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CASE REPORT Identity of patient Name Sex Registration number Age A ress !

#one number 'xamination ate History The Chief Complain ays ago History of present illness: !atients +resent ,it# )om+laine t#at ,as +im+le )ontents ,it# li-ui arise at #er ba)" an rig#t )#est sin)e 3 ays ago. !atients also .eel it)#y/ sore an +ain.ul in0uries su)# as burns. At .irst/ +atient )om+laine #a1e #ea a)#e/ .atigue an #er bo y .eels ,arm/ t#en a++ear re is# an .lui -.ille s+ot t#at .eels it)#y an sore % ays later at #er ba)" an s+rea to #er rig#t )#est. History of previous illness: !atient ne1er )om+laine li"e t#is be.ore. S#e e1er got 1ari)ella ,#en s#e ,as 2 years ol . History of Family disease : None o. #er .amily #a t#is "in o. isease History of Treatment: !atient #a Caladine +o, er. : !im+le )ontents ,it# li-ui ,it# +ain in t#e )#est rig#t u+ be#in #er ba)" sin)e 3 : Ms. CR : Female : 90-50-33 : 40 years ol : !anteri" : 0$%3&54%$$9$ : ()tober $t# %0*3

History of Social Habits: !atient #a a lot o. a)ti1ity 5 ays be.ore a mission. Physical Examination 3ital Sign Dermatological status : Not )#e)"e : At region t#ora)#alis extra et anterior an +osterior.

.oun grou+ 1esi)les on an eryt#ematous base/ 4osteri.orm arrangement/ some lesion are )on.luens an t#ere is normal s"in among t#e lesion/ milier to lenti"uler si4e/ an unilateral istribution.

Figure *. First 1isit at ()tober $t# / %0*3. 6rou+ 1esi)les on an eryt#ematous base ,it# lesion in t#e le.t 73 ermatomes le.t si e t#orax. A. 8esion on rig#t si e an +osterior t#orax. 5. 8esion on anterior t#orax. Clinical Test No )lini)al test a1ailable Differential Diagnosis *. 9er+es :oster %. ;ermatitis 9er+eti.ormis 3. ;ermatitis 3enenata 4. <m+etigo 5ulosa Planning Diagnosis 74an" smear/ but not )#e)"e . <. t#is t4an" test being )#e)"e multinu)leate giant )ell ,ill be .oun in mi)ros)o+i) examination. 6 a result is a

Diagnosis 9er+es :oster t#ora)#alis extra Treatment Systemic Medication : Anti1iral : A)y)lo1ir 5 x $00 mg =.or 2 ays> Analgeti) : Me.enami) a)i % x 500 mg =.or 3 ays> Topical Medication : A++ly sali)il tal) %? o1er t#e lesions are ry Asam .usi at )ream 3-5 x @ ay in eru+te lesions Education *. ;o not tou)# or s)rat)# o1er t#e lesions. %. 7a"e a rest an onAt o a lot o. a)ti1ity uring * ,ee" 3. ;onAt a.rai i. t#e lesion a++ear more t#an be.ore/ be)ause t#e a)ti1e +#ase o. t#e in.e)tion t#at ,ill be least in * ,ee". 4. A.ter * ,ee" lesion ,ill be )ruste an #eals normally an sometimes ,ill get a +ain an burn sensation o1er t#e lesion 5. 7a"e a me i)ine routinely as +res)ribe . Prognosis Buo A 3itam Buo A Fun)tionam Buo A Sana)tionam : ;ubia at bonam : ;ubia at bonam : ;ubia at bonam

Se)on 1isit at ()tober %*t#/ %0*3 ;ermatologi) status : At region t#ora)alis anterior an )o1ere ,it# )rust/ multi+le/ 4osteri.orm arrangement an +osterior .oun ru+ture 1esi)les on eryt#ematous base an #y+o+igmentation at some lesion/ some lesion also istribute unilaterally.

