Herpes zoster in AIDS patient … Hiremutt D et al Journal of International Oral Health 2016; 8(4):523-526

th th Received: 07 November 2015 Accepted: 08 February 2016 Conflicts of Interest: None Case Report Source of Support: Nil Doi: 10.2047/jioh-08-04-23

Herpes Zoster Involving Maxillary and Mandibular Branch of Trigeminal Nerve in HIV Patient: A Case Report Darshan Hiremutt1, Amit Mhapuskar2, Kedarnath Kalyanpur3, Santosh Jadhav1, Abhijeet Jadhav1, Sukhpreet Singh Mangat4

Contributors: VZV may occur spontaneously or when host defenses are 1Assistant Professor, Department of Oral Medicine & , compromised. Increased age, physical trauma, (including Bharati Vidyapeeth Dental College & Hospital, Pune, Maharashtra, dental procedures), psychological stress, malignancy, 2 India; Professor & Head, Department of Oral Medicine & radiation therapy, and immunocompromised states including Radiology, Bharati Vidyapeeth Dental College & Hospital, 3 transplant recipients, steroid therapy, and HIV infection are Pune, Maharashtra, India; Senior Lecturer, Department of Oral predisposing factors for VZV reactivation.3 The predisposing Medicine & Radiology, Sinhgad Dental College & Hospital, factor in the present case was immunocompromised state of Pune, Maharashtra, India; 4Associate Professor, Department of Orthodontics, Index Institute of Dental Sciences, Indore the patient as the medical history of the patient revealed HIV Correspondence: infection which was diagnosed about 6 years back. Onunu Dr. Hiremutt D. Department of Oral Medicine & Radiology, and Uhunmwangho4 evaluated the clinical spectrum of HZ Bharati Vidyapeeth Dental College & Hospital, Pune, Maharashtra, in HIV-infected patients and found that the age distribution India. Email: [email protected] of the patients in the HIV-positive group was 36.1 ± 16.14 How to cite the article: years and infection was generally more severe in the presence Hiremutt D, Mhapuskar A, Kalyanpur K, Jadhav S, Jadhav A. of HIV infection. Mangat SS. Herpes zoster involving maxillary and mandibular branch of the trigeminal nerve in HIV patient: A case report. J Int Case Report Oral Health 2016;8(4):523-526. A 35-year-old male patient reported to the out-patient Abstract: department with pain and swelling over the left mandibular Herpes zoster (HZ) or consist of a reactivation of the region radiating to the left ear since a week. The patient also Varicella Zoster virus that had entered cutaneous nerve endings complained of multiple ulcerations on the left side of the through an earlier occurrence of chicken pox, passes to the dorsal face extending from corner of the mouth to the temporal root ganglia and resides there in a latent form. Nerves usually region. The patient initially developed an extraoral swelling involved are C3, T5, L1, L2, and the first division of trigeminal nerve. The characteristic appearance of this condition is occurrence on the left side of the face associated with pain in the lower of multiple, unilateral, painful vesicles, and ulceration involving left posterior teeth for which he visited a local doctor and a single dermatome. The infection commonly affects elderly was prescribed antibiotics and analgesics. The patient individuals, however if present in the younger age group, raises the gave a history of fever about 10 days back, after which he suspicion of immunocompromised status such as acquired immuno developed ulcerations on the face since 5 days associated deficiency syndrome (AIDS)/human immunodeficiency virus. In with burning sensation intra-orally on the affected side. His this case report, we present a patient with AIDS who developed medical history revealed that he was diagnosed with human HZ of the left side involving the maxillary and mandibular divisions immunodeficiency virus (HIV) infection about 6 years of the trigeminal nerve. The patient presented with unilateral back. The CD4 count was 446 cells/mm3 for which he was crustations involving the left side of lower and middle one-third of advised antiretroviral therapy (ART) which included tablets the face along the tract of the trigeminal nerve, intra-orally involving buccal and labial mucosa ipsilaterally. Key Words: Acquired immuno deficiency syndrome, herpes zoster, shingles, trigeminal nerve, unilateral vesicular lesions

Introduction HZ is an acute viral infection characterized by vesicular skin lesions which are usually distributed over several unilateral adjacent sensory dermatomes.1 This infection occurs because of reactivation of Varicella zoster virus (VZV) which belongs to a b a subfamily of human alpha herpes virus2 which causes varicella Figure 1: Clinical picture of case. (a) Extraoral view showing (chicken pox) in childhood and then remains latent for crustations (dark arrow), lesions typically not crossing the decades in cranial nerve, dorsal root, and autonomic nervous midline (light arrow), (b) extraoral view showing ulcerations system ganglia along the entire neural axis. Reactivation of on labial mucosa (dark arrow).

