|Year : 2016 | Volume
| Issue : 4 | Page : 273-276
A clinicomorphological study of childhood herpes zoster at a rural based tertiary center, Gujarat, India
Rita V Vora, Rahul Krishna S Kota, Nidhi B Jivani
Department of Skin and VD, Shree Krishna Hospital, Anand, Gujarat, India
|Date of Web Publication||7-Oct-2016|
Rita V Vora
Skin OPD, Room No 111, Shree Krishna Hospital, Karamsad, Anand - 388 325, Gujarat
Source of Support: None, Conflict of Interest: None
Aims and Objectives: To study the clinical features of herpes zoster (HZ) in childhood along with prevalence of human immunodeficiency virus (HIV) seropositivity.
Materials and Methods: The study was carried out in the Department of Dermatology at a Tertiary Care Centre of Gujarat, India, for 6 years. Children aged ≤12 years with a diagnosis of HZ seen in the Departments of Dermatology were enrolled in a predesigned pro forma. Diagnosis of HZ was made on clinical grounds, confirmed by tzanck smear as and when required. Sera of all cases were tested for HIV.
Results: Total of 34 children aged ≤12 years were enrolled in the study. Nineteen (55.88%) were boys and 15 (44.12%) were girls. The mean age was 9.26 years. In 97.06% patient have localized dermatomal involvement. Most common symptom was burning pain seen in 30 (88.24%) patients. Previous history of chickenpox was present in 19 (55.88%) patients. Evidence of immunosuppression on history, clinical examination, and investigations was present only in one patient, who had HIV infection.
Conclusion: Although there is increased incidence of HZ in childhood, atypical presentations are rare, multidermatomal involvement is not commonly seen. Majority of these children do not show immunosuppression. Hence, we conclude HZ in childhood occurs as a relatively mild and self-limiting disease.
Keywords: Childhood, herpes zoster, immunosuppression
|How to cite this article:|
Vora RV, Kota RK, Jivani NB. A clinicomorphological study of childhood herpes zoster at a rural based tertiary center, Gujarat, India. Indian J Paediatr Dermatol 2016;17:273-6
|How to cite this URL:|
Vora RV, Kota RK, Jivani NB. A clinicomorphological study of childhood herpes zoster at a rural based tertiary center, Gujarat, India. Indian J Paediatr Dermatol [serial online] 2016 [cited 2020 May 30];17:273-6. Available from: http://www.ijpd.in/text.asp?2016/17/4/273/179505
| Introduction|| |
Herpes zoster (HZ) is a localized disease characterized by unilateral radicular pain and vesicular eruption limited to dermatome innervated by a single spinal or cranial sensory ganglion. It is caused by the neurodermotropic virus called“varicella zoster virus” (VZV) distributed worldwide. This benign localized viral disease has been recognized as a distinct entity since ancient times. It occurs as a result of reactivation of VZV that is lying dormant in the sensory ganglion following an earlier attack of varicella. During varicella infection, VZV passes from skin lesions into cutaneous sensory nerve endings and then travels centripetally to sensory ganglia where it remains in the latent stage. On reactivation, which is triggered by many factors, it travels back along the sensory afferents to the skin associated with hematogenous dissemination. Depending upon the immune status of the patient, the presentation may vary from no clinical lesions to typical zoster, scattered vesicles, zoster sine herpete, or disseminated zoster.
HZ has traditionally affected persons with more than 60 years of age. Lifetime risk in people who survive to 85 years is 50%. The condition is benign and self-limiting in patients with normal immunological status. Although extensive data regarding HZ in adults is available, studies regarding this disease in children are limited. Studies have shown an increasing incidence of childhood zoster. Overall rate of occurrence of HZ is 3.40 cases per 1000 persons while in children <10 years, it is 0.74/1000. The attack rate during the seventh decade is approximately 7 times the attack rate in the first two decades of life. Historically, childhood HZ was thought to be an indicator for an underlying malignancy or immunosuppression. HZ may also occur in immunocompetent children, and recent reports show an increase in the number of cases in apparently healthy children. This study was conducted to study the clinicoepidemiology, association of immunosuppressive states, and prevalence of seropositivity in children with HZ.