Figure %. !#oto ta"en at ()tober %*t#/ %0*3 a.ter ta"ing A)y)lo1ir/ lesion seeme to be re u)e an im+ro1ing/ 1esi)les ru+tere / lea1ing some )rust an #y+o+igmentation s)ar.

DISC SSIO! 9er+es 4oster is a )ammon )on ition t#at signi.i)antly a..e)t #ealt#-relate -uality o. li.e. 7#e ma0ority o. )ases o))ur in immuno)om+etent in i1i uals ol er t#an &0 years/ #o,e1er immunosu++resese +atients are at +arti)ulary #ig# rise. &/2 3:3 is a ;NA #er+es1irus/ ,#i)# in.e)ts sus)e+tible in i1i uals t#roug# airborne transmission. 7#e 1irus enters t#e bo y t#roug# )onta)t ,it# mu)ous membranes/ ,#ere it re+li)ates an isseminates 1ia t#e bloo an lym+#ati)s. 7#e 1irus in)ubates an re+li)ates .or a++roximately % ,ee"s/ at ,#i)# time it o1er,#elms t#e #ost immune res+onse/ an t#e isseminate 1esi)ular ras# o. )#i)"en +ox e1elo+s. $ ;uring t#e )ourse o. 1ari)ella/ t#e 3:3 in.e)ts t#e sensory ner1e en ings an tra1els along t#e axons/ e1entually establis#ing li.etime laten)y in t#e orsal root ganglia. Rea)ti1ation o))urs ,#en 1ari)ella 4oster s+e)i.i) )ellular immunity e)lines an )an no longer )ontain t#e 1irus/ an re+li)ation begins. 7#is +ro)ess is .ollo,e by se1ere in.lammation an #emorr#agi) ne)rosis o. ner1e )ells. 7#e 1ari)ella 1irus tra1els o,n t#e sensory ner1e/ usually )ausing intense neuritis/ an e1entually rea)#es t#e s"in ,#ere it +ro u)es a 1esi)ular ras#. 7#e ras# o. #er+es 4oster o))urs most o.ten in t#e .irst =o+#t#almi)> ensity.9 7#e ras# o. #er+es 4oster starts ,it# eryt#ematous ma)ules or +a+ules e1elo+ing into grou+e 1esi)ular lesions or bullae in a ermatomal istribution. (1er t#e )ourse o. 2 to *0 ays/ t#e lesions e1elo+ into +ustules an e1entually )rust o1er. <. a +atient )ontinues to e1elo+ ne, lesions a.ter about * ,ee"/ t#e +ossibility o. immuno e.i)ien)y s#oul be ex+lore .*/4 :oster in1ol1ing mu)ous membranes is o.ten o1erloo"e be)ause t#e .ragile e+i ermis in t#ese areas may not allo, .or t#e e1elo+ment o. 1esi)les but rat#er/ s#allo, ul)erations. (n)e a lesion is )ruste o1er/ it is no longer )onsi ere in.e)tious. Com+lete #ealing may ta"e u+ to 4 ,ee"s/ an +ostin.lammatory #y+o+igmentation or #y+er+igmentation may +ersist .or mont#s to years. <n most )ases s#ingles is unilateral in lo)ation/ an oes not )ross t#e mi line. 8esions t#at e1elo+ on t#e ba)" may )ross t#e mi line an still in1ol1e only one ermatome/ o,ing to t#e anatomy o. t#e s+inal ner1es. A small me ial bran)# arising .rom t#e +osterior +rimary ramus o. ea)# s+inal ner1e )rosses a .e, )entimeters +ast t#e mi line.9 :oster generally in1ol1es a single ermatome o. a single sensory 6 i1ision =3*> o. t#e trigeminal ner1e an .rom 7* to 8%/ be)ause t#ese are t#e ermatomes in ,#i)# t#e ras# o. 1ari)ella a)#ie1es t#e #ig#est

