CASE REPORT: HERPES ZOSTER

Supervised by : dr. Mimi Maulida, Sp.KK

Presented by: Veliqa Nadhila Fariyasni

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

INTRODUCTION
Definition Herpes zoster is a viral infection because the reactivated of latent Varicella Zoster viral in cranial-nerve or dorsal-root ganglia, with spread of the virus along the sensory nerve to the dermatome.

Etiology Human herpes virus 3 (HHV3) belongs to the herpes virus family ( Herpesviridae)

Epidemiology <45 years : 1 in 1000 >75 years : 4x more greaters 80 years : Risk of developing zoster is 1030%. More than 1 million cases of herpes zoster in the United States each year, with an annual rate ofCohen 3 to JI, 4 2013;369:255-63 cases per 1000 James WD, 2012:372 persons.

PATHOGENESIS Infection with VZV occurs

when the virus comes into contact with the mucosa of the upper respiratory tract or the conjunctiva of the eye. The virus travels in the bloodstream via mononuclear cells to the skin, resulting in the generalized rash of chickenpox Essentially protected from the human immune system, VZV typically remains dormant in the dorsal root ganglia of the spinal column and cranial nerve ganglia for decades

Gross G. Clinical Picture and Complications of Herpes Zoster: The View of the Dermatologist. MonogrVirol 2006;26:20

Dermatomes involved herpes zoster, which is T3 to L3 are most affected

Diagnosis 1. Prodromal : -Pain, itching and tingling in area affected -Headache, malaise, photophobia -Abnormal sensation : burning, throbbing or stabbing on lesion 2. Rash: -Begins as macules and papules vesicles then pustules Dries and crusted after 7-10 days - Rash doesnt cross the midlines and dermatomal
-

Laboratory is for atypical case : PCR (Polymerase Chain Reaction)

Management
A. DRUG THERAPY (conventional therapy) Antiviral agents Corticosteroid Analgesics NSAIDs

B. NON DRUG THERAPY (natural therapy) - Dietary/multiple nutrient Effects - Other Nutritional consideration

TREATMENT OF HERPES ZOSTER

PATIENT IDENTITY

Name : Ms. EPD Sex : Female Registration number : 96-85-20 Age : 18 years old Address : Lingke Examination date : September 10th 2013

ANAMNESIS
The Chief Complain

Vesicles with pain on the left side of thorax since 2 days before admission

HISTORY OF PRESENT ILLNESS

o Patient found reddish rash around her left thorax then after 1 day she found the same vesicles with erythematous base with pain, itchy and burning sensation around her left in front and back side of thorax. The rash become more itchy and pain. o Patient also felt her body becomes weak and convinced of fever. Fever was felt after the rash appear. Patient confesses that she has a lot of activity and admitted fatigue 3 days before the vesicles appears. Patient denied she got any insect bite or had a rash after consumed any food consist of wheat and yodium.

DERMATOLOGICAL STATUS

a/r Thorachalis sinistra et anterior and posterior found group vesicles on an erythematous base, zosteriform arrangement, some lesion are confluens and there is normal skin among the lesion, milier to lentikuler size, and unilateral distribution in the left T3 dermatomes

DIFFERENTIAL DIAGNOSIS

Dermatitis Herpetiformis Dermatitis Venenata Herpes zoster

PLANNING DIAGNOSIS

Tzank smear, but not checked. If this tzank test being checked a result is a multinucleated giant cell will be found in microscopic examination

DIAGNOSIS

Herpes Zoster at regio thorachalis anterior and posterior sinistra in the left T3 dermatomes

Systemic Medication : Antiviral : Acyclovir 5 x 800 mg (for 7 days) Analgetic : Mefenamic acid 3 x 500 mg Topical Medication : Apply salicil talc 2% over the lesion

TREATMENT

Education

Do not touch or scratch over the lesion.

Take a rest and dont do a lot of activity during 1 week Dont afraid if the lesion appear more than before, because the active phase of the infection that will be least in 1 week. After 1 week lesion will be crusted and heals normally and sometimes will get a pain and burn sensation over the lesion Take a medicine routinely as

PROGNOSIS

Quo ad vitam : dubia ad bonam

Quo ad functionam : dubia ad bonam

Quo ad sanactionam : dubia ad bonam

SECOND VISIT AT SEPTEMBER 17TH , 2013

The Chief Complain

Itchy and burning sensation of the previous lesion and arise new lesion on the left arm since 4 days ago

HISTORY OF PRESENT ILLNESS

o Patient complained itchy and burning sensation of the previous lesion. Some of the lesion already crusted, but another lesion still prominent o One day after admission to hospital, patient also found a new lesion on the left arm. The lesion was same with the previous lesion on the left thorax o Now the lesion on arm was already crusted too. Patient also confess that she routinely take a medicine as prescribed and feel more better than before

DERMATOLOGICAL STATUS

a/r Thorachalis sinistra et anterior and 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, milier to lentikuler size, and unilateral distribution in the left T3 dermatomes a/r Antebrachii sinistra et anterior and posterior found macula erythematous with crusted lesion, zosteriform arrangement, some lesion are confluens, milier size and unilateral distribution in the left T2 dermatomes.

TREATMENT

Systemic Medication : Analgetic : Mefenamic acid 3 x 500 mg

Topical Medication : Apply Mupiracin oint over the lesion 3 x 1

DISCUSSION
Patient is female in ages 18 years which is does not fit with incidence of herpes zoster based on the theory

The major risk factor for herpes zoster is increasing age, unlike levels of virus specific antibodies correlates with protection against herpes zoster. The risk is higher for women than man

Herpes zoster usually begins Patient ever felt her body becoming with a prodrome such as fatigue and also get fever for a few pain, itching or tingling on the day that indicate prodromal state of area that becomes affected. herpes zoster clinical features. She Typically, patients experience also experienced headache, pain headache, malaise and and itchy on the lesion sometimes photophobia or fever.

DISCUSSION
The rash of herpes zoster is The lesions appear on the left side of dermatomal and does not cross thorax which refers to T3 and in the left the midline arm which refers to T2 dermatomes that The thoracic (53%), cervical (20%), compliance as the most commonly trigeminal (15%) and lumbar(11%) involved dermatomes in herpes zoster dermatomes are the most frequent sites of rash

More severe cases may be treated, if seen within 48 hours of onset, with oral aciclovir (800 mg 5 timesper day for 7 days) or famciclovir(750 mg once daily for 7 days) which promote resolution, reduce the viral shedding time and may reduce post-herpetic neuralgia.

Patients as in this case is given an antiviral medication, which is oral Acyclovir five times daily with doses 800 mg for 7 days

Most complication is PHN (post herpetic neuralgia) PHN may suffer from constant pain (described as burning, aching, throbbing), intermittent pain ( stabing, shooting), and/or stimulus-evoked pain, including allodynia (tender, burning, stabbing) Age is the most significant risk factor for PHN. Clinically significant pain lasting 3 months or more is rare in immunocompetent persons younger than 50 years of age

Patient also dont have PHN which is involved by older age than younger

Supervised by : dr. Mimi , Sp.KK