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Case Report | DOI: https://doi.org/10.31579/2642-973X/150
School of Osteopathic Medicine in Arizona, A.T. Still University, Mesa, Arizona.
*Corresponding Author: Leonard B. Goldstein, School of Osteopathic Medicine in Arizona, A.T. Still University, Mesa, Arizona.
Citation: Aidan T. Radzat, James Keane, Leonard B. Goldstein, (2025), Painless Multi-dermatomal Shingles: A Case Report of Atypical Varicella Zoster impacting Cervical and Trigeminal Dermatomes in an Immunocompetent Elderly Female, J. Brain and Neurological Disorders, 8(3): DOI:10.31579/2642-973X/150
Copyright: © 2025, Leonard B. Goldstein. This is an open-access article distributed under the terms of The Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 02 July 2025 | Accepted: 10 July 2025 | Published: 18 July 2025
Keywords: unilateral vesicular; single dermatome; immunocompromised; trigeminal nerve; chickenpox or varicella; type II diabetes mellitus
Herpes zoster, or shingles, is a common pathology in the Emergency Room. It typically presents as a painful, unilateral vesicular rash confined to a single dermatome, often in immunocompromised or elderly patients. Multidermatomal involvement, particularly crossing spinal and cranial dermatomes, is rare and typically associated with significant immunosuppression.
We present the case of an 86-year-old female who presented to the ED with presyncope and pruritic neck rash on the left face and neck. Dermatologic exam revealed erythematous vesicular lesions involving cervical dermatomes C2-C5 and the mandibular division of the trigeminal nerve (V3). Diagnosis of varicella zoster virus was confirmed using PCR. Full clinical recovery was achieved with standard antiviral treatment. This case highlights an atypical case of painless, multidermatomal shingles in an immunocompetent patient. A review of the literature reveals that such presentations are exceedingly rare, with the absence of neuralgia contributing to delayed diagnosis. Early recognition remains critical for antiviral initiation and complication prevention, underscoring the need to maintain clinical vigilance even in the absence of pain or immunosuppression.
Herpes zoster, also known as shingles, is a common infectious dermatological condition characterized by painful, vesicular lesions presenting in a unilateral, dermatomal pattern. It is caused by reactivation of the varicella zoster virus (VZV), typically in immunocompromised individuals.1 The initial infection with VZV commonly occurs in childhood termed chickenpox or varicella, where it is transmitted via respiratory droplets or through direct contact with active lesions.2 Upon resolution of symptoms, VZV may remain latent indefinitely in the dorsal root ganglia of the CNS1. In elderly or immunocompromised individuals, VZV can reactivate, traveling up nerves to the skin corresponding with the infected nerve. This causes the localized, painful and blistering rash known as shingles. 1,2
In the United States, shingles has an incidence of 10.46 per 1000 people over age sixty.3 It is a common presentation in the Emergency Department, and the annual cost burden of Shingles treatment and complications is estimated to be around 1 billion per year.10 The majority of cases will affect the thoracic dermatomes (up to 50%) followed by cervical (up to 23%) and trigeminal (up to 15%).1,4,5 In 85% of cases, the distribution is limited to a single dermatome.5 Multidermatomal involvement, particularly including both spinal and trigeminal dermatomes, is a rare presentation of this condition that has only been documented a handful of times. It is typically associated with severely immunocompromised individuals, including those with HIV or malignancy.5 The presentation of an immunocompetent individual meeting these criteria was cause for documentation to further share atypical presentations of zoster.
We present the case of an 86-year-old female with a medical history of hypertension and well-controlled type II diabetes mellitus, who presented to the ED with chief complaints of presyncope and pruritic neck rash. She reported associated symptoms of global headache and episodes of dizziness and nausea prior to arrival. Upon initial assessment, the patient was comfortable and in no acute distress. Vital signs demonstrated hypertension at 171/74, with heart rate of 85, temperature of 37.3 C (99 F) and respirations of 18. Ophthalmologic, otologic, and oral exams revealed no significant findings. History was negative for new medications, creams, detergents, or environmental exposures. Patient denied a history of allergies or prior skin conditions. HIV rapid and HSV PCR testing was negative. CBC, renal function, hepatic function, and electrolytes were within normal limits other than mild thrombocytopenia (145,000). EKG showed sinus tachycardia with evidence of old inferior wall infarct that was unchanged from prior EKG. CT showed no evidence of an acute process. Neurologically, the patient was oriented to self and location only without any focal deficits.
