|Ahead of print publication
A rare case of Herpes Zoster in a child involving dermatomes V1 and V2
Nirmal Kumar Mohakud, KR Jishnu
Department of Pediatrics, Kalinga Institute of Medical Sciences, KIIT Deemed University, Bhubaneswar, Odisha, India
|Date of Submission||18-Apr-2021|
|Date of Decision||05-Jul-2021|
|Date of Acceptance||05-Jul-2021|
Nirmal Kumar Mohakud,
Department of Pediatrics, Kalinga Institute of Medical Sciences, KIIT Deemed University, Bhubaneswar, Odisha
Source of Support: None, Conflict of Interest: None
Herpes zoster (HZ) is rarely found in healthy children but may be attributed to immunocompromised children. Latent varicella-zoster virus (VZV) might have source from intrauterine exposure, chicken pox vaccination, or exposure to wild VZV. A 2 ½-year-old healthy boy presented with a painful red vesicular rashes with blisters on the right upper cheek, periorbital area, temporal and nasal area extending over the dermatomes V1 and V2 of 3 days' duration. There was an involvement of the right eye causing conjunctivitis. He had persistent frontal and temporal headache on the day 10 of the disease. Computed tomography scan of the brain reveals no abnormality. The child responded well to symptomatic management and routine skin care. Medications such as cetrizine, sup acyclovir, and local acyclovir ointment and emollients were given. Acyclovir was used orally in a dose of 20 mg/kg body weight every 6 hourly for 7 days. The patient recovered well in 10 days of treatment. HZ is a rare presentation in healthy children and needs a high index of suspicion to diagnose in cases with vesicular eruptions. In our case, the intrauterine infection is the source of latent VZV. HZ may not indicate that the child is immunocompromised.
Keywords: Acyclovir, children, herpes zoster, varicella-zoster virus, vesicular eruptions
| Introduction|| |
Herpes zoster (HZ) (shingles) is due to reactivation of latent varicella-zoster virus (VZV) present in a posterior root ganglion or cranial root ganglia following primary infection. During the viremic stage VZV infection, T-cells get infected and reach the neuronal cell bodies. VZV multiplies inside the neurons without cell death lead to ceasion of proliferation and establishment of latency. The latent virus may get activated due to alteration of the host immunity and travels along the sensory nerve axons and vesicular rash involves in one to two dermatomes. Pediatric cases may be attributed to the exposures from mother during intrauterine period, prior history of chicken pox, or child has taken live attenuated varicella zoster vaccine., HZ incidence is 230/100,000 person-years in 1–18 years' age group. Possibility of HZ among chickenpox-vaccinated children is around 14 cases/100,000 person-year. Furthermore, adverse effect of HZ noted following chickenpox vaccination is approximately 8.6%, mostly in the first 2 weeks after the administration of vaccine. Although HZ is found in immunocompromised children, it is unusual in immunocompetent children. It is diagnosed clinically by unilateral vesicular eruption involving a dermatome or dermatomes.
| Clinical Description|| |
A 2 ½-year-old male healthy child presented with right sided painful, vesicular rashes with indurated margin, blisters and crusts on upper cheek, periorbital area, temporal and nasal area of 3 days' duration [Figure 1]. The symptoms start with pain, burning, tingling, or itching on one part of the right side of the face. The child was born out of nonconsanginous marriage. Mother had a history of chicken pox in the second trimester of pregnancy. The child had no history of exposure to VZV or similar rashes in the past. He was immunized as per universal immunization program schedule and not taken VZV vaccine. On examination, lesions were in the dermal distribution of V1 and V2 segment. No lesions found in the other parts of the body. The presence of discharge and matting of eye lashes and the child was unable to open his left eye. Opthalmological evaluation reveals viral conjunctivitis of the left eye. He had a persistent frontal and temporal headache on the day 10 of the disease. Computed tomography scan of the brain was done inview of extensive lesions in such a small kid to exclude viral meningitis, encephalitis or mastoiditis or any space-occupying lesions, which reveals no abnormality.
|Figure 1: Crusted lesions and grouped vescicles with indurated base on the right side extending from temporal, periorbital, side of the nose and upper part of the lip corresponding to V1 and V2 dermatomes on day 3|
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Management and outcome
Examination of complete blood count reaveled leukocytosis (total leukocyte count 13,000/cmm) and lymphocytosis (lymphocytes 68%, neutrophil 27%, eosinophil 4%, and monocyte 1%). C-reactive protein was 32 mg/dl indicating increased acute-phase reactant. The child was clinically diagnosed with a case of HZ. In view of pain, paracetamol was started at a dose of 15 mg/kg 8 hourly and levocetrizine once daily before food for itching. Ofloxacin eye drop was put five times a day for 5 days. Acyclovir at a dose 20 mg/kg/dose orally every 6 hourly given for a period of 1 week. He became asymptomatic by day 5 and lesions get cleared in 12 days [Figure 2]. No complications were noted after 2 weeks of follow-up.
|Figure 2: Lesions subsided with hypopigmented marks and one big lesion with remaining crust on day 10|
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| Discussion|| |
Menifestations of HZ in cases of children are rare compared to the adults. HZ may occurs few weeks to years after exposure to VZV. The child had neither taken HZV vaccine nor had any history of exposure to wild VZV. In our case, the infection might have come through intrauterine route as other possibilities of VZV infection is excluded. Few of cases of HZ was detected in healthy children in a study attributing to HZV infection in utero. The T-cell-mediated immunity is the most important component to kill the intracellular organism. A decrease in cell-mediated immunity is associated with reactivation of VZV. It is to be noted that immunosupression of VZV-specific cellular immunity due to chemotherapy or prolong use of steroid or T-cell destruction in the HIV children may results in reactivation of latent VZV. Besides, natural-killer cells, lymphocytes, and cytokines are reportedly less in toddler and absence of anti-IgG for VZV leads reactivation of latent VZV.
The diagnosis is mostly by clinical clinical examination. Characteristic vesiculopostular lesion with indurated base extending over a particular dermatome are found. Sometimes, tzanck smear is done from the vesicles to look for multineucleated giant cells. Methods such as anti-immunoglobulin M VZV, direct fluorescent antibody tests, and viral culture are raely done. Differential diagnosis includes zosteriform herpes simplex, bullous impetigo, and insect bite reactions.
Specific treatment includes acyclovir oral dose of 20 mg/kg body weight every 6 hourly for 5–8 days or for 2 days from the last new lesions. Symptomatic management requiring paracetamol (15 mg/kg/dose) for pain, cetrizine, and emollients to prevent pruritus of skin. Corticosteroids may be used in cases with facial nerve palsy, polyneuritis, evidence of peripheral nerve compression, and involvement of the central nervous system.
This child get rid of the symptoms in a week and does not suffer from any complications. However, sequelae such as encephalitis, Ramsay Hunt syndrome, HZ ophthalmicus, postherpetic neuralgia, and disseminated HZ may occur.
| Conclusion|| |
HZ is a rare presentation in healthy children and needs a high index of suspicion to diagnose in cases with vesicular eruptions. HZ may not indicate that the child is immunocompromised.
- HZ manifestation involving multiple dermatomes in a healthy child
- HZ out of intrauterine transmission in a healthy child.
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.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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