [8].

We finally want to thank Dado and Chernev for their thoughtful comments and fully agree that physicians should evaluate gastrointestinal involvement in herpes zoster, especially in patients with unspecific gastrointestinal complaints.

• References

• 1 Krones E, Petritsch W, Valentin T et al. Visceral dissemination of herpes zoster with multiple ulcers in the upper gastrointestinal tract of an apparently immunocompetent patient. Endoscopy 2012; 44: E302-303
• 2 Gershon AA, Chen J, Davis L et al. Latency of varicella zoster virus in dorsal root, cranial, and enteric ganglia in vaccinated children. Trans Am Clin Climatol Assoc 2012; 123: 17-33 ; discussion 33-15
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