|Year : 2016 | Volume
| Issue : 3 | Page : 337-341
Zoster and its lurking shadow
Hina Handa1, Balaji Gandhi Babu Dara2, Giridhar S Naidu3, Ashwini Deshpande1
1 Department of Oral Medicine and Radiology, People's Dental Academy, Bhopal, Madhya Pradesh, India
2 Department of Oral Medicine and Radiology, Panineeya Mahavidyalaya Institute of Dental Science and Research Centre, Hyderabad, Telangana, India
3 Department of Oral Medicine and Radiology, New Horizon Dental College and Research Institute, Bilaspur, Chhattisgarh, India
|Date of Submission||29-Jul-2015|
|Date of Acceptance||01-Dec-2016|
|Date of Web Publication||13-Dec-2016|
Dr. Hina Handa
Department of Oral Medicine and Radiology, People's Dental Academy, Bhopal, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
A large number of oral mucosal lesions result in severe post-affliction deficits. One such defect is neurological fall out. Herpes zoster is a condition that occasionally results in a dreadful post-infection neuralgic pain. Although shingles is generally regarded as a self-limited condition, it can take several weeks to resolve and has the potential for development of complications. To identify this as well as appropriate management is required. Patients affected are in such severe distress that alleviation of pain and successful treatment protocol should be the primary consideration. We report one such case, which was successfully treated, and also intend to highlight the current concepts in the management of such cases.
Keywords: Herpes zoster, Post-herpetic neuralgia, varicella zoster virus
|How to cite this article:|
Handa H, Dara BG, Naidu GS, Deshpande A. Zoster and its lurking shadow. J Indian Acad Oral Med Radiol 2016;28:337-41
| Introduction|| |
Herpes zoster (HZ), commonly presenting with pain and rash on the skin, is caused by the infection of latent varicella zoster virus (VZV). Infection with VZV causes two distinct clinical conditions. Primary infection produces long-term immunity to varicella. Trigeminal HZ involves the ophthalmic, maxillary, or mandibular distribution in multiple combinations. The most common and debilitating sequelae of HZ is post-herpetic neuralgia (PHN). HZ mainly manifests unilaterally, does not cross the midline, and is localized to a single dermatome of a single sensory ganglion (adjacent dermatomes are involved in 20% of cases). Complications include scarring, hearing loss, conjunctivitis, and PHN. Hodgkin's lymphoma, radiation therapy and age more than 60 years are predisposing factors for the disease. Syndromes associated with the disease are Ramsay–Hunt Syndrome and Horners syndrome.
| Case Report|| |
A 54-year-old male patient reported to the department with the chief complaints of pain and ulceration on the right side of the face since 7 days. Patient gave a history of slight pain and burning sensation on the right side of the face, which was associated with small blister formations both on the skin of the right side of the face and inside the mouth on the palatal region. Patient had observed bursting of the blister and formation of raw ulcerations 5 days ago. There was no history of fever associated with the lesion. There was no significant history of hospitalization or illness. Patient also gave a history of extraction of the right upper front tooth 7 days back. The general physical examination was noncontributory.
On clinical examination, unilateral multiple encrustations were seen clustered on the right half of the face extending superiorly from right orbit to inferiorly up to the angle of mouth and medially from the right side of the face not crossing the midline, and laterally it extended up to the pre-tragal region [Figure 1]. On palpation, overlying skin was tender and surface of the skin was rough due to the presence of areas of crustations [Figure 2]. On intraoral examination, multiple areas of ulcerations were seen on the right half of the palate extending anteriorly from the rugae region to the junction of hard and soft palate posteriorly, mesially from midpalate raphae to interdental gingiva with respect to 11 to 16 laterally. The surface of the palatal lesion was covered with necrotic slough and the floor of the palatal lesion appeared erythematous [Figure 3].
|Figure 1: Right half of the face showing unilateral multiple encrustations|
Click here to view
|Figure 3: Intraoral view showing erythematous floor of the palatal lesion|
Click here to view
Based on the significant history and clinical manifestations, HZ of the right side of the face was considered as the provisional diagnosis. Investigations performed were exfoliative cytology, complete blood picture, liver function test, and serological essay. Cytology report was positive for viral bodies and other results were well within the normal range. HZ of the right side of the face involving maxillary division of trigeminal nerve was considered as the final diagnosis and treatment mentioned in [Table 1] was administered.
