Herpes zoster infection with trigeminal and facial nerve involvement

In most cases, herpes zoster (shingles) infections are benign and self-limited, requiring no treatment. However, if patients are elderly or immuno-compromised, they are at increased risk of complications such as visceral dissemination, cranial and nerve palsies, ophthalmic zoster, and postherpetic neuralgia. We present a case of herpes zoster infection complicated by both motor and sensory involvement in an elderly man.     

Complete ophthalmoplegia after herpes zoster

Motor loss caused by herpes zoster is infrequent, and only a few studies have focused on ocular motor paralysis in ophthalmic herpes zoster. We report a case of complete ophthalmoplegia resulting from ophthalmic herpes zoster. A 69-year-old man presented with complete left-side ptosis with total ophthalmoplegia 7 days after the onset of left ophthalmic herpes zoster. The patient was treated with aciclovir and prednisolone. Five months later, the ptosis had resolved and the extraocular motility had almost returned to normal.     

Passive immunotherapy in herpes zoster. A pilot study with intravenous hyperimmune globulin

While passive immunisation with hyperimmune globulin proved beneficial for the prevention of varicella infections in immuno-compromised patients, there has been no reliable evidence for such preparations to be effective with the treatment of or prophylaxis against zoster complications. This may be partly due to the minor significance of the humoral immune response in herpes zoster as well as to insufficient bioavailability of the preparation when administered intramuscularly. In an openly and prospectively conducted study, a recently available varicella-zoster hyperimmune globulin was intravenously given to an unselected group of 20 in-patients suffering from herpes zoster. There have not been observed any side effects. If therapy was started within the first week of manifestation of the disease (15 test persons), the patients showed rapid and uncomplicated healing.     

Annual pattern and clinical characteristics of herpes zoster in immunocompetent children in a rural area

This study aims to investigate the clinical signs, symptoms, complications and seasonal distribution of herpes zoster for otherwise healthy children and to demonstrate the outcome of varicella vaccinations on the herpes zoster incidence in a pediatric population. A retrospective study was conducted by using the data of the pediatric patients who were referred to two rural cities of Turkey, clinically diagnosed as Herpes Zoster (HZ). All participants were evaluated for clinical‐epidemiological factors, signs, symptoms, complications and varicella vaccination status for HZ. This study was comprised of 69 pediatric patients (29 [42%] female and 40 [58%] male) who were diagnosed with HZ. The mean age was 10.57 (6 months‐17) years old. The rash of HZ mostly appeared on the thoracic dermatome as seen in 29 patients. The findings revealed that among 56 unvaccinated patients of all, 25 (44.6%) had a painful rash, in comparison among vaccinated patients none reported pain as the characterization of shingles (P = .001). Annual distribution of cases showed two peaks (March and September), whereas in August no cases were detected. Of all participants, one patient had postherpetic neuralgia, who also had ophthalmic dermatomal involvement, and this was the only complication observed in this study cohort. In immunocompetent children, the most common involvement site was the thoracic dermatome. Our findings show that varicella vaccination has a protective role in the herpes zoster clinic, both by decreasing the prevalence and by making the infection course less severe.     

Herpes zoster in 2 sisters

Transmission of herpes zoster infection from one sister to the other is described, resultant from close everyday contacts. Clinical manifestations of the disease (severity, dissemination, course and type of involvement) were much more marked in the elder sister, suffering from disseminated Darier's dyskeratosis and marked debility. Herpes was complicated with vasculitis, necrosis, Pseudomonas aeruginosa infection, development of pneumonia and keratitis. Problems of treatment of such patients are discussed.     

Herpes zoster might be an indicator for latent COVID 19 infection

Various cutaneous manifestations have been observed in patients with COVID‐19 infection. Herpes zoster is a viral skin disease caused by varicella zoster that remains dormant in the dorsal root ganglia of cutaneous nerves following a primary chicken pox infection. In this report, we describe two cases COVID infection who first presented with herpes zoster. We are here by suggesting that the clinical presentation of HZ at the time of the current pandemic even in patients giving mild or no suggestive history of upper respiratory symptoms should be considered as an alarming sign for a recent subclinical SARS CoV2 infection.     

Corticosteroids for herpes zoster: what do they accomplish?

