Indian Journal of Dermatology
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STUDIES
Year : 2005  |  Volume : 50  |  Issue : 4  |  Page : 203-207
Clinical and morphological characteristics of herpes zoster in south India


Department of Dermatology and STD, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry - 605 006, India

Correspondence Address:
Devinder Mohan Thappa
Department of Dermatology and STD, JIPMER, Pondicherry - 605 006
India
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   Abstract 

One hundred and seven cases (6 children and 101 adults) of herpes zoster were recruited over a period of two years. The frequency of herpes zoster amongst skin OPD cases was found to be 0.34 per cent. The male to female ratio was 1.74:1. The most common prodromal symptom seen was paresthesia in 25 (23.36%) cases followed by itching in 21 (19.62%) cases.Most common presenting complaint was pain in 97 (90.65%) cases. Ninety nine cases had classical herpes zoster followed by necrotic / ulcerated herpes zoster in 5 cases and hemorrhagic herpes zoster in 3 cases. Thoracic dermatome was the most common dermatome involved in 64 (59.8%) cases followed by cervical in 17 (15.8%) cases. Unidermatomal involvement was seen in 81 (75.7%) cases, followed by multidermatomal in 18 (16.8%) cases and disseminated in 8 (7.4%) cases. Forty six cases were screened for HIV, out of them; six cases (4 males, 2 females) were seropositive for HIV. Classical herpes zoster was a feature in four cases; however, one case each also had necrotic and hemorrhagic form of herpes zoster. To conclude, herpes zoster commonly occurs in young adults in India with presenting symptoms such as pain, itching and fever.


Keywords: Herpes zoster; Dermatomes; HIV infection


How to cite this article:
Dubey AK, Jaisankar T J, Thappa DM. Clinical and morphological characteristics of herpes zoster in south India. Indian J Dermatol 2005;50:203-7

How to cite this URL:
Dubey AK, Jaisankar T J, Thappa DM. Clinical and morphological characteristics of herpes zoster in south India. Indian J Dermatol [serial online] 2005 [cited 2019 Jun 18];50:203-7. Available from: http://www.e-ijd.org/text.asp?2005/50/4/203/19745



   Introduction Top


Herpes zoster is a localized disease characterized by unilateral radicular pain and grouped vesicular eruption that is generally limited to the dermatome innervated by a single spinal or cranial sensory ganglion. It occurs as a result of reactivation of varicella zoster virus (VZV) that had persisted in latent form within sensory ganglion following an earlier attack of varicella.[1] Herpes zoster has traditionally affected persons with more than 60 years of age. It is also common in patients with neoplasms, especially Hodgkin's lymphoma. Recently, varicella zoster infections have been observed in young adults infected with human immunodeficiency virus infection.[2] The incidence of complicated and atypical herpes zoster has increased due to increasing prevalence of HIV infection and drug induced immunocompromized states. The condition is benign and self-limiting in patients with normal immunological status.

During varicella infection, VZV passes from skin lesions into cutaneous sensory nerve endings and ascends up the sensory fibers to the sensory ganglia where it remains in latent stage.[3] On reactivation, it travels back along the sensory afferents to the skin associated with hematogenous dissemination. Depending upon the rapidity of immune response, the presentation may vary from no clinical lesions, to typical zoster, scattered vesicles, zoster sine herpete or disseminated zoster.[4] Reactivation may be triggered by trauma, sunburn, exhaustion, injection, immunosuppression or irradiation. We undertook this study to know the clinical and morphological characteristics of herpes zoster and impact of underlying HIV infection or associated diseases on it.


   Materials and methods Top


The study was conducted between August 2002 and July 2004 at the department of Dermatology, Venereology and Leprosy, JIPMER Pondicherry. All cases of herpes zoster attending skin OPD and referred cases from other departments were studied. One hundred and seven consecutive cases of herpes zoster were recruited. Patient's demographic data, symptoms, location of lesions, risk factors, associated systemic disease and complications were noted in a proforma. Diagnosis was established by history and clinical examination, Tzanck smears and skin biopsy wherever required. In high risk cases, blood sample was taken for HIV serology after informed consent and counseling. The data obtained was tabulated and analyzed utilizing Chi square test and Fisher exact test.