Upon dermatological assessment, we appreciated a left-sided, erythematous rash with vesiculation and bullae in various stages of healing (Figure 1). Per family members at bedside, the lesions had first appeared 48 hours prior on the anterolateral surface of the left neck, eventually extending up to the earlobe and left mandibular region. The region affected first corresponded with the C3 dermatome, with spread into C2, C4, and C5. The facial region affected corresponded with the mandibular division of the trigeminal nerve (V3). The patient endorsed associated pruritus of the region but only endorsed irritation upon palpation of blisters. There was no extension of the rash into the nares, oral cavity, or ear canal, and cranial nerve exam did not reveal focal deficits.
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Figure 1: Neck rash on day of presentation.
Upon admission, the patient was started on IV acyclovir 10 mg/kg every 12 hours and prednisone 60 mg daily. She was also provided gabapentin acetaminophen as needed for pain and pruritus. By day two of the hospital stay, the rash had worsened, becoming more diffuse and erythematous. It spread to the central chest and anterior and posterior aspects of the shoulder (Figure 2).
Figure 2: Rash on day two of admission.
By day 3 of admission, the diagnosis of herpes zoster was confirmed via positive PCR testing for Varicella Zoster virus. After briefly spreading and worsening, the rash began to improve, with decreasing erythema and no new vesicles. The patient was treated with intravenous acyclovir and prednisone for a total of four days, until no new blisters had occurred and all vesicles were crusted over, indicating healing and decreased infectivity. On day four, she was discharged with oral valacyclovir 1 g, twice a day, with instruction to complete a seven-day course of treatment. Clinical resolution was achieved with this standard treatment course.
Reference | Age and Sex | Dermatomes | Co-Morbidities |
| Current | 86 F | V3, C2-C5 | Diabetes |
| Jung T, Hong C, Shin JE, Kim CH. Multi-dermatomal herpes zoster involving CN V3 and C2 territories with simultaneous vestibulocochlear deficit: A case report. Medicine (Baltimore). 2023;4(7): e284. Published 2023 Jul 25. doi:10.1097/MD9.0000000000000284 | 35 F | V3-C2 | None reported |
| Yogi TN, Bhusal A, Subedi S, Katwal S, Acharya K. Multi-dermatomal herpes zoster triggered by psychological stress in an immunocompetent young adult: a rare case report and clinical insights. Ann Med Surg (Lond). 2023;85(12):6231-6236. Published 2023 Oct 17. doi:10.1097/MS9.0000000000001409 | 26 M | C5, C8, T1, T2 | Psychological distress |
| Shaphe MA, Sharma R, Ghosh A, et al. Concurrent Involvement of Trigeminal and Facial Nerves in Herpes Zoster. anatol j fm. 2023;6(2):123-126. doi:10.5505/anatoljfm.2023.62681. | 51 F | V1-V2-V3 | Type II Diabetes Mellitus |
| Pelloni, L.S., Pelloni, R. & Borradori, L. Herpes zoster of the trigeminal nerve with multi-dermatomal involvement: a case report of an unusual presentation. BMC Dermatol20, 12 (2020). https://doi.org/10.1186/s12895-020-00110-1 | 71 M | V1-V2 | None reported |
| Alhayyas M, Chaudhry M, Berdouk S. An atypical presentation of multidermatomal herpes zoster: a case report. Int J Emerg Med. 2020;13(1):58. doi:10.1186/s12245-020-00325-6 | 30 M | T1-T4 | None reported |
| Dube S, Pratyush R, Rajshekhar V. Multidermatomal herpes zoster ophthalmicus in an immunocompetent male. J Clin Ophthalm Res. 2017; 5:38–40. [DOI: 10.4103/2320-3897.195308 | 55 M | CN V1-3, C2-C4 | None reported |
| Ganjoo S, Sawhney MPS, Chawla D. Painless multidermatomal herpes zoster in an immunocompetent elderly male: a case report. BMJ Case Rep. 2016; Published April 8, 2016. https://doi.org/10.1515/sjdv-2015-0015 | 85 M | T12, L1-L4 and S2 | None reported |
| Gomez E, Chernev I. Disseminated cutaneous herpes zoster in an immunocompetent elderly patient. Infect Dis Rep. 2014;6(3):5513. Published 2014 Aug 26. doi:10.4081/idr.2014.5513 | 95 F | V1-V3 | CAD, COPD |