ganglionC #o,e1er/ in %0? o. )ases a 0a)ent ermatomes may be in1ol1e . *0 Some +atients ,ill ex+erien)e a .e, s)attere 1esi)les lo)ate at some istan)e .rom t#e in1ol1e ermatome. 7#e most )ommon sites .or s#ingles are t#e t#ora)i) ner1es an t#e o+#t#almi) i1ision =3*> o. t#e trigeminal ner1e.$ Fe,er t#an %0? o. +atients #a1e signi.i)ant systemi) sym+toms/ su)# as .e1er/ #ea a)#e/ malaise/ or .atigue. ** <mmuno)om+romise +atients are at ris" o. e1elo+ing isseminate 4oster/ ,#i)# o.ten +resents ,it# a generali4e istin)t ermatomes an istribution o. 1esi)ular lesions a..e)ting se1eral .re-uently )rossing t#e mi line. '1aluation .or 1is)eral

in1ol1ement in)lu ing #e+atitis/ +neumonitis/ an )erebritis is im+ortant. (.ten t#ese 1is)eral mani.estations )an o))ur in t#e absen)e o. s"in lesions or ,it# late e1elo+ment o. blisters/ ,#i)# )an lea to elaye ,it# most eat#s attributable to +neumonia.*0 iagnosis an treatment. Re)ogni4ing isseminate 4oster is im+ortant be)ause t#e mortality is 5? to *5? in t#ese +atients/

Figure 3. !#atogenesis o. #er+es 4oster*0 <n more t#an 25? o. +atients/ t#e ras# o. 4oster is generally +re)e e by a +erio o. +ain in t#e ermatome ,#ere t#e ras# subse-uently a++ears.*2 7#e +ain #as been es)ribe as ee+ Dburning/E Dt#robbing/E Dstabbing/E or Ds#o)"-li"e.E%0 !ain may be )onstant or only +resent ,#en tou)#e . Sensiti1ity to tou)# =+arest#esia>/ exagger- ate res+onse to stimuli =#y+erest#esia>/ or +ain +ro1o"e by ot#er,ise tri1ial stimuli =allo ynia> #a1e all been es)ribe . Re+eate stimulation lea ing to es)alating +ain =,in u+ +ain> )an also o))ur.% 6

7#e )on)e+t o. D4oster sine #er+ete/E ,#i)# is

e.ine

as

ermatomal

istribution o. +ain ,it#out ante)e ent ras#/ #as also been raise . 4 '1aluations o. a .e, +atients ,it# ermatomal +ain ,it#out ras# #a1e emonstrate rising titers o. 3:3-s+e)i.i) antibo y in )erebros+inal .lui =CSF> an serum along ,it# ;NA in CSF an mononu- )lear )ells in +eri+#eral bloo ete)table by +olymerase )#ain rea)tion =!CR>. F#et#er 4oster sine #er+ete is a true )lini)al entity is still u+ .or ebate/ an ane) otal re+orts o. res+onse to anti1iral t#era+y are in)onsistent. 5 A +rolonge +ro rome or t#e absen)e o. ras# in t#e setting o. +ain is sub0e)t to a ,i e array o. mis iagnoses/ in)lu ing/ .or exam+le/ myo)ar ial in.ar)tion/ +leurisy/ )#ole)ystitis/ a++en i)itis/ uo enal ul)er/ o1arian )yst/ #erniate inter1ertebral is)/ an renal )oli)/ e+en ing on t#e ermatome in1ol1e .% 7#e longer t#e uration o. +ain be.ore t#e e1elo+ment o. ras#/ t#e more li"ely ot#er )auses ,ill be ex+lore / not only lea ing to elays in treatment but o.ten resulting in t#e im+lementation o. un- ne)essary an )ostly me i)al ex+enses. Gntil re)ently it ,as belie1e t#at re)urrent e+iso es o. 4oster generally o))urre in immuno)om+romise +atients only. An arti)le by Yawn and colleagues emonstrate #ig#er rates o. 4oster re)urren)e in immuno)om+etent an immuno)om+romise +atients t#an ,as +re1iously ex+e)te . <n t#is )o#ort stu y o. *&&9 +atients ,it# a +re1ious #istory o. #er+es 4oster/ t#e re)urren)e rate o. &.%? at $ years ,as e-ual to t#e in)i en)e o. a .irst e+iso e. 'ig#ty-.i1e +er)ent o. re)urren)es o))urre in immuno)om+etent +atientsC #o,e1er/ immuno)om+romise +atients/ ,omen ol er t#an 50 years at t#e time o. .irst in.e)tion/ an +ain lasting longer t#an 30 ays at .irst in.e)tion +re i)te a #ig#er li"eli#oo .or re)urren)e. 7#is in.ormation is im+ortant be)ause +ra)titioners o.ten remo1e #er+es 4oster .rom t#eir i..erential iagnosis in #ealt#y +atients ,it# unilateral +ain )om+laints i. t#ey re+ort a +re1ious #istory o. s#ingles. 7#ese ne, ata )onstitute a remin er to )onsi er re)urrent 4oster regar less o. immune status. A))or ing to t#e )ase/ +atient e1er .elt #er bo y be)oming .atigue an also get .e1er .or a .e, ay t#at in i)ate +ro romal state o. #er+es 4oster )lini)al .eatures. S#e also ex+erien)e #ea a)#e/ +ain an it)#y on t#e lesion. 7#is )on ition +resumably be)ause o. +atient #a a lot o. a)ti1ity an be)ome ,ea" in last t#ree ays. 7#e ras# o. #er+es 4oster o.ten +re)e e by tingling/ it)#ing/ or +ain =or a )ombination o. t#ese> .or % to 3 ays/ an t#ese sym+toms )an be )ontinuous or e+ iso i). 7#e ras# begins as ma)ules an +a+ules/ ,#i)# e1ol1e into 1esi)les an t#en +ustules. Ne, lesions a++ear o1er a +erio o. 3 to 5 ays/ o.ten ,it# .illing in o. t#e 6