| Materials and Methods|| |
The study was carried out in the Department of Dermatology in a teaching institute at a rural-based Tertiary Care Centre of Gujarat from June 2008 to May 2014 after getting ethical approval from HREC department of the institute. This was a cross-sectional, observational study. The study population included all the patients with a diagnosis of HZ, who were seen in the dermatology department, aged ≤12 years. Detailed history regarding precipitating factors, preexisting illness, drug history, chief complaints, dermatome involved, type of pain, prodromal symptoms, and detailed clinical examination was entered in a predesigned pro forma. The diagnosis of HZ was made on clinical grounds and confirmed by tzanck smear as and when required. Sera of all cases were tested for antibody to human immunodeficiency virus (HIV) after taking written informed consent from the parent of the child, using a commercially available immunocomb test. Subsequently, seropositivity was confirmed by Western blot assay.
| Results|| |
A total of 34 children with HZ were enrolled during 6 years in our study. Nineteen (55.88%) were boys and 15 (44.12%) were girls. The mean age of presentation was 9.26 years ranging from 4 to 12 years. Twenty (58.82%) patients presented to us within 3 days of the appearance of zoster, whereas 11 (32.35%) patients presented between 3 and 6 days, and 3 (8.82%) patients presented 6 days after developing lesions of HZ. Itching was the most common prodromal symptom seen in 15 (44.12%) patients [Table 1]. Most common presenting complaint was burning type of pain seen in 30 (88.24%) patients followed by throbbing pain and itching in 5 (14.71%) and 4 (11.76%) patients, respectively. Previous history of chicken pox in patient or chicken pox or HZ in close contact was present in 19 (55.88%) patients while 2 patients do not remember and rest deny chicken pox in the past. All the patients had unilateral involvement. Left-sided dermatomes were involved in 20 patients (58.82%), whereas right-sided dermatomes were involved in 14 patients (41.18%). Thirty-three patients (97.06%) had localized involvement, whereas 1 (2.94%) patient had multiple dermatomal involvement. Most common dermatome involved was thoracic in 20 (50%) patients followed by lumbar dermatome in 8 (23.53%) patients [Table 2] and [Figure 1] and [Figure 2]. All the 34 patients screened for HIV infection, one patient was found to be HIV positive; subsequently, it was confirmed by Western blot. No child has been immunized against varicella virus.
|Figure 1: Grouped vesicular lesions involving left T4 dermatomes in a 10-year-old boy on day 2|
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|Figure 2: Grouped vesicular lesions involving right C8 dermatomes in a 6-year-old girl on day 3|
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| Discussion|| |
HZ is a viral infection caused by reactivation of the VZV, a double-stranded DNA virus belonging to alpha Herpesviridae family. The virus lies latent in sensory ganglia after primary varicella exposure (chicken pox). HZ can arise years or decades following primary infection with VZV. Generally, reactivation occurs in the elderly and is associated with loss of cellular immunity which is varicella zoster virus-specific. HZ occurs less frequently among children, typically causing mild disease with minimal pain. It may be seen in children with acquired cellular immune deficiency as in patients on chemotherapy or with HIV. HZ may also occur in immunocompetent children as recent reports show an increase in the number of cases in apparently healthy children. Several authors have studied the epidemiology and clinical patterns of this condition in the pediatric population. There is increased incidence of HZ with an increase in age which can be explained by reduction of the cell-mediated immune response mechanism to VZV in older adult patients. The majority of cases of childhood zoster occur after the age of 5 years. Important factor in determining the onset of zoster in childhood is the immunological status of the child at the time of primary infection. Low levels of lymphocytes, natural killer, and cytokines, along with virus-specific immunoglobulins result in early appearance of zoster in infants.
