Learning along the way!
"The life so short, the craft so long to learn."
Hippocrates
I always remember this quote. Each day there is something new to learn and each patient we see teaches us something new.I have been seeing this lady for about two years now. She is my regular patient getting treated for diabetes mellitus. This particular day she barged into the consultation room with her 10 year old daughter looking very worried.
She said her daughter has developed a rash on her abdomen and says its quite painful. It has been there for 3 to 4 days now but pain and itching has worsened since last night. I said lets have a look at it, she had red vesicles (fluid filled blisters) on the right side of her torso like a band. It was a spot diagnosis: "Herpes zoster/shingles".
Herpes zoster is an acute cutaneous (skin) viral infection caused by reactivation of varicella zoster virus, a herpes virus that causes chicken pox. After a bout of chicken pox the virus remains dormant in the nerve roots for years or decades, when the host immunity is compromised due to some reason this virus reactivates and presents as herpes zoster.
Some of us might have seen a grandparent have a serpentine red band like rash on their torso and they are constantly nagging about the pain it causes even after years. It is called post herpetic neuralgia (PNH).
There was absolutely no doubt about the diagnosis, I have seen this many a time in my practice mostly in elderly, in people with decreased immunity like HIV, Renal failure, Post transplantation, underlying malignancy to name a few.
Here I was seeing a young girl, otherwise healthy child. There was nothing to suggest on history and clinical examination of any underlying immunocompromised condition. I was still wondering if I need to work up for any underlying condition.
This is what I learnt from the literature:
Herpes Zoster in Otherwise Healthy Children
Feder, Henry M. Jr. MD*; Hoss, Diane M.
MD†
In normal infants and children, zoster can occur at
any time after varicella or varicella vaccination. It is usually
diagnosed clinically: a unilateral vesicular eruption following a
dermatome or dermatomes. The incidence of zoster increases with age,
although children who have had varicella during the first year of life
(or in utero) are at increased risk of developing zoster. The
incidence of zoster is less after varicella vaccination than after
natural infection. Zoster in children is frequently mild, postzoster
neuralgia rarely if ever occurs, and antiviral therapy is usually not
needed. In a previously normal child with zoster, if the history and
physical examination are normal, a laboratory search for occult
immunodeficiency or malignancy is not needed.
Pediatric Infectious Disease Journal:
All the literature I read pointed to the same thing, and of course in discussion with the pediatrician I learnt although rare, they do see herpes zoster in healthy children.
As for my patient, she improved with symptomatic treatment without the antiviral treatment.She was totally fine in a week.
Some points to take away:
Adult Vaccination
Varicella vaccine(chicken pox vaccine)
- Persons aged over 13 years without evidence of varicella immunity should receive 2 doses of the vaccine 4-8 weeks apart. (those who never had chicken pox before)
- Post exposure prophylaxis
Varicella vaccine is recommended for post-exposure administration for un-vaccinated persons without other evidence of immunity against varicella. It
should preferably be given within 3 days of exposure to varicella rash and can be given up to 5 days of exposure to rash.
should preferably be given within 3 days of exposure to varicella rash and can be given up to 5 days of exposure to rash.
Zoster vaccine
Although vaccine is available in india, due to lack of reliable epidemiological data about the burden of herpes zoster it is not yet recommended for routine use. In developed countries, herpes zoster vaccine is being advocated to adults aged 60 years and above who are at high risk for developing recurrent herpes zoster, such as patients with chronic medical conditions (e.g., CKD, diabetes mellitus,.rheumatoid arthritis, and chronic pulmonary disease); persons
who are likely to have severe immunosuppression in near future.
who are likely to have severe immunosuppression in near future.