   Results Top


One hundred and seven cases of herpes zoster were recorded from August 2002 to July 2004. A total of 31294 new cases attended skin OPD during the study period, thus the frequency of occurrence of herpes zoster amongst skin OPD cases was 0.34 per cent. The herpes zoster cases included 6 children (4 males, 2 females) and 101 adults (65 males, 36 females).

The mean age at presentation was 37.65 years with the range from 2 to 77 years. Male to female sex ratio was 1.74:1.Four children (66.6%) were in the age group of 10 - 14 years and one (16.6%) case each in the age group of 0-4 and 5-9 years. In adults, 38(37.62%) cases were in age group of 14-29 years, 29 (28.71%) cases in age group of 30 - 45 years, 23(22.77%) cases in age group of 46 - 60 years and 11 (10.89%) cases were above 60 years of age.

Most common occupation of these patients was that of labourer 26 (24.29%) followed by farmers 22 (20.56%), students 14 (13.08%), house wife 13 (12.14%), driver 5 (4.67%) and others (27 cases).

The average duration at presentation was 3.25 days. Majority of the cases (90 cases, 84.1%) presented between 0- 5 days, followed by 16 cases (14.9%) between 5- 10 days and one case (0.93%) between 10- 15 days.

Prodromal symptoms were recorded in seventy three cases. Most common prodromal symptom was paresthesia in 25 (23.36%) followed by itching in 21 (19.62%) cases, tingling in 14 (13.08%) cases, burning in 6 (5.6%) cases, watering from eyes in 5 (4.6%) cases and headache and fever in one (0.93%) case each.

Most common presenting complaint was pain in 97 (90.65%) patients followed by localized itching in 7 cases and fever in three cases. Most common type of pain was burning pain (in 44 cases) followed by pricking pain (in 35 cases) and shooting pain (in 18 cases).

Out of 107 cases, 99 cases were having classical herpes zoster (62 males and 37 females). Five cases had necrotic / ulcerative lesions (4 males and one female) and three cases had hemorrhagic lesions (all males).

Dermatomes involved in herpes zoster

Thoracic dermatome was most commonly involved [Table - 1]. Cervical and lumbar dermatomes were more frequently involved in females than males and this finding was statistically significant ( x2p value=0.03)

Out of 107 cases, 81 (75.7%) cases were having localized involvement, 18 (16.8%) cases were having multidermatomal involvement and 8 (7.4%) cases had disseminated herpes zoster. Multidermatomal and disseminated herpes zoster was more frequent in females than males. This difference was statistically not significant (x2p value =0.16).

Eighty cases were below 50 years of age and 27 cases above 50 years. Though, cervical dermatomes were more frequently involved in patients less than 50 years of age but this finding was statistically not significant (p =0.065) [Table - 2]. In 61 (57%) cases, lesions of herpes zoster were seen on right half of the body and in 44 (41.12%) cases on left side.

Risk factors in herpes zoster

Thirty-two cases were having risk factors for herpes zoster. Out of 32 cases, most common risk factor seen was promiscuity in 13 (12.14%) cases followed by corticosteroid therapy in 9 (8.4%) cases, radiotherapy and chemotherapy in 5 (4.6%) cases each.

Associated diseases

Systemic diseases seen in association with herpes zoster were diabetes mellitus in 3 cases, pulmonary tuberculosis in 3 cases, epilepsy in 2 cases and systemic lupus erythematosus, chronic renal failure and disseminated discoid lupus erythematosus in one case each. Most of these cases had unidermatomal herpes zoster. Multidermatomal herpes zoster was recorded in one case each of seizures and disseminated discoid lupus erythematosus.

Complications

Most common complication seen was secondary infection seen in 21 (19.62%) cases, followed by post herpetic neuralgia (PHN) in 16 (14.95%) cases, scarring in 3 (2.8%) cases, Ramsay Hunt syndrome in 2 (1.86%) and urinary retention in 1 (0.93%) case.

Herpes zoster and HIV infection

Forty six herpes zoster cases were tested for HIV serology. Out of the 46 cases, 6 cases (13.06%, 4 males and 2 females) were seropositive for HIV. Out of 4 male cases, 2 cases were drivers; one each was a farmer and mechanic by occupation.

Mean duration at presentation in HIV seropositive cases was 3.16 days with 5 cases presenting in 0 - 5 days and 1 case presenting in 6 - 10 days.

