|Year : 2015 | Volume
| Issue : 6 | Page : 769-771
Herpes zoster infection: Report of a treated case
Kotya Naik Maloth1, K Vinay Kumar Reddy1, Srikanth Kodangal1, Kesidi Sunitha1, Nagajyothi Meka2
1 Department of Oral Medicine and Radiology, Mamata Dental College and Hospital, Khammam, Telangana, India
2 Department of Oral Medicine and Radiology, Dr. Hedgewar Smruti Runga Seva Mandals Dental College and Hospital, Hingoli, Maharashtra, India
|Date of Web Publication||19-Nov-2015|
Kotya Naik Maloth
Assistant Professor, Department of Oral Medicine and Radiology, Mamata Dental College and Hospital, Giriprasad Nagar, Khammam - 507 002, Telangana
Source of Support: None, Conflict of Interest: None
Herpes zoster (HZ) is an acute infectious viral disease result from reactivation of the DNA varicella-zoster virus, which occurs more frequently among older adults and immunocompromised persons. The most common complication of HZ is postherpetic neuralgia, a chronic often debilitating pain condition that can last months or even years. Deaths attributable to zoster are common among immunocompromised persons. Prompt treatment with the antiviral drugs, corticosteroids and analgesics decrease the severity and duration of acute pain from HZ. Here, we report a treated case of HZ in 35-year-old male involving all three branches of the trigeminal nerve without any complication.
Keywords: Acyclovir, herpes zoster, postherpetic neuralgia, trigeminal nerve, varicella-zoster
|How to cite this article:|
Maloth KN, Reddy K V, Kodangal S, Sunitha K, Meka N. Herpes zoster infection: Report of a treated case. Med J DY Patil Univ 2015;8:769-71
|How to cite this URL:|
Maloth KN, Reddy K V, Kodangal S, Sunitha K, Meka N. Herpes zoster infection: Report of a treated case. Med J DY Patil Univ [serial online] 2015 [cited 2020 Nov 27];8:769-71. Available from: https://www.mjdrdypu.org/text.asp?2015/8/6/769/169922
| Introduction|| |
Herpes zoster (HZ) also known as "Shingles" is an acute infectious viral disease result from reactivation of the DNA varicella-zoster virus (VZV), which causes chickenpox.  It manifests as painful vesicular eruptions of the skin or mucous membrane in the area supplied by the affected nerve.  The pain may persist for months, even years after the muco-cutaneous lesions heal, and this phenomenon is known as postherpetic neuralgia (PHN), one of the most common complication of HZ. The most commonly affected dermatomes are the thoracic (45%), cervical (23%) and trigeminal (15%). HZ can affect any of the three trigeminal branches, most commonly affecting the ophthalmic branch. We report a treated case of 35-year-old male involving all three branches of the trigeminal nerve. 
| Case Report|| |
A 35-year-old male patient reported to our department with multiple vesicular eruptions containing a clear fluid on his left side of the face associated with severe pain along the affected area. Lesions were preceded by prodrome of fever and malaise for 5 days, followed by erythematous maculopapular rash. On examination, there were multiple pins headed active vesicular lesions on left side of the face involving the outer canthus region, zygoma region, the ear, the upper and lower lips and lower border of the face. Associated with pain, pruritus, burning tingling sensation over the involved areas [Figure 1]. Intraorally the labial mucosa of upper lip, lower lip, left buccal mucosa, retromolar area and the left side of the hard palate was also involved not crossing the midline showing a dermatomal pattern [Figure 2]. No previous history of similar lesions were reported, and patient was unaware of the occurrence of chickenpox in his childhood. Based on the history and clinical presentation of the lesions, a provisional diagnosis of HZ involving the left ophthalmic, maxillary and mandibular nerve, division of trigeminal (V) nerve was given.
Routine blood investigations along with HIV 1 and 2 antibody tests were performed, and the blood values were within normal limits and negative test result for HIV.
Antiviral therapy was instituted immediately with acyclovir −800 mg tablets 5 times a day for 10 days, cvir cream −5 mg applied 2 times a day. Corticosteroids are given in the form of prednisolone 20 mg twice a day for 10 days to prevent postcomplications like neuralgia-related disorders. For pain control, patient advised to take tramadol 50 mg tablets twice a day for 5 days. Betadine mouth wash was also given to improve oral hygiene, and topical lidocaine was prescribed for painful skin lesions. The patient was regularly reviewed.
On examination of the patient after 10 days, there was complete regression of the lesion extraorally with encrustations and intraorally with hypopigmented areas respectively [Figure 3] and [Figure 4]. No fresh vesicles were found. Patient was asked to taper the dose of corticosteroids gradually, and finally, the medications were stopped.
|Figure 3: Complete regression of the lesion extraoral with formation of scar tissue and hypopigmented areas|
Click here to view
| Discussion|| |
Herpes zoster is an acute infectious viral disease, and it is a sporadic disease with an estimated life time incidence of 10-20%, 15 times higher in HIV-infected than in uninfected patients and 25% of patients with Hodgkin's lymphoma develop HZ. Household transmission rates were approximately. 15%.  HZ is characterized by inflammation of dorsal root ganglia or extra-medullary cranial nerve ganglia, associated with vesicular eruptions of the skin or oral mucous membrane in the area supplied by the affected nerve.  The nerves most commonly affected in HZ are C 3 , T 5 , L 1 , L 2 and 1 st branch of the trigeminal nerve.  The incidence of HZ increases with age and in immunocompromised patients. The predisposing factors for reactivation of the virus are trauma, benign or malignant tumor involving the dorsal root ganglia, local X-ray irradiations and immunosuppressive therapy and immunosenescence. 