| Gupta LK, Kuldeep CM, Mittal A, Singhal H. Multidermatomal herpes zoster in an immunocompetent female. Indian J Dermatol Venereol Leprol. 2005;71(3):210-211. doi:10.4103/0378-6323.16247 | 25 F | C2-C5 | None reported |
| Jin A, Dejesus Y. Two cases of herpes zoster in multiple adjacent dermatomes. Consultant360. Published online January 23, 2012. Available at:https://www.consultant360.com/articles/two-cases-herpes-zoster-multiple-adjacent-dermatomes. | 65 M | V3, C1-C8, T1-T3 | None reported |
| Jin A, Dejesus Y. Two cases of herpes zoster in multiple adjacent dermatomes. Consultant360. Published online January 23, 2012. Available at:https://www.consultant360.com/articles/two-cases-herpes-zoster-multiple-adjacent-dermatomes. | 74 F | V3, C1-C8, T1-T3 | None reported |
Table 1: Literature review of case reports of multidermatomal herpes zoster in immunocompetent patients.
This case describes an elderly female without significant immunosuppression who was diagnosed with a particularly unusual, relatively painless presentation of varicella zoster. This case showed a rare pattern of involvement across multiple cervical dermatomes, with an even rarer extension into the V3 trigeminal dermatome.
In preparation for this report, a review of existing literature was conducted and summarized (Table 1). Parameters included relatively immunocompetent status, zoster impacting multiple dermatomes, and presentation within the past 30 years. This review revealed evidence of eleven documented cases reporting multi-dermatomal zoster in immunocompetent individuals. Of those, five included both trigeminal and cervical dermatomes. Multi-dermatomal involvement, particularly between both cervical and trigeminal dermatomes, is a particularly rare presentation in an immunocompetent individual such as this patient. Other notable factors about this case include the relative lack of pain reported. A constant, burning, neuralgic pain, with or without lesions, is considered a characteristic presenting symptom of shingles, however an estimated 10%-20% of cases may be painless.1 While the patient did endorse discomfort with the palpation or disruption of vesicles, this pain mechanism appears to be related to the presence of open, inflamed skin rather than the severe neuropathic pain that which is characteristic of shingles.
In examining this case, we reviewed cases suggesting the etiology of multi-dermatomal spread of rare cases of shingles. One report from Jung et al (2023) described an immunocompetent 35-year-old female with herpes zoster involving right CN V3 and C3. This presentation was complicated by rotatory vertigo and right sided hearing loss with tinnitus that resolved with antiviral treatment, and was reported as the first reported case with these involvements. In our case, while the dermatological evidence of spread to V3 was apparent, no facial auditory, or visual deficits were noted. The authors stipulated that the spread of zoster could be attributed to the convergence of the afferent sensory fibers of CN V and C2 in the trigeminocervical nucleus.8 This theory may also be supported by the shorter lengths of sensory nerves in the cervical and trigeminal regions, however nerve length would not explain involvement of thoracic dermatomes in two of the discussed cases. Other proposed mechanisms include the cutaneous transfer of infectious virions across peripheral nerves. Considering the highly infectious nature of active zoster vesicles, this theory seems plausible, however it does not explain the unilateral distribution of most multi-dermatomal cases.
Future studies may further examine the timeline and directionality of multi-dermatomal shingles. While this case describes the lesions as having started in the C3 dermatome, the majority of cases did not report the starting point of the lesions. This poor timeline may be due to patient presentation occurring after multi-dermatomal spread had already occurred. This case highlights the importance of considering herpes zoster as an early and treatable differential diagnosis in elderly patients with atypical presentations.
Verbal and written consent from the patient for publication of this case was obtained by the author.
