Case Report

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Simultaneous herpes zoster rash in the upper extremity andinterscapular region that resembles innervation zone of the dorsal
ramus of the cervical nerve root: a case report
Hiroshi Nomura, Shigeharu Nomura
Nomura Orthopaedic Clinic, Yamaguchi, Japan
Correspondence to: Hiroshi Nomura, MD, PhD. Department of Orthopedic Surgery, Nomura Orthopedic Clinic, 4-8-1, Ayaragihon-machi,
Shimonoseki, Yamaguchi 751-0849, Japan. Email: hiroshi20052002@yahoo.co.jp.

Abstract: In daily medical practice, scapular pain associated with cervical radiculopathy is commonly seenprior to the onset of pain of the upper extremity; however, the cause of the scapular pain is uncertain. We
report a case of herpes zoster with simultaneous skin rash in both the upper extremity and interscapularregion, which corresponds to the painful scapular region in case of C8 cervical radiculopathy. A 71-yearold healthy woman complained of shoulder and scapular pain followed by a blistering skin rash on both theulnar side of her upper extremity and intrascapular region on the right side. She was diagnosed with herpes
zoster and was prescribed amenamevir as oral treatment with vidarabine ointment. After 1 year, she still had
mild causalgia on her III–V fingers and needed oral treatment with pregabalin. To our knowledge, this is
the first case report of a herpes zoster rash in the upper extremity and intrascapular region simultaneously.
We speculate that the rash in the two regions is caused by the varicella zoster virus (VZV) traveling fromthe same ganglion, probably the C8 ganglion, considering the dermatome of the rash area in the upper
extremity and the intrascapular region correspond to the innervation zone of the medial branches of thedorsal ramus of the cervical nerve root, which resembles the scapular region in case of cervical radiculopathy.
This phenomenon implies the mechanism of scapular pain is related to cervical radiculopathy. Further casereports are needed to confirm this.
Keywords: Herpes zoster; interscapular region; dorsal ramus of the cervical nerve root; cervical radiculopathy
Received: 03 January 2021; Accepted: 25 March 2021; Published: 25 July 2021.
doi: 10.21037/acr-21-1
View this article at: http://dx.doi.org/10.21037/acr-21-1

Introduction
Cervical radiculopathy is the clinical description of acondition in which a nerve root in the cervical spine
becomes inflamed or damaged, resulting in a changeof neurological function. Radiculopathy rarely occurs
from spontaneous neurogenic inflammation, and it iscommonly caused by compression of the cervical nerve
root by a substance from a herniated intervertebral disc or
arthritic bone spur in the cervical foramen by degenerative
alteration. It leads to radicular pain, sensational disturbance,and motor dysfunction along the nerve’s pathway into theupper extremity on the ipsilateral side, corresponding to adermatome pattern (1). In addition, neck or scapular pain

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is commonly seen before the onset of pain in the upper
extremity during cervical radiculopathy (2,3). Although aprevious article reported cervical nerve root involvementin cervical radiculopathy as the origin of neck or scapular
pain, the cause of the pain had been uncertain (4). The
aim of this report is to present a case of herpes zoster
with simultaneous skin rash in the upper extremity andinterscapular region. To the best of our knowledge, thisis the first report to visualize the innervation zone of themedial branches of the dorsal ramus of the cervical nerve
root on the scapula, which corresponds to the painfulscapular region in cases of cervical radiculopathy.
We present the following case in accordance with theAME Case Rep 2021;5:25 | http://dx.doi.org/10.21037/acr-21-1

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AME Case Reports, 2021

Figure 1 A 71-year-old woman showed blistering skin rash in the ulnar side of her upper extremity (left and center) and interscapular region(right) on the right side simultaneously.