523 Herpes zoster infection in AIDS patient … Hiremutt D et al Journal of International Oral Health 2016; 8(4):523-526 lamivudine, zidovudine, and nevirapine. The patient took erythrocyte sedimentation rate of 32 mm at the end of 1 the above-mentioned medicines regularly for a month after h. Distinct fall in CD4 count (280 cells/mm3) was noted. which he discontinued abruptly. Exfoliative cytology (Tzanck smear) was made by scrapping an intact vesicle located on the left labial mucosa of the lower On extraoral examination, the skin over the left side of face lip and stained with H and E stain. showed diffuse crustations extending from the chin region along the left side of the face up to the temporal region Histopathological examination of the Tzanck preparation characteristically not crossing the midline (Figure 1). Gross showed acantholysis along with numerous free-floating Tzanck asymmetry of the face was seen with a diffuse oval swelling cells and ballooning degeneration (Figure 2) confirming the approximately 2 cm × 2 cm was seen on the left side of the clinical diagnosis of HZ infection. face extending over the left body of the mandible with normal overlying skin, soft in consistency, tender on palpation with The patient was referred to his physician for overall assessment no local rise in temperature. Multiple, irregular ulcerations and reconsideration to restart the ART. The ART was restarted along with intact vesicles were present over the vermilion which consisted of tablets lamivudine (150 mg) twice daily, border and labial mucosa of the lower lip on the left side zidovudine (300 mg) twice daily, and nevirapine (200 mg) not crossing the midline (Figure 1). The crustations and once daily for 2 weeks. ulcers appeared large, irregular, and seemed to coalesce Furthermore, in consultation with the treating physician, the with each other and were tender on palpation. Intraoral patient was prescribed tablets acyclovir (800 mg) five times a examination revealed deep occlusal caries with a lower day for 10 days and benzydamine mouth rinse (tantum oral left first molar. Limited mouth opening led to incomplete rinse) 4-5 times per day for 10 days for symptomatic relief. intraoral examination. Based on the history and clinical examination, a provisional diagnosis of chronic periapical For the dental infection, the patient was prescribed tablets abscess secondary to advanced occlusal caries with 36 and augmentin (500 mg/125 mg, amoxicillin/clavalunic acid) herpes zoster (HZ) infection involving the maxillary and twice a day for 5 days and combiflam thrice a day for 5 days. mandibular division of the trigeminal nerve in HIV-infected The offending tooth, 36 was extracted after the swelling had individual was made. subsided about a week after initial presentation. The lesions associated with HZ infection had reduced by almost 80%, and Radiographic investigations included a mandibular left lateral there were drastic improvements in the symptoms as well. The oblique radiograph which revealed a grossly carious lower patient was then lost for further follow-up. left first molar associated with a well-defined, smooth, round, continuous, corticated radiolucency approximately 2 cm in Discussion diameter (Figure 3). Blood investigations were carried out. HZ is commonly known as shingles, derived from the Latin Complete hemogram showed elevated white blood cells word “cingulum” meaning girdle. This is because a common (17000/µL), decreased hemoglobin (8.4 g/dl), and raised presentation of HZ involves unilateral rash that can wrap around the waist or chest like a girdle. Similarly, the name “zoster” is derived from Greek word referred to a belt-like binding structure used by warriors to secure armor.5

Figure 2: Acantholysis with the formation of numerous free-floating Tzanck cells and ballooning degeneration. Hematoxylin and eosin section (×40) showing acantholysis (dark arrow) with the formation of numerous free-floating Figure 3: Lateral oblique radiograph showing badly carious Tzanck cells (light arrow). 36 associated with the infected periapical .

