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Case Report

Herpes zoster infection: Report of a treated case

Kotya Naik Maloth, K. Vinay Kumar Reddy, Srikanth Kodangal, Kesidi Sunitha, Nagajyothi Meka1
Department of Oral Medicine and Radiology, Mamata Dental College and Hospital, Khammam, Telangana, 1Department of Oral Medicine and
Radiology, Dr. Hedgewar Smruti Runga Seva Mandals Dental College and Hospital, Hingoli, Maharashtra, India

ABSTRACT Access this article online

Herpes zoster (HZ) is an acute infectious viral disease result from
reactivation of the DNA varicella-zoster virus, which occurs
more frequently among older adults and immunocompromised
persons. The most common complication of HZ is postherpetic
neuralgia, a chronic often debilitating pain condition that can last
months or even years. Deaths attributable to zoster are common
among immunocompromised persons. Prompt treatment with
the antiviral drugs, corticosteroids and analgesics decrease the
severity and duration of acute pain from HZ. Here, we report
a treated case of HZ in 35-year-old male involving all three
branches of the trigeminal nerve without any complication.
Keywords: Acyclovir, herpes zoster, postherpetic neuralgia,
trigeminal nerve, varicella-zoster
Introduction
Herpes zoster (HZ) also known as “Shingles” is an acute
infectious viral disease result from reactivation of the DNA
varicella-zoster virus (VZV), which causes chickenpox.[1]
It manifests as painful vesicular eruptions of the skin or
mucous membrane in the area supplied by the affected
nerve.[2] The pain may persist for months, even years after
the muco-cutaneous lesions heal, and this phenomenon is
known as postherpetic neuralgia (PHN), one of the most
common complication of HZ. The most commonly affected
dermatomes are the thoracic (45%), cervical (23%) and
trigeminal (15%). HZ can affect any of the three trigeminal
branches, most commonly affecting the ophthalmic branch.
We report a treated case of 35-year-old male involving all
three branches of the trigeminal nerve.[3]
Case Report
A 35-year-old male patient reported to our department with
multiple vesicular eruptions containing a clear fluid on his
left side of the face associated with severe pain along the
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DOI:
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affected area. Lesions were preceded by prodrome of fever and
malaise for 5 days, followed by erythematous maculopapular
rash. On examination, there were multiple pins headed
active vesicular lesions on left side of the face involving the
outer canthus region, zygoma region, the ear, the upper and
lower lips and lower border of the face. Associated with pain,
pruritus, burning tingling sensation over the involved areas
[Figure 1]. Intraorally the labial mucosa of upper lip, lower
lip, left buccal mucosa, retromolar area and the left side of
the hard palate was also involved not crossing the midline
showing a dermatomal pattern [Figure 2]. No previous history
of similar lesions were reported, and patient was unaware of
the occurrence of chickenpox in his childhood. Based on the
history and clinical presentation of the lesions, a provisional
diagnosis of HZ involving the left ophthalmic, maxillary and
mandibular nerve, division of trigeminal (V) nerve was given.
Routine blood investigations along with HIV 1 and
2 antibody tests were performed, and the blood values were
within normal limits and negative test result for HIV.
Antiviral therapy was instituted immediately with acyclovir
−800 mg tablets 5 times a day for 10 days, cvir cream −5 mg
applied 2 times a day. Corticosteroids are given in the form
of prednisolone 20 mg twice a day for 10 days to prevent
postcomplications like neuralgia-related disorders. For pain
control, patient advised to take tramadol 50 mg tablets twice
a day for 5 days. Betadine mouth wash was also given to

Address for correspondence:

Dr. Kotya Naik Maloth, Assistant Professor, Department of Oral Medicine and Radiology, Mamata Dental College and Hospital, Giriprasad Nagar,
Khammam - 507 002, Telangana, India. E-mail: dr.kotyanaik.maloth@gmail.com

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Maloth, et al.: Herpes zoster infection: Report of a treated case