The diagnosis of HZ is mostly clinical, but when in doubt, laboratory investigations such as tzanck smear preparation of scrapings from the floor of the vesicles, which reveal multinucleated giant cells on direct microscopy, or by direct fluorescent antibody tests, presence of high or rising titers to VZV, or culture studies can fetch the diagnosis. HZ should be differentiated from zosteriform herpes simplex, which is more common in children, and can be done by direct fluorescent monoclonal antibody test or by detection of serum specific immunoglobulin M by the indirect fluorescent antibody method. The other differential diagnosis for dermatomal vesicular eruptions in children is bullous impetigo and bullous insect bite reaction. As the above-mentioned tests were not available to us, our diagnosis was mainly clinical or by tzanck smear in doubtful cases. Rising incidence of HZ in otherwise healthy children can be attributed to acquiring primary varicella infection in utero, or in infancy, wherein the immunity is not fully developed. Vaccination with live attenuated virus may also contribute.
Our study showed male preponderance similar to Malik et al. study  and in contrast to Prabhu et al. study which showed female preponderance. All the patients aged between 4 and 12 years. Mean age of presentation was 9.26 years in our study, whereas Malik et al. study showed mean age of 8.2 years. In our study, 55.9% patients had a history of chicken pox in patient or chickenpox or HZ in close contact while in Malik et al. study, it was seen in 31% patients. In these cases, where the history of varicella was not obtained, it is suggested that the initial contact with the virus may result in zoster. None of our patients were vaccinated for varicella virus. Evidence of immunosuppression was seen only in 1 (2.94%) patient in our study, in contrast to Malik et al. study, in which 7 out of 42 patients showed evidence of immunosuppression in the form of hepatitis C virus infection in 3 patients, pulmonary tuberculosis in 2 patients, leukemia in one patient, and the other patient was on steroid treatment. Three children had shown hepatitis C positivity, this might be due to the second highest prevalence of hepatitis C in the world ranging from 4.5% to 8% in Pakistan. Historically, childhood HZ was thought to be an indicator for an underlying malignancy or immunosuppression. About 3% of pediatric zoster cases were associated with malignancies, whereas recent studies have shown no increase in the incidence of malignancy in children with HZ. Our study proves the same. In Malik et al's. study, only one patient had malignancy (leukemia), whereas in our study, there was not even a single case of malignancy.
In our study, there was left-sided preponderance similar to Malik et al. study. The thoracic dermatomes were most commonly affected dermatome in half of the patients followed by lumbar dermatome in 23.5% patients. Similar findings were reported by Malik et al. Prabhu et al., Bharija et al. and Hope- Simpson's  studies, and various other studies,,,, whereas Leung et al. noted predilection of cervical and sacral dermatomes.
Very few case reports of childhood HIV patients acquiring zoster are reported. In our study, an 11-year-old girl diagnosed to be HIV positive 1 year ago, who had blood transfusion for anemia 2 years back presented to us with typical presentation of HZ involving left-sided single cervical dermatome (C6). In HIV patients, progressive primary varicella, a syndrome with persistent new lesion formation and visceral dissemination, may occur and may be life-threatening.
Clinical features included pain, itching, and fever. Itching was seen as prodromal symptom in 44.1% patients, whereas it was present in active disease only in 4 (11.8%) patients. Most common presenting complaint was burning type of pain in 88.2% patients, whereas in Malik et al. study, itching was the most common presenting complaint. In Malik et al. study, 69% patients showed one dermatome involvement and 28.6% showed involvement of 2 dermatomes. More than 2 dermatomes were involved in only 1 (2.4%) patient, whereas in our study, only 1 (2.94%) patient had multidermatomal involvement. Incidence of postherpetic neuralgia in childhood is rare., As the nature of HZ in children is mild, treatment among healthy children is symptomatic, and antiviral therapy is reserved usually for immunocompromised or children with disseminated disease.
| Conclusion|| |
HZ is increasingly being observed in children. Most of them show no evidence of immunosuppression and the disease is generally mild and of shorter duration than its adult variety. Previous exposure to varicella is seen only in about half of the patients. Most common dermatome involved is thoracic dermatome in children. Atypical presentations are very rare when compared to adults and elderly patients.
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Conflicts of Interest
There are no conflicts of interest.
| References|| |
Straus SE, Schmader KE, Oxman MN. Varicella and herpes zoster. In: Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, editors. Fitzpatrick's Dermatology in General Medicine. 6th
ed., Vol. 2. New York: McGraw-Hill; 2003. p. 2070-85.
