JIAOMR 10.5005/jp-journals-10011-1259 CASE REPORT Herpes Zoster: Report of a Treated Case with Review of Literature Herpes Zoster: Report of a Treated Case with Review of Literature

K Srikrishna, MPV Prabhat, Praveen Kumar Balmuri, S Sudhakar, D Ramaraju

ABSTRACT nature and was associated with low-grade since Herpes zoster is a localized, generally painful cutaneous eruption 5 days. After 1 or 2 days, patient developed fluid-filled that occurs most frequently among older adults and over the left side of face. The blisters were initially immunocompromized persons. It is caused by reactivation of small in size and few in number, later they increased in latent varicella zoster (VZV). Approximately one in three number by almost involving the entire left half of the face. persons will develop zoster during their lifetime. A common of zoster is postherpetic (PHN), a chronic, The blisters were associated with watery discharge. Patient often debilitating condition that can last months or even was not able to eat food and also not cleaning the mouth years. The risk for PHN in patients with zoster is 10 to 18%. since 3 days. No relevant medical, dental and family history Approximately 3% of patients with zoster are hospitalized. Death was reported by the patient. He had the habit of chewing attributable to zoster are common among immunocompromized persons. Prompt treatment with the oral antiviral agents, in the form of gutkha for the past 20 years with a and decreases the severity and frequency of 15 packets per day. duration of pain from zoster. This article reviews herpes On general physical examination, the patient was found zoster and reports one such case, which was treated to be moderately built and nourished. No abnormality was successfully without any complications. detected IRT gait, nails, upper and lower limbs. No clinical Keywords: Herpes zoster, Varicella zoster, , Post signs of pallor, icterus, clubbing, cyanosis, edema and herpetic neuralgia, Acyclovir, Corticosteroids. lymphadenopathy were present. On assessment of vital How to cite this article: Srikrishna K, Prabhat MPV, signs, temperature was noted to be 100°F and blood pressure Balmuri PK, Sudhakar S, Ramaraju D. Herpes Zoster: Report 150/90 mm Hg. of a Treated Case with Review of Literature. J Indian Aca Oral Med Radiol 2012;24(1):51-55. On extraoral examination, the patient had mesocephalic head (Fig. 1). No abnormality detected IRT eyes, nose, TMJ, Source of support: Nil salivary glands, paranasal sinuses. Numerous vesicles were Conflict of interest: None declared present on the left preauricular, auricular and scalp of the temple region along with scar tissue in some areas (Fig. 2). INTRODUCTION Clusters of vesicles were also seen in left lower one-third of face, especially in the left perioral region with yellowish Herpes zoster (HZ) also known as shingles, is an acute viral discharge (Figs 3 and 4). The skin was appearing swollen, results from the reactivation of the DNA virus shiny and the involved areas were very tender on palpation. varicella zoster (VZV), which causes .1 It On intraoral examination, left half of the lower was manifests as a painful vesicular which runs its course swollen, with few crustated areas. in a matter of 4 to 5 weeks. The pain may persist for months, Multiple ulcers were seen on left buccal and lower labial even years, after the skin heals. This phenomenon is known mucosa, left retromolar area, left half of soft and on as (PHN).2 Herpes zoster can affect any of the three trigeminal branches, most commonly affecting the ophthalmic branch. The involvement of maxillary and mandibular branches without the involvement of ophthalmic branch is comparatively rare, which accounts for 1.7% of total cases of herpes zoster.3 The aim of this article is to report one such rare case along with the review of herpes zoster.