ermatome es+ite anti1iral treatment. 7#e ras# usually ries ,it# )rusting in 2 to *0 ays. C#ara)teristi)s o. +ain asso)iate ,it# #er+es 4oster 1ary. !atients may #a1e +arest#esias =e.g./ burning an tingling>/ ysest#esia =altere or +ain.ul sensiti1ity to tou)#>/ allo ynia =+ain asso)iate ,it# non+ain.ul stimuli>/ or #y+erest#esia =exaggerate or +rolonge res+onse to +ain>. !ruritus is also )ommonly asso)iate ,it# #er+es 4oster.5 5ase on t#is )onsi eration +atient also .eel +ain/ .e1er/ an malaise o))ur be.ore eryt#ematous +a+ules e1elo+ in t#e area o. t#e a..e)te ermatome. 7#e 1esi)les e1elo+ o1er se1eral ays/ )rusting o1er as 2 ay an ne, lesion ,as a++ear at least 3 ays a.ter +re1ious lesion. <t be)ause t#e in)ubation +erio o. #er+es 4oster is 2-*0 ays&. 7#e ras# o. #er+es 4oster is ermatomal an oes not )ross t#e mi line/ a .eature t#at is )onsistent ,it# rea)ti1ation .rom a single orsal-root or )ranial-ner1e ganglion. 7#e t#ora)i) =53?>/ )er1i)al =%0?>/ trigeminal =*5?> an lumbar=**?> ermatomes are t#e most .re-uent sites o. ras#/ alt#oug# any area o. t#e s"in )an be in1ol1e . <n non immuno)om+romise +ersons/ a .e, s)attere lesions outsi e t#e a..e)te ermatome are not unex+e)te . 2/*0 5ase on t#e )ase/ t#e lesions a++ear on ermatomes in #er+es t#e le.t si e o. t#orax ,#i)# re.ers to 73 an in t#e le.t arm ,#i)# re.ers to 7% ermatomes t#at )om+lian)e as t#e most )ommonly in1ol1e 4oster.

