Herpes Zoster

Supervised by: dr. Mimi Maulida, Sp.KK

Case Report

Presented by: Jamalul Adil

Dermato-Venereology Department Medical Faculty of Syiah Kuala University Dr. Zainoel Abidin General Hospital Banda Aceh

Introduction

Definition
Herpes zoster (HZ) or Shingles is a viral infection because the reactivated of the Varicella zoster virus (VZV), the same virus responsible for chickenpox. Localized disease characterized by unilateral radicular pain and a vesicular rash limited to the area of skin innervated by a single dorsal root or cranial sensory ganglion

Etiology

VZV structure is characterized by an icosahedral nucleocapsid surrounded by a lipid envelope. Doublestranded DNA is located at its center. The virus is approximately 150-200 nm in diameter and has a molecular weight of approximately 80 million.

The pathogenesis of herpes zoster according to Hope-Simpson, 1965.

Oxman M N J Am Osteopath Assoc 2009;109:S13-S17

Published by American Osteopathic Association

Pathophysiology

Dermatomes involved in Herpes Zoster

Diagnosis
Diagnosis of herpes zoster is usually clinical. Based on the history and physical examination of the patient. Laboratory confirmation is recommended for more atypical cases.

Management

Drug Therapy (Conventional Therapy)

Antiviral agents Corticosteroids Analgesics NSAIDs

Non-Drug (Natural Therapy)

Dietary/Multiple-Nutrient Effects Other Nutritional Considerations

Case Report

Identity of Patient
Name Sex Registration number Age Address Phone number Examination Date : IJ : Male : 0-89-89-77 : 53 years old : Ketapang : 08126939796 : December 6th 2012

History
The Chief Complaint : Vesicles on the left side of the thorax since 1 week before admission.

History of Present Illness

No past history of any headache

Reddish rash around his left thorax

Vesicles develops upon the erythematous base without any pain, itchy and burning sensation on the left side of the thorax since 1 week before admission.

Spread around his left back

Patient felt his body becomes weak and got fever for a few days.

History of Previous Illness: Patient never complained like this before. He ever got varicella when he was young. History of Family Disease: None of his family had this kind of disease.

History of Treatment : Patient had done chemotheraphy for final cycle due to lung neoplasm stage IV 2 months ago. History of Social Habits: Patient take a bath twice daily with good sanitary. Patient was a non-alcoholic, and already stop smoking for years.

First visit at December 6th, 2012. Group vesicles and bullous on an erythematous base with some lesion already crusted along the left T4-T7 dermatomes. A. Left side of thorax B. Left back.

Physical Examination
Dermatological status : a/r thoraxalis sinistra anterior et posterior found group vesicles and bullous on an erythematous base with some lesion already crusted, zosteriform arrangement, some lesion are confluens and there is normal skin among the lesion, lenticuler in size, and unilateral distribution along the left T4-T7 dermatomes.

Differential Diagnosis
1. Herpes Zoster at regio thoraxalis sinistra along the left T4-T7 dermatomes 2. Bullous Impetigo 3. Dermatitis Herpetiformis

Planning Diagnostic

Tzank smear

Microscopic finding of a multinucleated giant cell indicates the presence of a virus of the herpes family

Clinical Diagnosis

Herpes Zoster at regio thoxakalis sinistra along the left T4-T7 dermatomes

Treatment
Systemic Medication: Antiviral: Acyclovir 5 x 800 mg (for 7 days) Vitamin B Compleks 3x1 tablet Topical Medication: Apply compresses normal saline for the wet lesions or Salicylicum Acidum 2% for dry lesions If the lesions get erosion, apply sodium fusidate over the lesion.

Education
1. Do not touch or scratch and contaminate the lesions. 2. Keep the cutaneous lesions clean (soap and water) and dry to prevent secondary infections. 3. Wear loose-fitting clothing for improved comfort. 4. Rest well and eating foods with high calorie/high protein. 5. Avoid contact with susceptible infants or small children, susceptible pregnant women or potentially susceptible immunocompromised individuals.

Prognosis
Quo ad Vitam Quo Ad Functionam Quo ad Sanactionam :Dubia ad bonam :Dubia ad bonam :Dubia ad bonam

Discussion

Case
53-years-old male who had undergone chemotherapy presented to the hospital with chief complaint of vesicles develops upon the erythematous base without any pain, itchy and burn sensation on the left side of the thorax since 1 week before admission. Before the vesicles emerged, patient found reddish rash around his left thorax which becoming vesicles that slightly spread around his left back.

As mentioned in definition: Herpes zoster (HZ) or Shingles is a viral infection because the reactivated of the Varicella zoster virus (VZV), the same virus responsible for chickenpox. Localized disease characterized by unilateral radicular pain and a vesicular rash limited to the area of skin innervated by a single dorsal root or cranial sensory ganglion

 Herpes zoster often in association with declining cellular immunity associated with advancing age, certain diseases (such as HIV infection), or effects of immunosuppressive therapy. Herpes zoster occurs only occasionally before the age of 50 but most often after the age of 50.

 Immunosupressed patients have a 20 to 100 times greater risk of herpes zoster than immunocompetent individuals of the same age. Immunusuppressive conditions associated include human immunodeficiency virus (HIV) infection, bone marrow transplant, leukemia and lymphoma, use of cancer chemotherapy, and use of corticosteroids.

Case
Patient ever felt his body becoming more weak and he also got fever for a few day that indicate prodrome state of herpes zoster clinical features. However, he denied to experienced headache, photophobia and even pain or itchy.

 Herpes zoster usually begins with a prodrome, such as pain, itching or tingling in the area that becomes affected. Typically, patients experience headache, malaise and sometimes photophobia or fever. Abnormal sensation or pain, often described as burning, throbbing or stabbing, occurs in approximately 75% of patients and may be the first noticeable feature. Often pruritus in the affected region is the most prominent feature.

Patient ever felt his body becoming more weak and he also got fever for a few day that indicate prodrome state of herpes zoster clinical features. However, he denied to experienced headache, photophobia and even pain or itchy. This conditions presumably because of the adverse effect of chemotherapy. Patient had already done final cycle of chemotherapy for lung neoplasm stage IV in last two months.

Case

Lesions appear on the left side of the thorax which refers to T4-T7 dermatomes.

 The zoster rash is usually unilateral and does not cross the mid-line, erupting in one or two adjacent dermatomes. The most commonly involved area are thoracic (53%), followed by cervical (20%), cranial especially trigeminal (15%), and lumbar (11%); sacral dermatomes are least frequently involved.

Case
Patient as in this case are still given an antiviral medication, which is oral Acyclovir five times daily with doses 800 mg for 7 days.

 Treatment of HZ with antiviral medication appears to be the method of choice, particularly when treating elderly and immunocompromised patients. Consideration should be given to treating immunocompromised patients or those with disseminated disease because in immunocompromised individuals who get herpes zoster may have prolonged viral shedding.

Case
There is no place of using corticosteroids because patient already in immunocompromised state as a consequence of his chemotherapy for lung neoplasm stage IV yet patient also do not complained any pain in the affected area so far. Thus, analgesics or NSAIDs also have no role in this case.

Thank You