Male to female sex ratio of HIV seropositive cases was 2:1. Mean age was 25.5 years with age range from 2 - 38 years. Most common symptom was pain seen in 3 (50%) cases followed by fever in 2 (33.3%) cases and itching and watering from eyes in 1 (16.6%) case each.

Five (83.33%) cases were having unidermatomal involvement and 1 (16.6%) case had disseminated zoster. Four cases had classical herpes zoster whereas one case each had necrotic and hemorrhagic lesions. One case had recurrent herpes zoster. Scarring and secondary infection was seen in 2 (33.33%) cases each; one (10.6%) case each had Ramsay Hunt syndrome and urinary retention.

Most common dermatome involved was thoracic in 3 (50%) cases followed by one (16.6%) case each involving lumbar, ophthalmic and mandibular branch of trigeminal nerve.


   Discussion Top


Herpes zoster is common among immunocompromised persons, so the elderly are at particular risk, because immunocompetence declines with age. Whitley, et al [5] reported that zoster afflicts 20% of general population, during their life time, especially in elderly. In a similar study on herpes zoster the rate of occurrence is in the range at 1.3 to 5 per thousand persons per year, although it may be seen in any age group.[6] More than two thirds of the reported cases occur in individuals over fifty years of age and less than ten percent occur in those under the age of twenty years. Sharma and Mendiratta [7] at the Kalawati Saran children's hospital found that 5.2% of the cutaneous viral infections were herpes zoster. In our study, one hundred and seven cases (6 children, 101 adults) were seen over a period of two years. Six (5.6%) of them were children.

The average age at presentation in our study was 37.65 years which is a decade less than the findings of Goh and Khoo. Eighty (74.7%) of our cases were less than 50 years that is much higher than seen in the above study.

In our study, thoracic dermatome was involved in 64 (54.81%) cases followed by cervical in 17 (15.8%) cases, lumbar in 13 (12.1%) cases, ophthalmic branch of trigeminal nerve in 10 (9.3%) cases, sacral and maxillary branch of trigeminal nerve in one case each. This is in contrast to the study by Goh and Khoo [8] where dermatomes most commonly involved were thoracic in 45% and cervical in 23%. Ophthalmic zoster was seen only in 3% cases.

A study[9] on forty cases of herpes zoster, which included 5 children and 35 adults; majority of the cases (75%) occurred below 50 years of age, 22.5% of cases were below 20 years. The dermatomes involved in decreasing frequency were thoracic (24 cases), followed by ophthalmic (6 cases) and sacral (5 cases). Localized dermatomal zoster was seen in 30 cases, multidermatomal zoster in 7 cases and disseminated zoster in one case. Fourteen cases (35%) were seropositive for HIV infection among high risk group. Multidermatomal, recurrent and disseminated zoster were exclusively seen in the HIV seropositive group.

Cervical and lumbar dermatomes were more frequently involved in females than males and this finding was statistically significant (p < 0.05). Localized dermatomal zoster was seen in 81 (75.7 %) cases followed by multidermatomal involvement in 18 (16.8%) cases and disseminated zoster in 8 (7.4%) cases. Multidermatomal and disseminated zoster was more frequent in females than males. This difference was statistically not significant (p > 0.05).

Gottlieb et al [10] had reported limited cutaneous varicella zoster virus (VZV) infection in AIDS patients as early as 1983. In addition, Rogers, et al [11] in 1983 reported that AIDS patients are likely to have lower levels of VZV antibodies than patients without AIDS. Smith et al [12] in their study of 912 HIV-1 seropositive patient, found that 53 patients (16%) of the study population had herpes zoster. Approximately 15% of their patients had previous history of herpes zoster.

In a similar study[13] at Lusaka, Zambia, it was found that 30% of the AIDS cases and 26.1% of the ARC had developed herpes zoster. In our study, 6 (13%) cases of the 46 patients who were tested for HIV were seropositive.

Although, zoster often occurs early in HIV disease, the course is fairly uneventful. It is most often unidermatomal, but may be multidermatomal, recurrent or disseminated.[15] The eruption may be bullous, hemorrhagic or necrotic and accompanied by severe pain.