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My article, titled 'No Way Out of the Smartphone Epidemic Without Considering the Insights of Brain Research,' has been republished in the International Journal of Clinical Case Reports and Reviews. The review process was seamless and professional, with the editors being both friendly and supportive. I am deeply grateful for their efforts.
To Dear Erin Aust – Editorial Coordinator of Journal of General Medicine and Clinical Practice! I declare that I am absolutely satisfied with your work carried out with great competence in following the manuscript during the various stages from its receipt, during the revision process to the final acceptance for publication. Thank Prof. Elvira Farina
Dear Jessica, and the super professional team of the ‘Clinical Cardiology and Cardiovascular Interventions’ I am sincerely grateful to the coordinated work of the journal team for the no problem with the submission of my manuscript: “Cardiometabolic Disorders in A Pregnant Woman with Severe Preeclampsia on the Background of Morbid Obesity (Case Report).” The review process by 5 experts was fast, and the comments were professional, which made it more specific and academic, and the process of publication and presentation of the article was excellent. I recommend that my colleagues publish articles in this journal, and I am interested in further scientific cooperation. Sincerely and best wishes, Dr. Oleg Golyanovskiy.
Dear Ashley Rosa, Editorial Coordinator of the journal - Psychology and Mental Health Care. " The process of obtaining publication of my article in the Psychology and Mental Health Journal was positive in all areas. The peer review process resulted in a number of valuable comments, the editorial process was collaborative and timely, and the quality of this journal has been quickly noticed, resulting in alternative journals contacting me to publish with them." Warm regards, Susan Anne Smith, PhD. Australian Breastfeeding Association.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. I appreciate the journal (JCCI) editorial office support, the entire team leads were always ready to help, not only on technical front but also on thorough process. Also, I should thank dear reviewers’ attention to detail and creative approach to teach me and bring new insights by their comments. Surely, more discussions and introduction of other hemodynamic devices would provide better prevention and management of shock states. Your efforts and dedication in presenting educational materials in this journal are commendable. Best wishes from, Farahnaz Fallahian.
Dear Maria Emerson, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. I am delighted to have published our manuscript, "Acute Colonic Pseudo-Obstruction (ACPO): A rare but serious complication following caesarean section." I want to thank the editorial team, especially Maria Emerson, for their prompt review of the manuscript, quick responses to queries, and overall support. Yours sincerely Dr. Victor Olagundoye.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews. Many thanks for publishing this manuscript after I lost confidence the editors were most helpful, more than other journals Best wishes from, Susan Anne Smith, PhD. Australian Breastfeeding Association.
Dear Agrippa Hilda, Editorial Coordinator, Journal of Neuroscience and Neurological Surgery. The entire process including article submission, review, revision, and publication was extremely easy. The journal editor was prompt and helpful, and the reviewers contributed to the quality of the paper. Thank you so much! Eric Nussbaum, MD
Dr Hala Al Shaikh This is to acknowledge that the peer review process for the article ’ A Novel Gnrh1 Gene Mutation in Four Omani Male Siblings, Presentation and Management ’ sent to the International Journal of Clinical Case Reports and Reviews was quick and smooth. The editorial office was prompt with easy communication.