For some patients, herpes zoster infections not only result in acute pain but serious consequences, including postherpetic neuralgia and damage to ocular tissues. Some authors have recommended corticosteroids for the treatment of these acute symptoms and complications. The literature concerning the use of corticosteroids for herpes zoster, however, either provides conflicting results or includes recommendations based on clinical experience rather than clinical trials. The author performed a search of the literature to address the question of whether corticosteroids are well tolerated and effective for the treatment/prevention of the acute pain of herpes zoster, postherpetic neuralgia, and/or the ocular complications resulting from herpes zoster. While smaller trials found oral corticosteroids beneficial for preventing postherpetic neuralgia, larger, better designed trials have not found oral corticosteroids to be more efficacious than placebo in preventing postherpetic neuralgia. Trials investigating the effect of oral corticosteroids for the acute pain of herpes zoster have found that corticosteroids provide a statistically significant improvement. Whether these improvements are clinically significant is uncertain. Thus, oral corticosteroids may confer a slight benefit for initial symptoms as long as the patient is not at risk for complications resulting from corticosteroid therapy. Most trials of topical and injectable corticosteroids are limited by several shortcomings. Therefore, topical and most forms of parenteral corticosteroids have yet to be proven effective for the treatment of acute pain or prevention of complications. Two controlled, blinded trials investigating the use of intrathecal corticosteroid administration for intractable postherpetic neuralgia suggest that corticosteroid administration results in a significant improvement in pain. Despite this, several authors have voiced concern over possible serious adverse events with the intrathecal administration of corticosteroids. Intrathecal corticosteroids may provide a benefit for intractable postherpetic neuralgia, but because of risks of serious complications, this is a last-line option and should only be administered by experienced personnel.     

Ramsay Hunt syndrome in patients infected with human immunodeficiency virus

Ramsay Hunt syndrome (RHS) is defined as herpes zoster infection of the head and neck that involves the facial nerve. Immunocompromised people, such as those infected with human immunodeficiency virus (HIV), are predisposed to herpes zoster. However, reports of RHS in patients with HIV are rare. We report two cases of RHS in patients with HIV at our hospital, located in southern Brazil. We hope this report will increase the awareness of this condition among doctors caring for patients with HIV.     

Cost-benefit of oral acyclovir in the treatment of herpes zoster

Background Oral acyclovir is a costly antiviral agent shown to be effective in the treatment of herpes zoster. Herpes zoster runs a relatively benign course in young, healthy individuals, as compared with elderly and immunologically compromised patients, in whom complications are common. This study attempts to assess the cost-benefit of treatment with oral acyclovir in young healthy adults with herpes zoster. Patients and methods The records of 42 healthy young adults suffering from herpes zoster and treated with oral acyclovir (800 mg five times daily for 7 days) were compared with those of 40 healthy young adults with herpes zoster seen during the same period but treated without oral acyclovir. The duration of zoster-associated pain and the presence of complications were noted. Results There was no statistically significant difference in the duration of zoster-associated pain between the two groups of patients (P= 0.11). Other complications of herpes zoster were few and similar in the two groups. Conclusions At a cost of $250 to $300 for a 7–day course of oral acyclovir, the use of this antiviral agent in healthy young individuals with herpes zoster is not justified, especially in developing countries with limited resources.     

Wolf's isotopic response: rosacea appearing at the site of healed herpes zoster

A 40-year-old man developed an erythematous rash on the right side of his face 3 weeks after a herpes zoster infection at the same location. Examination revealed an erythematous papular eruption and telangiectasias along the ophthalmic and maxillary divisions of the right trigeminal nerve, exactly at the site of the consistent with previous herpes zoster infection, Wolf's isotopic response. Histological examination showed vascular ectatic dilatation and perivascular and perifollicular infiltration of lymphocytes and histiocytes consistent with rosacea. The rash was resistant to oral doxycycline and topical metronidazole 1% cream and resolved with oral isotretinoin therapy.     

Isolated double herpes zoster paresis involving the left facial nerve and the right peroneal nerve following disseminated herpes zoster

A 72-year-old Japanese male developed disseminated herpes zoster and could not easily walk due to right drop foot and pain. He soon developed numbness and pain on the left side of his face, and noticed difficulty closing his left eye. The left angle of his mouth dropped. The patient was diagnosed as having a double mononeuropathy (a left facial nerve paresis and a right peroneal nerve paresis) following disseminated herpes zoster. Given that the patient was elderly and had diabetes mellitus, the patient appeared to be an immunocompromised host. We also describe other rare complications of herpes zoster from the published work.     