Tyndall et al [14] in their study found that the duration of zoster was longer (32 vs 22 days) and patients were more likely to have generalized lymphadenopathy (74% vs 3%), severe pain (69%), bacterial super infection (15%) and more than one dermatome (38% vs 18%) affected. In our study, most common symptoms seen was pain in 3 (50%) patients followed by fever in 2 (33.3%) cases, itching and watering from eyes in 1 (16.6%) case each. Unidermatomal involvement was seen in 5 (83.3%) cases whereas one case had disseminated zoster. Two patients had scarring as complications, two had secondary infection and one each had Ramsay Hunt syndrome and urinary retention.

To conclude, herpes zoster commonly occurs in young adults in India with presenting symptoms such as pain, itching and fever. Most common type of pain was burning pain. The occurrence of hemorrhagic, crusted and ulcerated lesions is possible in herpes zoster. Thoracic dermatome was most frequently involved dermatome. Amongst the HIV seropositive cases, multi-dermatomal, recurrent and disseminated zoster may occur. Occurrence of zoster in young age group who give history of promiscuity may need HIV testing.

 
   References Top

1.Straus SE, Schmader KE, Oxman MN. In: Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, eds. Fitzpatrick's Dermatology in General Medicine. 6th edn., Vol. 2. New York: McGraw Hill, 2003: 2070-85.   Back to cited text no. 1    
2.Colebunders R, Mann JM, Francis H, et al . Herpes Zoster in African patients: A clinical predictor of human immunodeficiency virus infection. J Infect Dis 1988; 157(2): 314 - 8.   Back to cited text no. 2    
3.Talwar S, Shrivastava VK. Herpes zoster ophthalmicus with total ophthalmoplegia. Indian J Dermatol Venereol Leprol 1991;56:454-5.   Back to cited text no. 3    
4.Talwar S. Herpes zoster associated with varicelliform eruption. Indian J Dermatol Venereol Leprol 1991; 57:52.   Back to cited text no. 4    
5.Whitley RS. Varicella - zoster virus. In : Mandel GZ, Bennet JE, Dolin R, eds. Principles and practice of infectious disease. 4th edn., New York: Churchill Living stone, 1995; 1345 - 51.   Back to cited text no. 5    
6.Ragozzino MW, Melton LJ, Kurland LT, et al . Population based study of herpes zoster and its sequelae. Medicine (Baltimore) 1982; 6: 310 - 6.   Back to cited text no. 6    
7.Sharma RC, Mendiratta V. Clinical profile of cutaneous infections and infestations in the pediatric age group. Indian J Dermatol 1999; 44: 174 - 8.   Back to cited text no. 7    
8.Goh CL, Khoo L. A retrospective study of the clinical presentation and outcome of herpes zoster in a tertiary dermatology outpatient referral clinic, Int J Dermatol 1997; 36: 667 - 72.   Back to cited text no. 8    
9.Laxmisha C, Thappa DM, Jaisanker TJ. The spectrum of varicella zoster virus infection: a hospital based clinic in south India. Indian J Dermatol 2004; 49(1):28 - 31.   Back to cited text no. 9    
10.Gottlieb MS, Groopman JE, Weinstein WM, et al . The acquired immunodeficiency syndrome. Ann Intern Med 1983; 99: 208 - 20.   Back to cited text no. 10    
11.Rogers MF, Morens DF, Stewart JA, et al . National case control study of Kaposi's sarcoma and pneumocystis carinii pneumonia in homosexual men. Part 2 laboratory results. Ann Intern Med 1983; 99: 151 - 8.  Back to cited text no. 11    
12.Smith KJ, Skelton HG, Yeager J, et al . Cutaneous findings in HIV - 1 positive patients. A 42 - months' prospective study. J Am Acad Dermatol 1994;3:746-54.  Back to cited text no. 12    
13.Hira SK, Wadhawan D, Kamanga J, et al . Cutaneous manifestation of human immuno deficiency virus in Lusaka, Zambia. J Am Acad Dermatol 1988,19: 451-7.   Back to cited text no. 13    
14.Tyndall MW, Nasio J, Agoki E, Malisa W, Ronald AR, Plummer FA. Herpes zoster as the initial presentation of human immunodeficiency virus type 1 infection in Kenya. Clin Infect Dis 1995; 21:1035- 7.  Back to cited text no. 14    
15.Choo PW, Donahue JG, Manson JE, Platt R. The epidemiology of varicella and its complications. J Infect Dis 1995; 172: 706-12.   Back to cited text no. 15    


Tables

[Table - 1], [Table - 2]



 

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