Dear Erin Aust, Editorial Coordinator, Journal of General Medicine and Clinical Practice. We are pleased to share our experience with the “Journal of General Medicine and Clinical Practice”, following the successful publication of our article. The peer review process was thorough and constructive, helping to improve the clarity and quality of the manuscript. We are especially thankful to Ms. Erin Aust, the Editorial Coordinator, for her prompt communication and continuous support throughout the process. Her professionalism ensured a smooth and efficient publication experience. The journal upholds high editorial standards, and we highly recommend it to fellow researchers seeking a credible platform for their work. Best wishes By, Dr. Rakhi Mishra.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. The peer review process of the journal of Clinical Cardiology and Cardiovascular Interventions was excellent and fast, as was the support of the editorial office and the quality of the journal. Kind regards Walter F. Riesen Prof. Dr. Dr. h.c. Walter F. Riesen.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. Thank you for publishing our article, Exploring Clozapine's Efficacy in Managing Aggression: A Multiple Single-Case Study in Forensic Psychiatry in the international journal of clinical case reports and reviews. We found the peer review process very professional and efficient. The comments were constructive, and the whole process was efficient. On behalf of the co-authors, I would like to thank you for publishing this article. With regards, Dr. Jelle R. Lettinga.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, I would like to express my deep admiration for the exceptional professionalism demonstrated by your journal. I am thoroughly impressed by the speed of the editorial process, the substantive and insightful reviews, and the meticulous preparation of the manuscript for publication. Additionally, I greatly appreciate the courteous and immediate responses from your editorial office to all my inquiries. Best Regards, Dariusz Ziora
Dear Chrystine Mejia, Editorial Coordinator, Journal of Neurodegeneration and Neurorehabilitation, Auctores Publishing LLC, We would like to thank the editorial team for the smooth and high-quality communication leading up to the publication of our article in the Journal of Neurodegeneration and Neurorehabilitation. The reviewers have extensive knowledge in the field, and their relevant questions helped to add value to our publication. Kind regards, Dr. Ravi Shrivastava.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, Auctores Publishing LLC, USA Office: +1-(302)-520-2644. I would like to express my sincere appreciation for the efficient and professional handling of my case report by the ‘Journal of Clinical Case Reports and Studies’. The peer review process was not only fast but also highly constructive—the reviewers’ comments were clear, relevant, and greatly helped me improve the quality and clarity of my manuscript. I also received excellent support from the editorial office throughout the process. Communication was smooth and timely, and I felt well guided at every stage, from submission to publication. The overall quality and rigor of the journal are truly commendable. I am pleased to have published my work with Journal of Clinical Case Reports and Studies, and I look forward to future opportunities for collaboration. Sincerely, Aline Tollet, UCLouvain.
Dear Ms. Mayra Duenas, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews. “The International Journal of Clinical Case Reports and Reviews represented the “ideal house” to share with the research community a first experience with the use of the Simeox device for speech rehabilitation. High scientific reputation and attractive website communication were first determinants for the selection of this Journal, and the following submission process exceeded expectations: fast but highly professional peer review, great support by the editorial office, elegant graphic layout. Exactly what a dynamic research team - also composed by allied professionals - needs!" From, Chiara Beccaluva, PT - Italy.
Dear Maria Emerson, Editorial Coordinator, we have deeply appreciated the professionalism demonstrated by the International Journal of Clinical Case Reports and Reviews. The reviewers have extensive knowledge of our field and have been very efficient and fast in supporting the process. I am really looking forward to further collaboration. Thanks. Best regards, Dr. Claudio Ligresti
Dear Chrystine Mejia, Editorial Coordinator, Journal of Neurodegeneration and Neurorehabilitation. “The peer review process was efficient and constructive, and the editorial office provided excellent communication and support throughout. The journal ensures scientific rigor and high editorial standards, while also offering a smooth and timely publication process. We sincerely appreciate the work of the editorial team in facilitating the dissemination of innovative approaches such as the Bonori Method.” Best regards, Dr. Matteo Bonori.
I recommend without hesitation submitting relevant papers on medical decision making to the International Journal of Clinical Case Reports and Reviews. I am very grateful to the editorial staff. Maria Emerson was a pleasure to communicate with. The time from submission to publication was an extremely short 3 weeks. The editorial staff submitted the paper to three reviewers. Two of the reviewers commented positively on the value of publishing the paper. The editorial staff quickly recognized the third reviewer’s comments as an unjust attempt to reject the paper. I revised the paper as recommended by the first two reviewers.
Dear Maria Emerson, Editorial Coordinator, Journal of Clinical Research and Reports. Thank you for publishing our case report: "Clinical Case of Effective Fetal Stem Cells Treatment in a Patient with Autism Spectrum Disorder" within the "Journal of Clinical Research and Reports" being submitted by the team of EmCell doctors from Kyiv, Ukraine. We much appreciate a professional and transparent peer-review process from Auctores. All research Doctors are so grateful to your Editorial Office and Auctores Publishing support! I amiably wish our article publication maintained a top quality of your International Scientific Journal. My best wishes for a prosperity of the Journal of Clinical Research and Reports. Hope our scientific relationship and cooperation will remain long lasting. Thank you very much indeed. Kind regards, Dr. Andriy Sinelnyk Cell Therapy Center EmCell