CARE reporting checklist (available at http://dx.doi.
org/10.21037/acr-21-1).
Case presentation
A 71-year-old healthy woman presented to our clinicwith sudden shoulder pain on the right side without any
traumatic episodes. She had no major medical history, andno immunodeficiencies were noted. On initial physicalexamination, she had motion pain and stiffness on theright shoulder, the painful arc test was positive at 90°
of abduction, and the Hawkins sign was positive (5).
Radiological examination showed no abnormality of theshoulder, and on the basis of these findings, non-calcifictendonitis of the rotator cuff was first suggested, and thenshe was treated with triamcinolone acetonide injection into
the subarachnoid space. She was transiently relieved fromthe shoulder pain for 3 days, and afterward, she repeatedlysuffered from shoulder and scapular pain associated withneuralgia in the upper extremity on the right side. On thesecond physical examination, Jackson’s test and Spurling’s
test showed positivity for scapular pain and neuralgia, which
was similar to the symptom of cervical radiculopathy (1). Atthe same time, she had a blistering skin rash on the ulnarside of her upper extremity and interscapular region on theright side (Figure 1). She was referred to a dermatologist,
who diagnosed this rash as herpes zoster and prescribed oral
amenamevir and topical vidarabine ointment for 7 days. Herneuralgia continued after the disappearance of the skin rashand oral treatment with 300 mg/day pregabalin for 14 days,
and she was treated by a pain physician. After 1 year, she
presented with mild postherpetic neuralgia of the 3rd to
5th fingers of the right hand and required 75 mg/day oral
pregabalin.
A copy of the written consent is available for review© AME Case Reports. All rights reserved.

by the Editor-in-Chief of the journal. All procedures
performed in studies involving human participants were inaccordance with the ethical standards of the institutional
research committee and with the Helsinki Declaration (asrevised in 2013).
Discussion
Cervical radiculopathy is often accompanied by neck or
scapular pain on the backside (2,4). In 2006, Tanaka et al.
demonstrated a distinct clinical relationship between theregion of scapular pain and each study indicated a level ofthe involved nerve root in cervical radiculopathy (4). They
showed that scapular pain occurs in the suprascapular,interscapular, and scapular regions, which correspondto C5 or C6, C7 or 8, and C8 cervical radiculopathy,
respectively (Figure 2). Indeed, this report is so accuratethat the level of the compressed nerve root from the regionof the associated scapular pain in clinical situations totreat cervical radiculopathy is predictable. To clarify thecause of the scapular pain, Mizutamari et al. attempted
an anatomical study to reveal scapular pain secondary tocervical radiculopathy arising from the medial branches ofthe dorsal ramus of the individual spinal nerve roots (2).
They found that the C5 and C8 dorsal ramus changed toa cutaneous nerve, gradually descending inferolaterally
to the suprascapular region and to the middle of thescapular region, respectively; however, they found no C6or C7 dorsal ramus descending to the scapular region,and it seemed incomplete enough to confirm the distinct
mechanism of the scapular pain secondary to cervical
radiculopathy. In the current case, there was a blistering
skin rash of herpes zoster on the ulnar side of her upper
extremity and interscapular region. In case of herpes zoster
originating from the spinal dorsal root ganglia, reactivated

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C5 or C6

C7 or 8C8Figure 2 The Schema modified with the previous report byTanaka et al. in 2006 (4). Note that the scapular pain occurs in thesuprascapular, interscapular and scapular regions corresponding toC5 or C6, C7 or 8 and C8 cervical radiculopathy, respectively.

