The great mimicker: zona zoster at the mastectomy site causing contralateral intramammary lymph node enlargement

Zona zoster is rarely observed in patients with malignancy; when present, it follows a dermatomal fashion. Involvement of widely separated regions is very rare. Hereby, zona zoster causing enlarged intramammary lymph nodes (IMLN) in the opposite breast is reported for the first time in literature. The masses were hypoechoic on US with no hilum and hypervascular on color Doppler US. MRI showed hypointense masses with type 3 time-intensity curve and adjacent vessel sign. The complete regression of the nodes after the antiviral therapy confirmed the diagnosis. In breast cancer patients, IMLN enlargements may mimic breast cancer metastasis, and zona zoster infection of the mastectomy site may present with contralateral IMLN enlargement due to altered lymphatic drainage. When breast US is not sufficient for the differential diagnosis, breast MRI may warrant proper diagnosis, and prevent unnecessary biopsies. Antiviral treatment with followup would be sufficient for management.