CASE REPORT A 49-year-old male patient reported to the department of oral medicine and radiology complaining of painful blisters over the left side of face since 3 days. The patient gave history of pain which was severe, continuous, radiating in Fig. 1: Patient photograph Journal of Indian Academy of Oral Medicine and Radiology, January-March 2012;24(1):51-55 51 K Srikrishna et al the left lateral border of tongue extending upto ventral over left lower 1/3rd of face extraorally and left buccal surface (Figs 5 and 6). The ulcers were irregular in shape mucosa intraorally. It revealed acantholytic cells with few measuring approximately 10 × 5 mm in size with exfoliated squamous cells and inflammatory cells (Fig. 7). erythematous margins and sloping edges. The floor of the Upon correlating with the history, clinical findings and showed yellowish white slough. The ulcers were tender cytological examination the final diagnosis of herpes zoster on palpation. No induration was noted. Fibrous bands were was given. palpable bilaterally on buccal mucosa. The The patient was then admitted in the hospital under status of the patient was poor and was having many physician’s opinion and was given hydration, supportive periodontally compromised teeth. and proper management. To start with, the patient was given Based on history, clinical findings, a provisional intravenous ringer lactate and dextrose normal saline (DNS). diagnosis of herpes zoster on left side of face involving Antiviral therapy was started with acyclovir 800 mg tablets 2nd and 3rd branches of , chronic 5 times per day for 10 days. Corticosteroids are given in the generalized periodontitis and oral submucous were form of prednisolone 20 mg, twice daily. For pain control considered. patient adviced to take 500 mg tablets thrice Patient was subjected for routine hematological and daily. Betadine mouth wash was also given to improve oral serological investigations. Complete blood picture was hygiene. The patient was reviewed regularly. found to be within satisfactory limits except ESR, which was On examination of the patient after 1 week, there was slightly raised to 15 mm/1st hour. Cytological examination regression in the number of extraoral and intraoral lesions was performed after taking smear from the lesions present with formation of scar tissue and hypopigmented areas

Fig. 2: Vesicles present over the auricular and scalp of the Fig. 4: Unilateral distribution of lesions temple region

Fig. 3: Vesicles present over the left lower 1/3rd of face Fig. 5: Lesions present over the left buccal mucosa, left half of the lip 52 JAYPEE JIAOMR

Herpes Zoster: Report of a Treated Case with Review of Literature

from Greek word referring to a belt-like binding structure used by warriors to secure armor.2 HZ is characterized by of dorsal root ganglia or extramedullary cranial nerve ganglia, associated with vesicular eruptions of the skin or in an area supplied by the affected nerve.1 The most commonly affected dermatomes are the thoracic (45%), cervical (23%) and trigeminal (15%). The nerves most commonly affected in HZ are C3, T5, L1, L2 and the first division of the trigeminal nerve. The of HZ increases with age or . The predisposing factors for reactivation of the virus are trauma, benign or malignant tumor involving the dorsal root ganglia, local Fig. 6: Lesions present over the left ventrolateral X-ray irradiation and immunosuppressive therapy.4,5 surface of tongue Patients with HZ may progress through three stages: Prodromal stage, active or acute stage and chronic stage.6,7 The prodromal stage presents as sensations like burning, tingling, itching, pricking and boring, occurring in cutaneous

Fig. 7: Photomicrograph respectively (Figs 8 and 9). No fresh vesicles were found. The dose of the prednisolone was tapered to 10 mg. The patient was then discharged and recalled after 1 week. The Fig. 8: Extraoral healed lesional areas patient was again reviewed after 2 weeks. On examination tremendous improvement was noticed both extraorally and intraorally regarding the herpes zoster lesions. Few pigmented areas were present over the skin corresponding to the previous lesions. Patient was asked to taper the dose of corticosteroids gradually and finally all the were stopped. The patient was further reviewed and treated for by using the combination of corticosteroids and hyaluronic acid intralesionally.

