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Genital herpes zoster in an immunocompetent child

Herpes simplex viruses (HSV-1/2) and varicella-zoster virus (VZV) are human neurotropic alpha herpesvirus causing similar cutaneous vesicular eruption. After primary infection, HSV remains latent in trigeminal or sacral ganglia and can reactivate causing orolabial or anogenital herpes lesions. After varicella infection (VZV primary infection), VZV remains latent within the ganglia throughout the entire neuraxis and can reactivate causing herpes-zoster infection. Herpes-zoster is common in elderly and immunosuppressed persons but is rarely seen in young children’s genital or perianal regions. In September 2017 a 10-year-old boy presented with a rash on the penis, progressing over a week, in the Dermatology Department of Grenoble University Hospital (France). He was prescribed topical steroid cream for the rash, but after several days, there was no improvement. The child was well vaccinated according to the French vaccine schedule that does not include VZV. The medical history included minimal atopic dermatitis, asthmatic bronchiolitis and otitis in childhood as well as previous weakly symptomatic chickenpox. The child’s mother, in early 2017, had presented with a relapse of HSV on her chin. Neither the child nor the mother had any recent contact with people with VZV infection or a similar rash. Cutaneous examination revealed vesicles and crusts on an erythematous base extending in a strip from the base of the penis to its tip (supplementary figure 1). No lesion was found on other areas of the body. Because of the location, the rash was suspicious of herpes or HSV infection, which raised the issue of sexual abuse. Faced with this sensitive issue, serology testing for anti-HSV and anti-VZV IgG/IgM (Enzygnost®) and multiplex qPCR for HSV-1/2 and VZV (TibMolbiol®) on the lesion were performed. The qPCR was negative for HSV-1/2 and unequivocally positive for VZV. IgG/IgM anti-HSV were negative. IgG/IgM anti-VZV were positive (IgG>4000 IU/mL, IgM=0.2 OD). These results reoriented the diagnosis towards a genital zoster infection, ruling out the hypothesis of sexual abuse. Additional studies were conducted to exclude an immunodeficiency state and severe reactivation. VZV DNA in blood was undetectable. HIV serology was negative. Blood cell count, lymphocyte typing, and protein electrophoresis were normal. Herpes-zoster rash is typically painful, unilateral and dermatomal. Its location varies upon the sensory ganglion in