Interleukin‐33 is expressed in the lesional epidermis in herpes virus infection but not in verruca vulgaris

Interleukin (IL)‐33 is released on cell injury and activates the immune reaction. IL‐33 is involved in antiviral reaction in herpes virus infection, but the source that secretes IL‐33 has not been identified. We speculate that keratinocytes injured in herpes virus infection secrete IL‐33. In order to detect IL‐33 in the lesional epidermis of patients with herpes virus infection, we immunostained several cutaneous herpes virus infection samples with an anti‐IL‐33 antibody, and compared them with cutaneous human papilloma virus (HPV) infection samples. We observed strong nuclear and mild cytoplasmic staining in epidermal keratinocytes of the lesional skin samples with herpes simplex virus and varicella zoster virus infections. However, staining was not observed in the epidermis of verruca vulgaris (VV) samples. We assumed that the strong immune reaction to herpes virus infection may depend on strong IL‐33 expression in the epidermis, while very weak immune reaction in samples from patients with VV may be due to low or no expression of IL‐33 in the lesional epidermis.     

Multiple erythematous nodules and ecthyma gangrenosum as a manifestation of Pseudomonas aeruginosa sepsis in a previously healthy infant

Pseudomonas aeruginosa septicemia is rare in healthy infants and children. Also not common, dermatologic manifestations such as ecthyma gangrenosum and indurated erythematous nodular lesions may be the first signs of pseudomonas infection, or may appear later in the course of the disease. Peripheral facial paralysis and mastoiditis are also rare and serious complications of acute otitis media caused by P. aeruginosa. We report a previously healthy 6-month-old boy who had an uncommon presentation and rare complications during the course of P. aeruginosa sepsis.     

Herpes folliculitis: clinical, histopathological, and molecular pathologic observations

BACKGROUND: Herpes folliculitis is a rare manifestation of herpes virus infection and it is often misdiagnosed. Diagnostic criteria are not well established, only 24 patients being reported in the literature. Recently it has been suggested that herpetic folliculitis is more common in infections with varicella zoster (VZV) than in those with herpes simplex viruses (HSV-1 and -2). OBJECTIVES: To refine diagnostic criteria for folliculitis caused by VZV, HSV-1 and HSV-2, and to study whether follicular involvement enables morphological differentiation between VZV and HSV infections. PATIENTS AND METHODS: Twenty-one patients with herpetic infection of follicular epithelium were assessed clinically and histopathologically. Polymerase chain reaction (PCR) studies for specific DNA of herpes viruses were performed on paraffin-embedded biopsy specimens. RESULTS: In 17 of our cases PCR was positive for VZV, four were positive for HSV-1, none for HSV-2. The clinical presentation of herpes folliculitis often lacked vesicles or pustules (14/21). Histopathological features were often devoid of ballooning (12/21), multinucleated giant cells (12/21) and keratinocytes with steel grey nuclei (15/21). The most consistent findings were lymphocytic folliculitis and perifolliculitis (20/21) and necrotic keratinocytes in follicular epithelium (12/21). In zoster, but not in varicella eruption or HSV infections, follicular involvement was unaccompanied by marked changes in the epidermal surface. CONCLUSIONS: In biopsy specimens taken from herpes virus infections, involvement of follicular units is more commonly encountered in VZV infections compared with HSV infections. Early in the course, herpes folliculitis presents as lymphocytic folliculitis devoid of epithelial changes considered to be diagnostic of herpes virus infections. Exclusive involvement of follicles is rather typical of zoster.     

Herpes zoster: a clinical study in 205 patients

Background:

Even though herpes zoster is a common condition its incidence and pattern of occurrence in the era of HIV disease is significant.

Aim:

To analyze the incidence, pattern of occurrence and evolution of herpes zoster with special attention to provocative factors if any.

Materials and Method:

This was an analytical study conducted for 2 years based on a preformed proforma containing preliminary information, a detailed clinical evaluation regarding the segment of involvement, morphology, pattern of lesions, complications, disseminations etc. and investigations to establish provocative factors if any.