REVIEW Herpes zoster (HZ) is the reactivated form of the (VZV). It is commonly known as Shingles, derived from the Latin word cingulum, meaning ‘girdle’. This is because a common presentation of herpes zoster involves unilateral rash that can wrap around the waist or chest, like a girdle. Similarly, the name zoster is derived Fig. 9: Intraoral healed lesional areas Journal of Indian Academy of Oral Medicine and Radiology, January-March 2012;24(1):51-55 53 K Srikrishna et al distribution of the and is believed to represent Facial and intraoral lesions are characteristic of HZ viral degeneration of nerve fibrils.8 During this period, if involving the second and third divisions of the trigeminal branches of the trigeminal nerve are affected, odontalgia nerve. Lesions affecting maxillary nerve involve mid face, may occur.9 In this condition, the reactivated virus may scalp on the anterior part of the temporal region, lower travel along the length of the nerve, infect the eye lid, upper lip and lateral side of the nose.15 Lesions vasculature which leads to infarction and of pulp.8 affecting the mandibular nerve involve lower face, tongue The symptoms of the prodromal stage may present up to and lower lip. 1 month or for more duration before the acute mucocutanous The history and clinical examination largely lead to the lesions appear, posing diagnostic difficulties to the clinician. diagnosis, however for the confirmation, patients can be This is known as zoster sine herpete or zoster sine subjected for investigations like , antigen eruptione.8,9 The active stage is characterized by the detection test by using modified Tzanck technique, emergence of the rash which is usually accompanied by Serological test via ELISA or latex agglutination, systemic upset. The characteristic skin rash progresses from Polymerase chain reaction (PCR). PCR is useful to detect erythematous and edematous to vesicles and finally VZV DNA in body fluids, even when the patient is not results in the formation of pustules within 1 to 7 days. Later having active infection. the lesions may dry to form crustations, which will be In majority of the patients herpes zoster is a self-limiting exfoliated over 2 to 3 weeks leaving erythematous macules condition and healing is usually complete. However, the that may form scar. It may take several weeks for the skin active management is indicated as follows: to become normal. During the active phase the HZ will be • To reduce the acute symptoms of pain and , most contagious and could pose a significant cross infection • To limit the spread and duration of the skin lesions and risk. A child without prior contact with VZV can develop • To prevent the development of postherpetic neuralgia chickenpox after contact with an individual with HZ. The and ophthalmological complications in herpes zoster chronic stage is seen in approximately 10% of all patients ophthalmicus. with HZ, and is termed as postherpetic neuralgia (PHN). It Early diagnosis and prompt treatment of the in is defined as a brief, recurrent, shooting, deep pain remaining the prodromal phase by the use of antiviral agents should for over a month or 3 months after the healing of the be the mainstay of its management. mucocutaneous lesions. It may persist for years and is a To start with, the patient should be isolated to prevent significant cause of morbidity. Risk of occurrence of the transmission of the virus to healthy individuals. Keep postherpetic neuralgia increases significantly after the age the cutaneous lesions clean and dry to reduce the risk for of 60 years, which may be due to the decline in cell-mediated bacterial superinfection. The lesions should be protected 10 immunity. Although postherpetic neuralgia is the most with sterile, occlusive, nonadherent dressing and patient common complication of HZ, other complications like acute is instructed to wear loose fitting clothes for their comfort. retinal necrosis, , , peripheral nerve If patient is not able to take proper diet, then he or she palsies, contralateral hemiparesis can occur. Immuno- should be kept on intravenous fluids. Antiviral therapy compromised individuals with HZ exhibit a significantly (Table 1) has been shown to be very much beneficial in higher rate of complications. Periapical lesions, root decreasing the duration of viral shedding, new lesion resorption, tooth exfoliation and alveolar osteonecrosis have formation, severity of pain and accelerating the events of also been reported in association with HZ infection.11,12 If cutaneous healing. However, these benefits have only the geniculate is involved, it may result in James demonstrated in patients who received antiviral agents Ramsay Hunt’s syndrome, which includes facial paralysis, within 72 hours after the onset of the rash.16 For effective painful vesicular eruptions of external auditory meatus and pain control short acting narcotic analgesics such as pinna of the .13 HZ may also occasionally affect motor oxycodone can also be given. nerves. HZ of the sacral region may cause paralysis of the bladder. The ophthalmic branch is affected several times more Table 1: Antiviral therapy for herpes zoster frequently than the second or third divisions. Lesions Dosage affecting ophthalmic nerve usually involve lacrimal glands, • Acyclovir 800 mg orally five times daily for 7 to 10 days or 10 mg per kg IV every 8 hours for 7 to conjunctiva, upper eyelid, forehead, scalp and root, lower 10 days half of the nose. HZ of the first division can lead to blindness • 500 mg orally three times daily for 7 days secondary to corneal scarring, which is known as herpes • Valacyclovir 1,000 mg orally three times daily for 7 days • Brivudin 125 mg once daily for 7 days zoster ophthalmicus.14 54 JAYPEE JIAOMR