Figure 4. ;ermatomes in1ol1e in #er+es 4oster*0 5y its )lasi))al mani.estation/ t#e signs an sym+toms o. 4oster are usually istin)ti1e enoug# to ma"e an a))urate )lini)al iagnosis on)e t#e ras# #as a++eare . 5 t#us/ +atient on t#is )ase is iagnose ,it# #er+es 4oster at region t#ora)alis sinistra in t#e le.t 73 ermatomes. 7#e goal o. treatment .or #er+es 4oster is to s#orten an lessen t#e )lini)al )ourse an +ossibly e)rease )om+li)ations .rom t#e isease. 7#ere is e1i en)e t#at treatment ,it# t#e antiretro1irals a)y)lo1ir =$00 mg 5 times+er ay .or 2 ays>/ .am)i)lo1ir =250 mg on)e aily .or 2 ays>/ an 1ala)y)lo1ir lessens a)ute neuritis an #astens #ealing o. t#e ras#. (+timal uration o. treatment is 2 aysC t#ere a++ears to be no bene.it .or +rolonge )ourses o. treatment. *% (ne #ea -to-#ea trial o. 1ala)y)lo1ir an a)y)lo1ir s#o,e -ui)"er #ealing in t#e 1ala)y)lo1ir-treate arm. 4 7#era+y s#oul be initiate ,it#in 2% #ours o. t#e onset o. lesions. 7#e osing regimen .or a)y)lo1ir ma"es it a i..i)ult rug to use )lini)ally.

Anti1iral t#era+y is t#e )ornerstone in t#e management o. #er+es 4oster. Sin)e anti1iral t#era+y oes not re u)e t#e rate o. 4osterasso)iate +ain/ )lini)ians may un era++re)iate t#e tremen ous bene.it t#ese anti1iral +ain9. 7#e +rognosis o. #er+es 4oster in t#is )ase is ubia at bonam. 9er+es 4oster may be atten e by neurologi) )om+li)ations o. ,#i)# !9N =!ost 9er+eti) Neuralgia> is t#e most )ommon an im+ortant. !atiens ,it# !9N may su..er .rom )onstant +ain = es)ribe as burning/ a)#ing/ t#robbing>/ intermittent +ain = stabing/ s#ooting>/ or stimulus-e1o"e +ain/ in)lu ing allo ynia =ten er/ burning/ stabbing>. !9N #as been 1ariably e.ine as any +ain a.ter #ealing or any +ain * mont#/ 3 mont#s/ 4 mont#s or & mont#s a.ter ras# onset/ ,it# most re)ent e.initions .o)using on 90 to *%0 a.ter ras# onset. Age is t#e most signi.i)ant ris" .a)tor .or !9N. Clini)ally signi.i)ant +ain lasting 3 mont#s or more is rare in immuno)om+etent +ersons younger t#an 50 years o. age&. 5ase on t#is )ase/ +atient also onAt #a1e !9N ,#i)# is in1ol1e by ol er age t#an younger. Most +eo+le re)o1er )om+letely .rom an a)ute e+iso e ,it# no +ain an s"in )olor returns to normal. 9er+es 4oster )omes ba)" in only about %? o. +eo+le/ but in u+ %0 ? o. +eo+le ,it# 9<3 A<;S. 8ong term )om+li)ations su)# as +ost-#er+eti) neuralgia/ may )ontinue .or mont#s an many years. 7#e isease also may )ause 1arying egrees o. s"in is)oloration/ +rimarily ar"ening. rugs +ro1i e. 7#e main bene.it o. t#era+y is in re u)tion o. t#e uration an se1erity o. 4osterasso)iate

Second "isit at Octo#er $%th& $'%( ;ermatologi) status : at region t#ora)alis anterior an )o1ere ,it# )rust/ multi+le/ 4osteri.orm arrangement an +osterior .oun ru+ture 1esi)les on eryt#ematous base an #y+o+igmentation at some lesion/ some lesion also istribute unilaterally.

Figure 3. !#oto ta"en at ()tober %*t#/ %0*3 a.ter ta"ing A)y)lo1ir/ lesion seeme to be re u)e an im+ro1ing/ 1esi)les ru+tere / lea1ing some )rust an #y+o+igmentation s)ar.

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