LAUSR

Immunosuppressed and elderly individuals have an increased risk of reactivation of the varicella virus causing herpes zoster (HZ) infection (1). It is estimated that about 25% of individuals with a previous varicella infection will suffer from HZ (2). Studies have suggested symptomatic motor neuron involvement manifesting as paresis or paralysis to occur in about 1–15% of patients referred to hospital with HZ (3, 4). Total recovery of the paresis is reported in about 50% (3). Eosinophilic fasciitis is a rare disease that may be accompanied by myositis and present with a variety of musculoskeletal symptoms and dermatological findings (5). The treatment is individually adjusted, often including systemic corticosteroids and methotrexate (MTX) (5). A 73-year old female developed, within 4 weeks, muscular pain, generalized muscular weakness with gait difficulty, and facial and extremity oedema. She had elevated C-reactive protein, thrombocytosis and fluctuating eosinophilia; electromyography showed discrete signs of myopathy and bone marrow biopsy showed eosinophilia. Muscle biopsy showed fasciitis with muscular inflammation, and the patient was diagnosed with eosinophilic fasciitis with myositis. The disease was in remission for 6.5 years on MTX and 7.5 mg prednisolone. At the age of 79, the patient experienced fatigue and pain in the lower left extremity for 1 week before she developed a vesicular rash confined to the L5 and S1 dermatomes of the left shin and plantar aspect of the left foot, and left foot drop, which led to admission (Figure 1A, B). MRI of the lumbar spine was without signs of intraspinal compression of the nerve roots. Disease activity in the underlying fasciitis andmyositis, or the development of secondary vasculitis, was suspected and the patient was transferred to the rheumatological department 3 days after admission for treatment with high-dose prednisolone (75 mg/day). The vesicular rash was biopsied and swabbed, and oral valaciclovir treatment was initiated after dermatological evaluation owing to a clinical suspicion of shingles. The inoculation turned out positive for varicella zoster virus (VZV). A nerve conduction study showed axonal affection of the peroneus profundus and superficialis, compatible with HZ-mediated motor neuron affection of the common peroneal nerve. Skin biopsy showed lesions compatible with HZ and no sign of vasculitis.