In our case, based on the history, the predisposing factor was found to be malnutrition with physical and psychological stress secondary to the economic status and poverty. Patient with HZ may progress through 3-stages, 
- Prodromal stage,
- Active or acute stage,
- Chronic stage.
The prodromal stage presents as sensations like burning, tingling, itching, pricking and boring occurring in the cutaneous distribution of the dermatome and is believed to represent viral degeneration of nerve fibrils.  If the trigeminal nerve is affected in this period odontalgia may occur. The symptoms of the prodromal stage may present up to 1-month or for more duration before the acute mucocutaneous lesions appear, posing diagnostic difficulties to the clinician. This is known as zoster-sine herpetic or zoster-sine eruption. 
The active stage is characterized by the emergence of the skin rash that may be accompanied by headache, malaise and low-grade fever. The rash progresses from erythematous and edematous papules to vesicles and finally results in the formation of pustules within 1-week which is the contagious period. The pustules begin to dry with crust formations, which will be exfoliated over 2-3 weeks, leaving erythematous macular lesions that result in scar formation.  During this phase, the HZ is most contagious and could pose a significant cross-infection risk.
The chronic pain syndrome stage is seen in approximately 10% of all patients with HZ and is termed as PHN. PHN is defined as a brief, recurrent, shooting, deep pain lasting 1-3 months after the healing of the muco-cutaneous lesions.  Risk of occurrence of PHN increases significantly after the age of 60 years, which may be due to a decline in cell-mediated immunity. 
The most common complication of HZ is PHN, but the other complications like neurologic components such as Guillian - Barre syndrome, encephalitis, myelitis, Ramsay-Hunt syndrome and ocular complications such as conjunctivitis, optic neuritis, corneal scarring or HZ opthalmicus and acute retinal necrosis. The oral complications are periapical lesions, root resorption, tooth exfoliation and alveolar osteonecrosis. ,
The addition of steroids to an antiviral regimen has not been proven to prevent PHN, but should be considered in patients with severe pain in order to reduce the duration of acute symptoms. Patients with HZ can transmit VZV to others through direct contact with draining skin lesions. Only people who have never had chickenpox are at risk, and the resulting illness is primary varicella infection (chickenpox).
Current treatment regimens directed against the prevention and control of the HZ and PHN includes the development of live attenuated vaccine against VZV, HZ vaccine (Zostavax; , Merck) was developed which was approved for use in Canada in 2008, which was going to be released into the market probably in 2015. It is contraindicated during pregnancy and is currently not recommended in HIV-infected individuals, although its safety in this population is under evaluation. Vaccination against VZV is currently recommended for the following susceptible adults (without a reliable history of chickenpox or a serologic test indicating immunity): Health care workers, those with close contact to immunocompromised individuals or young children, and women who could become pregnant. 
| Conclusion|| |
Herpes zoster infection leads to various complications if left untreated, oral physicians should have a thorough knowledge of this disease will help in early diagnosis, treatment and prevention of the complications having an edge on the regular updated treatment strategies in HZ.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
| References|| |
Mehta DN, Thakkar B, Asrani M. Herpes Zoster of orofacial region - A review. Natl J Integr Res Med 2013;4:112-6.
Arduino PG, Porter SR. Herpes Simplex Virus Type 1 infection: Overview on relevant clinico-pathological features. J Oral Pathol Med 2008;37:107-21.
Roxas M. Herpes zoster and postherpetic neuralgia: Diagnosis and therapeutic considerations. Altern Med Rev 2006;11:102-13.
Deshmukh R, Raut A, Sonone S, Pawar S, Bharude N, Umarkar A, et al
. Herpes Zoster (Hz): A fatal viral disease: A comperhensive review. Int J Pharm Chem Biol Sci 2012;2: 138-145.
Srikrishna K, Prabhat MP, Balmuri PK, Sudhakar S, Ramaraju D. Herpes Zoster: Report of a treated case with review of literature. J Indian Acad Oral Med Radiol 2012;24:51-5.
Thomas SL, Hall AJ. What does epidemiology tell us about risk factors for herpes zoster? Lancet Infect Dis 2004;4:26-33.
Opstelten W, van Loon AM, Schuller M, van Wijck AJ, van Essen GA, Moons KG, et al.
Clinical diagnosis of herpes zoster in family practice. Ann Fam Med 2007;5:305-9.
Weinberg JM. Herpes zoster: Epidemiology, natural history, and common complications. J Am Acad Dermatol 2007;57:S130-5. Shaikh S, Ta CN. Evaluation and management of herpes zoster ophthalmicus. Am Fam Physician 2002;66:1723-30.
Schmader KE, Levin MJ, Gnann JW Jr, McNeil SA, Vesikari T, Betts RF, et al.
Efficacy, safety, and tolerability of herpes zoster vaccine in persons aged 50-59 years. Clin Infect Dis 2012;54:922-8.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]