524 Herpes zoster infection in AIDS patient … Hiremutt D et al Journal of International Oral Health 2016; 8(4):523-526

The incidence of HZ increases by 15 times in HIV-infected There are various syndromes associated with HZ such as James patients and also about 25% cases of Hodgkin’s lymphoma Ramsay Hunt syndrome,11 Congenital varicella syndrome,12 suffers from HZ infection.6 Transmission of HZ infection Guillain-Barre syndrome,13 progressive outer retinal occurs by the spread of infectious particles from oral secretion, syndrome,14 and crocodile tear syndrome.15 Most of the times, skin lesions, or via direct contact with the patient.7 Clinical the signs and symptoms are pathognomonic for diagnosing appearance of HZ can be categorized into three phases the condition. In confusing cases, Tzanck smear or biopsy prodromal, acute, and chronic.6 In the prodromal phase, of the lesion may be utilized. Tzanck smear demonstrates inflammation of ganglion occurs due to replication of virus multinucleated giant cells showing intranuclear inclusion which causes necrosis of the affected sensory nerve resulting bodies, syncitium, and ballooning degeneration of nuclei. in occurrence of intense pain along with burning, itching, Biopsy shows acantholysis along with the presence of many 15 tingling boring, and prickly sensation in the skin and/or oral free-floating Tzanck cells-Lipschutz bodies. In the present mucosa supplied by that nerve.7 Prodromal phase is followed by case, histopathological examination of the Tzanck preparation patchy erythema, occasionally accompanied by indurations that demonstrated acantholysis along with the formation of appear in the dermatome area of involvement.8 Rash is usually many free-floating Tzanck cells and ballooning degeneration accompanied by malaise, headache, nausea, low grade fever, which confirmed he clinical diagnosis of HZ infection. Other and further advances to blisters with erythematous base on the approaches to confirm the clinical diagnosis consists of affected area of skin which then postulates and further results virological test which includes viral culture and is considered as in ulceration. Subsequently, lesion dries and form crustations a most accurate method with higher sensitivity and specificity. along the tract of affected sensory nerve and ends at the midline. Other advanced investigation technique such as direct and indirect immunofluorescence, complement fixation test can These crustations reduce in 14-21 days leaving behind an 15 erythematous macular lesion that further result in hyper or also be used. hypopigmentation of the affected area of the skin.9 The present Therapeutic intervention for management of HZ infection case also presents a history of fever about 10 days back, after should be intended at pain control, treatment of skin, and which the patient developed ulcerations on the face associated oral lesions, use of antiviral therapy and should be aimed at with burning sensation intra-orally on the affected side. prevention of complications. Skin lesion can be treated by applying of open wet dressings soaked in cool water and pain Involvement of the maxillary or mandibular divisions of the can be managed by prescribing mild to moderately strong trigeminal nerve may result in lesions either on the analgesics along with inflammatory agents.13,7 or skin or both.10 In the present case, HZ infection involving the maxillary and mandibular division of the trigeminal nerve was Antiviral drug therapy reduces the duration and severity in the diagnosed. The lesion was presented with multiple, irregular acute phase of the HZ infection. Acyclovir is the drug of choice ulcerations along with intact vesicles over the vermilion with recommended dosage of 800 mg four to five times a day for border and labial mucosa of the lower lip on the left side not 10 days. Other newer agents such as Famciclovir 500 mg and crossing the midline. The crustations and ulcers appeared Valacyclovir 1 g can be prescribed three times a day for 7 days.10 large, irregular, and seemed to coalesce with each other and In the present case, as the patient was earlier diagnosed as HIV, were tender on palpation. ART was restarted in consultation with the treating physician which consisted of tablets lamivudine (150 mg), zidovudine HZ infection can also involve all the three branches of trigeminal (300 mg) both tablets twice daily, and nevirapine (200 mg) 10 nerve. Skin lesions usually herald the intraoral lesions as oral once daily for 2 weeks along with acyclovir (800 mg) five times lesions generally appear after the cutaneous rash. Erythematous a day for 10 days and benzydamine mouth rinse (tantum oral zone surrounds the intraoral vesicles which then become rinse) 4-5 times per day for 10 days for symptomatic relief. ulcerated followed by a white pseudomembrane.11 The most common complication of HZ infection is a chronic stage or Antiviral therapy has been found to halt progression post-herpetic neuralgia (PHN). The pain in PHN generally and dissemination of acute phase of HZ in patients with occurs for 1-3 months after the active lesion that may continue immunocompromised status, even if commenced more than for years and even decades. Other dental complications include 72 h after rash onset. Such therapy is recommended for all internal resorption, necrosis of alveolar bone, non-vitality of HZ patients with immunocompromised status who present teeth, tooth exfoliation, and periodontitis.7 before the complete crusting of all lesions. IV acyclovir is preferred drug for the cases with advanced HIV/acquired Symptoms when associated with characteristic lesions limited immuno deficiency syndrome (AIDS) who harbor active to the area supplied by the nerve involved, the diagnosis is opportunistic or exhibit prominent wasting. Antiviral easier. Furthermore, in cases of unilateral HZ, the lesions therapy should not be stopped until all lesions have resolved.16 characteristically stop at the midline making it pathognomonic Thus, early detection and timely treatment of the HZ in the which was also evident in the present case. prodromal phase by the use of antiviral agents may serve in

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