varicella zoster virus (VZV) typically travels from theindividual single ganglia along the sensory nerves to theskin, causing prodromal pain followed by eruption of therash (6), as there is no anatomical communication among
the ganglia in the spine. It seems that the rash in the upper
extremity and interscapular region is caused by VZVtraveling from the same ganglion, probably from the C8ganglion, considering the dermatome of the rash region
in the upper extremity corresponds to the scapular region
related to C7 or C8 cervical radiculopathy, as illustrated
by Tanaka et al. in 2006 (4). There is little possibility ofa rash in the interscapular region originating from thethoracic spinal root ganglion because the rash pattern is not
linear along the intercostal nerve. Thus, our findings areimportant for visualizing the innervation zone of the medial
branches of the dorsal ramus of the C8 cervical nerve rooton the scapula, implying that scapular pain occurs in casesof cervical radiculopathy.
Skin rash due to reactivation of herpes zoster iscommonly seen in the thoracic dermatomes and cranialnerves, and it is relatively rare in cervical dermatomes (7-11).
There are a few case reports of herpes zoster in theupper extremity, particularly in ulnar nerve distribution(7,9-11), which are similar to our case; however, to ourknowledge, no study has reported a rash in the simultaneous© AME Case Reports. All rights reserved.

interscapular region. One possibility is that no clinician canimagine skin rash in the scapular region and ulnar nerve
innervation in the upper extremity originating from thesame ganglion of the cervical spine because of the large
distance between the two regions. Another possibility isthat VZV traveling along the medial branches of the dorsal
ramus of the cervical nerve root causing skin rash in theinterscapular region itself is extraordinary; thus, our case is
the first report on this phenomenon.
In the current case, amenamevir is used for the treatmentof herpes zoster. Amenamevir, a herpesvirus helicaseprimase inhibitor, has been used for the treatment of herpes
zoster in Japan since 2017 (12). It has a different action
mechanism from previously approved synthetic nucleosidecompounds for the treatment of herpes zoster, including
acyclovir, valacyclovir, and famciclovir. The usual adultdose is 400 mg amenamevir p.o. once daily for 7 days. The
benefit is its ability to cure herpes zoster as well as prevent
postherpetic neuralgia (12); however, in the current case,the patient still had mild postherpetic neuralgia after 1 year,
and she still needed oral pregabalin treatment.
In conclusion, a case of herpes zoster with simultaneous
skin rash in the upper extremity and interscapular region
was reported. The interscapular region illustrated by theskin rash corresponded to the innervation zone of themedial branches of the dorsal ramus of the cervical nerveroot, which resembled the scapular region in the case of C8
cervical radiculopathy. However, further case reports arerequired to confirm this unique phenomenon.
Acknowledgments
Funding: None.
Footnote
Reporting Checklist: The authors have completed the CARE
reporting checklist. Available at http://dx.doi.org/10.21037/
acr-21-1
Peer Review File: Available at http://dx.doi.org/10.21037/
acr-21-1
Conflicts of Interest: Both authors have completed theICMJE uniform disclosure form (available at http://dx.doi.
org/10.21037/acr-21-1). Both authors have no conflicts ofinterest to declare.

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Ethical Statement: The authors are accountable for all
aspects of the work in ensuring that questions related
to the accuracy or integrity of any part of the work areappropriately investigated and resolved. Written informed
consent was obtained from the patient for publication ofthis case report and any accompanying images. A copy of
the written consent is available for review by the Editor-inChief of the journal. All procedures performed in studies
involving human participants were in accordance with theethical standards of the institutional research committee
and with the Helsinki Declaration (as revised in 2013).
Open Access Statement: This is an Open Access article
distributed in accordance with the Creative Commons
Attribution-NonCommercial-NoDerivs 4.0 International
License (CC BY-NC-ND 4.0), which permits the noncommercial replication and distribution of the article withthe strict proviso that no changes or edits are made and theoriginal work is properly cited (including links to both theformal publication through the relevant DOI and the license).
See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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doi: 10.21037/acr-21-1
Cite this article as: Nomura H, Nomura S. Simultaneous
herpes zoster rash in the upper extremity and interscapularregion that resembles innervation zone of the dorsal ramus of
the cervical nerve root: a case report. AME Case Rep 2021;5:25.

© AME Case Reports. All rights reserved.

AME Case Rep 2021;5:25 | http://dx.doi.org/10.21037/acr-21-1