Herpes Zoster: Report of a Treated Case with Review of Literature

Orally administered corticosteroids are commonly used 11. Ramchandani PL, Mellor TK. Herpes zoster associated with in the treatment of herpes zoster, even though clinical trials and periapical lesions. Br J Oral Maxillofac Surg 2007;45:71-73. have shown variable results. Corticosteroids thought to 12. Schwartz O, Kvorning SA. Tooth exfoliation, osteonecrosis of decrease the degree of caused by active infection, the jaw and neuralgia following herpes zoster of the trigeminal resulting in the reduction of the residual damage to affected nerve. Int J Oral Surg 1982;1:364-71. nerves. Prednisolone used in conjunction with acyclovir has 13. Sun WL, Yan JL, Chen LL. Ramsay hunt syndrome with been shown to reduce the pain associated with herpes unilateral polyneuropathy involving cranial nerves V, VII, VIII 17 and XII in a diabetic patient. Quintessence Int 2011;42:873-77. zoster. Oral corticosteroids can be used as 10 to 14 days 14. Shaikh S, Ta CN. Evaluation and management of herpes zoster tapering course of prednisolone, starting at 60 mg daily. ophthalmicus. Am Fam Physician 2002;66:1723-30. 15. Liu CL, Lee JYY, Hsu MML, Chao SC, Wong TW, Sheu HM. CONCLUSION The ocular complications of Herpes zoster ophthalmicus— a study of Hutchinson’s sign. Dermatol Sinica 1999;17:104-11. Herpes zoster of the trigeminal nerve is a disease that falls 16. Stankus S, Dlugopolski M, Packer D. Management of herpes within the diagnostic purview of all dental specialists. zoster (shingles) and postherpetic neuralgia. American family A thorough knowledge of this disease will help in early physician 2000;61(8):2437-44. diagnosis and prevents delayed treatment for the patient thus 17. Whitley RJ, Weiss H, Gnann J, Tyring S, Mertz GJ, Pappas PG, et al. Acyclovir with and without for reducing the complications. the treatment of herpes zoster. A randomized, placebo-controlled trial. The national institute of allergy and infectious REFERENCES collaborative antiviral study group. Ann Intern Med 1996;125: 1. Fristad I, Bardsen A, Knudsen GC, Molven O. Prodromal herpes 376-83. zoster–a diagnostic challenge in . International Endodontic Journal 2002;35:1012-16. ABOUT THE AUTHORS 2. Roxas M. Herpes zoster, postherpetic neuralgia. Diagnosis and therapeutic considerations. Altern Med Rev 2006;11(2): K Srikrishna 102-13. 3. Pattni N, Hudson P, Yates JM. Herpes zoster, odontalgia and Professor and Head, Department of Oral Medicine and Radiology nephropathy: A case report and review. Oral Surgery 2011;4: Hazaribag Institute of Dental Sciences, Hazaribag, Jharkhand, India 35-38. 4. Schmader KE, Dworkin RH. Natural history and treatment of MPV Prabhat herpes zoster. J Pain 2008;9:S3-9. 5. Thomas SL, Hall AJ. What does epidemiology tell us about Professor, Department of Oral Medicine and Radiology, St Joseph risk factors for herpes zoster? Lancet Infect Dis 2004;4: Dental College, Eluru, Andhra Pradesh, India 26-33. 6. Carmichael JK. Treatment of herpes zoster and postherpetic Praveen Kumar Balmuri (Corresponding Author) neuralgia. AmFam Physician 1991;44:203-10. Reader, Department of Oral Medicine and Radiology, St Joseph Dental 7. Strommen GL, Pucino F, Tight RR, Beck CL. Human infection College, Eluru, Andhra Pradesh, India, e-mail: [email protected] with H zoster: Etiology, pathophysiology, diagnosis, clinical course and treatment. Pharmacotherapy 1988;8:52-68. 8. Tidwell E, Hutson B, Burkhart N, Gutmann JL, Ellis CD. Herpes S Sudhakar zoster of the trigeminal nerve third branch: A case report and Reader, Department of Oral Medicine and Radiology, St Joseph Dental review of the literature. Int Endod J 1999;32:61-66. College, Eluru, Andhra Pradesh, India 9. Gregory WB, Brooks LE, Penick EC. Herpes zoster associated with pulpless tooth. J Endod 1975;1:32-35. D Ramaraju 10. MacFarlane LL, Simmons MM, Hunter MH. The use of corticosteroids in the management of herpes zoster in children Professor, Department of Oral Medicine and Radiology, SVS Institute and adolescents. Pediatr Infect Dis J 1998;17:905-08. of Dental Sciences, Mahabubnagar, Andhra Pradesh, India

Journal of Indian Academy of Oral Medicine and Radiology, January-March 2012;24(1):51-55 55