# Exploring Risk Factors and Patterns in Uncommon Recurrences of Varicella-Zoster Reactivation: A Review of Case Reports

## TL;DR

This paper reviews unusual cases of varicella-zoster virus reactivation, highlighting diagnostic challenges and varied presentations across different age groups.

## Contribution

The paper presents a novel compilation of atypical VZV reactivation cases, emphasizing diagnostic delays and clinical variability.

## Key findings

- Unusual VZV presentations include zoster sine herpete and vocal fold paralysis.
- Diagnostic delays occurred in all cases due to atypical symptoms.
- Two patients experienced incomplete recovery despite antiviral therapy.

## Abstract

Varicella-zoster virus (VZV) causes chickenpox and then establishes latency in the autonomic ganglia. Reactivation of the virus, known as herpes zoster or shingles, manifests as a unilateral, vesicular rash localized within one dermatome accompanied by pain and pruritus. While the classic rash resolves within three weeks, older or immunocompromised individuals may experience prolonged symptoms, increased vesicle number, and complications such as post-herpetic neuralgia. Although the classic manifestations of VZV are well known, more cases are appearing with an atypical presentation. We highlight eight reports of unusual presentations describing confirmed cases of VZV that become reactivated and note a wide range of ages, with half over 70 years of age and half under 40 years of age, two including children. Unusual presentations include zoster sine herpete, vocal fold paralysis due to vagal nerve involvement, and encephalitis with massive pulmonary emboli in a previously healthy 37-year-old woman. One case features a child who developed shingles from the vaccine strain of VZV. Diagnostic delays occurred in all cases due to the atypical nature of the presentations, often resulting in initial misdiagnoses and inappropriate treatments such as antibiotics or corticosteroids. Despite eventual antiviral therapy, two patients experienced incomplete recovery, suffering from persistent neuropathic pain or muscle atrophy. These cases emphasize the variability in VZV presentations, the importance of timely diagnosis, and the need for greater clinical awareness to prevent delayed treatment and adverse outcomes.