Talwar S, Shrivastava VK. Herpes zoster ophthalmicus with total ophthalmoplegia. Indian J Dermatol Venereol Leprol 1991;56:454-5.
Talwar S. Herpes zoster associated with varicelliform eruption. Indian J Dermatol Venereol Leprol 1991;57:52.
Prabhu S, Sripathi H, Gupta S, Prabhu M. Childhood herpes zoster: A clustering of ten cases. Indian J Dermatol 2009;54:62-4.
Jain A, Singal A, Baruah MC. Herpes zoster in a 9 - month - old infant. Indian J Dermatol Venereol Leprol 1999;65:294-5.
Hope-Simpson RE. The nature of herpes zoster: A long-term study and a new hypothesis. Proc R Soc Med 1965;58:9-20.
Kakourou T, Theodoridou M, Mostrou G, Syriopoulou V, Papadogeorgaki H, Constantopoulos A. Herpes zoster in children. J Am Acad Dermatol 1998;39(2 Pt 1):207-10.
Terada K, Kawano S, Yoshihiro K, Miyashima H, Morita T. Characteristics of herpes zoster in otherwise normal children. Pediatr Infect Dis J 1993;12:960-1.
Takayama N, Yamada H, Kaku H, Minamitani M. Herpes zoster in immunocompetent and immunocompromised Japanese children. Pediatr Int 2000;42:275-9.
Gnann JW Jr., Whitley RJ. Clinical practice. Herpes zoster. N Engl J Med 2002;347:340-6.
Berger R, Florent G, Just M. Decrease of the lymphoproliferative response to varicella-zoster virus antigen in the aged. Infect Immun 1981;32:24-7.
Whitley RJ. Varicella-zoster virus. In: Mandell GL, Bennett JE, Dolin R, editors. Principles and Practice on Infectious Diseases. 7th
ed. Philadelphia: Churchill Livingstone/Elsevier; 2011. p. 1963-70.
Guess HA, Broughton DD, Melton LJ 3rd
, Kurland LT. Epidemiology of herpes zoster in children and adolescents: A population-based study. Pediatrics 1985;76:512-7.
Papadopoulos AJ, Birnkrant AP, Schwartz RA, Janniger CK. Childhood herpes zoster. Cutis 2001;68:21-3.
Gupta LK, Khare AK, Mittal A, Kuldeep CM. Herpes zoster in infancy. Indian Dermatol Online J 2013;4:252-4.
Terada K, Tanaka H, Kawano S, Kataoka N. Specific cellular immunity in immunocompetent children with herpes zoster. Acta Paediatr 1998;87:692-4.
Solomon AR. New diagnostic tests for herpes simplex and varicella zoster infections. J Am Acad Dermatol 1988;18(1 Pt 2):218-21.
Malik LM, Azfar NA, Rahim Khan A, Ijaz H, Jahangir M. Herpes zoster in children. J Pak Assoc Dermatologists 2013;23:2267-71.
Latif R, Shope TC. Herpes zoster in normal and immunocompromised children. Am J Dis Child 1983;137:801-2.
Khattak MF, Salamat N, Bhatti FA, Qureshi TZ. Seroprevalence of hepatitis B, C and HIV in blood donors in Northern Pakistan. J Pak Med Assoc 2002;52:398-402.
Bharija SC, Kanwar AJ, Belhaj MS. Herpes zoster. Indian J Pediatr 1988;55:301-3.
Leung AK, Robson WL, Leong AG. Herpes zoster in childhood. J Pediatr Health Care 2006;20:300-3.
von Seidlein L, Gillette SG, Bryson Y, Frederick T, Mascola L, Church J, et al.
Frequent recurrence and persistence of varicella-zoster virus infections in children infected with human immunodeficiency virus type 1. J Pediatr 1996;128:52-7.
Baba K, Yabuuchi H, Takahashi M, Ogra PL. Increased incidence of herpes zoster in normal children infected with varicella zoster virus during infancy: Community-based follow-up study. J Pediatr 1986;108:372-7.
[Figure 1], [Figure 2]
[Table 1], [Table 2]