On 4th week follow-up, the patient reported pain and burning sensation on the right side of the face since 3 days. Pain was sudden in onset, sharp and shooting in nature, paroxysmal, and was radiating towards the right side ala of the nose and outer canthus of eye. Visual analog scale (VAS) was recorded to be 9. Infraorbital diagnostic nerve block was administered, following which the patient experienced relief in symptoms of pain and burning sensation, and VAS was reduced to 2. Post-herpetic neuralgia of the infraorbital division of the right maxillary nerve was confirmed as the final diagnosis. Treatment regime followed for PHN in the patient is presented in [Table 2].
| Discussion|| |
HZ (from the Greek herpein meaning to creep, and zoster meaning girdle or belt) is commonly referred to as shingles. It results from the reactivation of latent VZV in sensory dorsal root or cranial nerve ganglia. Maxillary and mandibular branches are the most commonly involved ones. Appropriate treatment and early diagnosis reduces the risk of long-term complications. PHN is the most dreadful complication of HZ in an immunocompetent host. It has been known that PHN is represented as a pain of moderate intensity, and is a constant or intermittent burning, itching or aching, with paroxysmal or lancinating pain. Research states that pain persists for ≥90 days after the onset of HZ rash. The disease is represented through different stages of prodrome, acute, active, and chronic stage, with chronic stage of PHN being debilitating where pain can persist for months or years after the acute disease phase.
Various drug trials done for treatment of PHN are shown in [Table 3]., A live attenuated HZ vaccine was effective in decreasing the incidence of herpes in people aged 60 years and older. Shingles vaccine (Zostavax®) reduces the risk of developing shingles and long-term pain from PHN caused shingles. The vaccine contained the strain used in the childhood VZV vaccine and was very potent. In a study conducted by Oxman et al. in the vaccine group there was a trend toward reduction in PHN cases compared with the placebo group (27/315 (8.6%) vs 80/642 (12.5%) patients). Similarly, a Cochrane review concluded that there was insufficient evidence to determine whether the vaccine was effective in preventing PHN beyond its effect on reducing herpes zoster.
In our case, complete follow-up was done, and by 8 weeks, no fresh lesions were noted, and the VAS score for PHN was reduced to 2. Gabapentin played a vital role in the management of pain, helping to improve the patient's quality of life with no side effects noted. [Figure 4] and [Figure 5] depict the patients profile after commencement of treatment. Early diagnosis, and accurate and timely management of the disease prevented neurological complications in the patient. Moreover, the patient was elderly and could possibly be immunocompromised. Our treatment protocol not only cured the patient but also led to an improvement of the quality of life of the patient [Figure 6] and [Figure 7].
|Figure 5: On right palatal region, size of lesion and erythematous area was reduced, but the lesion still persisted|
Click here to view
HZ, PHN, and other conditions that cause neuropathic pain adversely affect health-related quality of life, including physical and emotional functioning. Such assessments of the impact of pain on the health-related quality of life, combined with evaluation of the presence, location, duration, intensity, and quality of pain can provide the basis for future studies of pain and its response to treatment or prevention in patients with HZ and PHN.
| Conclusion|| |
The incidence of HZ and PHN increases with increasing patient age. Early diagnosis of HZ and treatment with antiviral medications decreases the risk of PHN. PHN is the most common complication and is difficult to treat. The treatment protocol may range from antiviral drugs to antidepressants. Current treatment protocol may shorten the duration and severity of acute HZ and alleviate the pain of PHN.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kwamin F, Parkins G, Nyako E. Herpes zoster infection is human immunodeficiency virus with maxillary and mandibular osteonecrosis with teeth exfoliation. Int J Dent Case Rep 2012;2:7-10.
Arvin A. Aging, immunity, and the varicella-zoster virus. N Engl J Med 2005;352:2266-7.
Gnann JW Jr. Vaccination to prevent herpes zoster in older adults. J Pain 2008;9(Suppl 1):S31-6.
Johnson RW, Dworkin RH. Treatment of Herpes zoster and postherpetic neuralgia. Br Med J 2003;326:748-50.
Schmader K, Gnann JW Jr, Watson CP. The epidemiological, clinical, and pathological rationale for the herpes zoster vaccine. J Infect Dis 2008;197(Suppl 2):S207-15.
Johnson RW. Zoster-associated pain: What is known, who is at risk and how can it be managed? Herpes 2007;14(Suppl 2):30-4.
Wilson JF. In the clinic. Herpes zoster. Ann Intern Med 2011;154:ITC31-15; quiz ITC316.
Dworkin RH, Portenoy RK. Pain and its persistence in herpes zoster. Pain 1996;67:241-51.
Oxman MN, Levin MJ, Johnson GR, Schmader KE, Straus SE, Gelb LD, et al
. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med 2005;352:2271-84.
Chen N, Li Q, Zhang Y, Zhou M, Zhou D, He L. Vaccination for preventing postherpetic neuralgia. Cochrane Database Syst Rev 2011:CD007795.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3]