improve oral hygiene, and topical lidocaine was prescribed
for painful skin lesions. The patient was regularly reviewed.
On examination of the patient after 10 days, there
was complete regression of the lesion extraorally with
encrustations and intraorally with hypopigmented areas
respectively [Figures 3 and 4]. No fresh vesicles were
found. Patient was asked to taper the dose of corticosteroids
gradually, and finally, the medications were stopped.
Discussion
Herpes zoster is an acute infectious viral disease, and it is
a sporadic disease with an estimated life time incidence
of 10-20%, 15 times higher in HIV-infected than in
uninfected patients and 25% of patients with Hodgkin’s
lymphoma develop HZ. Household transmission rates were
approximately. 15%.[4] HZ is characterized by inflammation of
dorsal root ganglia or extra-medullary cranial nerve ganglia,
associated with vesicular eruptions of the skin or oral mucous
membrane in the area supplied by the affected nerve.[1] The
nerves most commonly affected in HZ are C3, T5, L1, L2 and
1st branch of the trigeminal nerve.[5] The incidence of HZ
increases with age and in immunocompromised patients.
The predisposing factors for reactivation of the virus are
trauma, benign or malignant tumor involving the dorsal
root ganglia, local X-ray irradiations and immunosuppressive
therapy and immunosenescence.[6]
In our case, based on the history, the predisposing factor was
found to be malnutrition with physical and psychological
stress secondary to the economic status and poverty. Patient
with HZ may progress through 3-stages,[7]
a. Prodromal stage,
b. Active or acute stage,
c. Chronic stage.
The prodromal stage presents as sensations like burning,
tingling, itching, pricking and boring occurring in the
cutaneous distribution of the dermatome and is believed
to represent viral degeneration of nerve fibrils.[8] If the

Figure 1: Vesicular lesions on left side of face

Figure 2: Lesions present over the left buccal mucosa

Figure 3: Complete regression of the lesion extraoral with formation

of scar tissue and hypopigmented areas Figure 4: Complete regression of the lesion intraorally

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Maloth, et al.: Herpes zoster infection: Report of a treated case
trigeminal nerve is affected in this period odontalgia may
occur. The symptoms of the prodromal stage may present
up to 1-month or for more duration before the acute
mucocutaneous lesions appear, posing diagnostic difficulties
to the clinician. This is known as zoster-sine herpetic or
zoster-sine eruption.[8]
The active stage is characterized by the emergence of the
skin rash that may be accompanied by headache, malaise
and low-grade fever. The rash progresses from erythematous
and edematous papules to vesicles and finally results in
the formation of pustules within 1-week which is the
contagious period. The pustules begin to dry with crust
formations, which will be exfoliated over 2-3 weeks, leaving
erythematous macular lesions that result in scar formation.[8]
During this phase, the HZ is most contagious and could pose
a significant cross-infection risk.
The chronic pain syndrome stage is seen in approximately
10% of all patients with HZ and is termed as PHN. PHN
is defined as a brief, recurrent, shooting, deep pain lasting
1-3 months after the healing of the muco-cutaneous
lesions.[8] Risk of occurrence of PHN increases significantly
after the age of 60 years, which may be due to a decline in
cell-mediated immunity.[8]
The most common complication of HZ is PHN, but the
other complications like neurologic components such
as Guillian — Barre syndrome, encephalitis, myelitis,
Ramsay-Hunt syndrome and ocular complications
such as conjunctivitis, optic neuritis, corneal scarring
or HZ opthalmicus and acute retinal necrosis. The oral
complications are periapical lesions, root resorption, tooth
exfoliation and alveolar osteonecrosis.[3,4]
The addition of steroids to an antiviral regimen has not been
proven to prevent PHN, but should be considered in patients
with severe pain in order to reduce the duration of acute
symptoms. Patients with HZ can transmit VZV to others
through direct contact with draining skin lesions. Only
people who have never had chickenpox are at risk, and the
resulting illness is primary varicella infection (chickenpox).
Current treatment regimens directed against the prevention
and control of the HZ and PHN includes the development
of live attenuated vaccine against VZV, HZ vaccine
(Zostavax®, Merck) was developed which was approved for
use in Canada in 2008, which was going to be released into
the market probably in 2015. It is contraindicated during
pregnancy and is currently not recommended in HIV-
infected individuals, although its safety in this population
is under evaluation. Vaccination against VZV is currently
Medical Journal of Dr. D.Y. Patil University | November-December 2015 | Vol 8 | Issue 6 771
recommended for the following susceptible adults (without
a reliable history of chickenpox or a serologic test indicating
immunity): Health care workers, those with close contact
to immunocompromised individuals or young children, and
women who could become pregnant.[9]
Conclusion
Herpes zoster infection leads to various complications if
left untreated, oral physicians should have a thorough
knowledge of this disease will help in early diagnosis,
treatment and prevention of the complications having an
edge on the regular updated treatment strategies in HZ.
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.
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How to cite this article: Maloth KN, Reddy KV, Kodangal S,
Sunitha K, Meka N. Herpes zoster infection: Report of a treated case.
Med J DY Patil Univ 2015;8:769-71.
Source of Support: Nil. Conflicts of interest: None declared.