Results:

Incidence of herpes zoster was mainly in the fourth and third decades of life. A definite history of chicken pox was present in only 63.4% cases. In the majority (70%) herpes zoster occurred spontaneously. In 30% cases, immunosuppression due to chemotherapy, malignancy, HIV infection, diabetes mellitus were observed. The commonest segment affected was thoracic (42.4%) followed by cranial (28.2%) and cervical (12.1%). Majority resolved in 7–14 days except immunosuppressed. 34.6% of the patients had complications such as secondary bacterial infection, post herpetic neuralgia, and motor weakness. Ten patients had HIV infection as a provocative factor.

Conclusion:

The results of incidence and clinical pattern of herpes zoster is almost parallel to the previous studies. Any factors of immunosuppression should be checked, especially HIV, particularly in disseminated and long-lasting cases.     

Is Eczema Herpeticum Associated with the Use of Hot Tubs?

Cutaneous bacterial infections, most commonly caused by Pseudomonas aeruginosa, have been clearly linked to use of hot tubs. A 10-year-old female with atopic eczema developed eczema herpeticum after hot tub use with a friend who had "fever blisters"; herpes simplex virus was recovered from cutaneous vesicles. Since herpesvirus has been shown to survive in the hot tub environment, herpes simplex should be considered as another potential cause of disease in the spa setting.     

Revisiting childhood herpes zoster

Herpes zoster is rare in otherwise healthy children, but it is more common in association with immunosuppression. Maternal varicella infection during pregnancy and varicella occurring in the newborn represent risk factors for childhood herpes zoster. However, some controversies persist about risk factors, diagnosis, and the natural history of childhood disease. In a 2-year prospective study, 18 children with herpes zoster were clinically diagnosed in outpatient consultations in a hospital dermatology unit. Data about age, dermatome involvement, underlying disease, and history of previous varicella were recorded. Tzanck smears, biopsy specimens, and sera were obtained from 18, 4, and 10 children, respectively. The varicella zoster virus major envelope glycoprotein gE was detected in 16 of 18 smears and all four biopsies. Herpes simplex virus I was demonstrated in one of the smears. The established risk factors for childhood herpes zoster were only found in one child. Evidence for previous full-blown varicella and varicella with few lesions was recorded in 7 and 4 of the 17 immunocompetent children, respectively. No history of varicella was recalled in 6 of 17 cases, although a serologic clue of past varicella infection (IgM negative, IgG positive) was disclosed. Recurrent herpes zoster was diagnosed in one immunocompromised child. Zoster-associated pain was localized and the disease severity remained mild in all children. Established risk factors for childhood herpes zoster were only rarely found in our series of patients. In contrast, unrecognized varicella and varicella with few lesions were frequently recorded and may represent additional risk factors for shingles in childhood. Zosteriform herpes simplex virus infections should be differentiated from childhood herpes zoster, emphasizing the importance of precise viral identification.     

Pediatric Human Immunodeficiency Virus Infection and its Cutaneous Manifestations

Acquired immunodeficiency syndrome was first observed in children in 1982. Human immunodeficiency virus (HIV) is now known to be the etiologic agent of this disease complex. Children acquire the viral infection in utero or perinatally, or by receiving contaminated blood products. The cutaneous manifestations include persistent oral thrush, herpes simplex, herpes zoster, molluscum contagiosum, and a variety of fungal and bacterial skin infections. Vasculitis, unusual drug eruptions, and cutaneous manifestations of nutritional deficiencies are also seen.     

CHILDHOOD HERPES ZOSTER: A CLUSTERING OF TEN CASES

Herpes zoster occurs due to reactivation of the latent varicella zoster virus and is usually a disease of the elderly. Childhood herpes zoster is believed to be rare, though recent studies suggest increasing incidence in children. Here we report ten cases of childhood herpes zoster, seven of which occurred within a short span of six months, at a tertiary care level hospital in Pokhara, Nepal. Only three of the ten children reported previous history of varicella infection and none was immunized against varicella. Though childhood herpes zoster accounted for less than 1% of the total zoster cases in the past, recent reports show an increase in the number of cases in apparently healthy children. So far, no studies have been done linking childhood herpes zoster with HIV, though there are many studies linking it with other immunocompromised conditions.     

Dissecting cellulitis of the scalp in 2 girls

Two girls with dissecting cellulitis of the scalp are described. In one Pseudomonas aeruginosa was isolated from the sinus discharge. Both patients were controlled with prolonged antibiotic therapy and periodic aspiration of the fluctuant lesions. Role of infection in perpetuating the condition is highlighted.