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ORIGINAL ARTICLE
ABSTRACT
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 6years. Children aged12years 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 aged12years 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 selflimiting disease.
DOI: How to cite this article: Vora RV, Kota RK, Jivani NB. A clinicomorphological
10.4103/2319-7250.179505 study of childhood herpes zoster at a rural based tertiary center, Gujarat,
India. Indian J Paediatr Dermatol 2016;17:273-6.
HZ has traditionally affected persons with more than 6days, and 3(8.82%) patients presented 6days
60years of age. Lifetime risk in people who survive after developing lesions of HZ. Itching was the most
to 85years is 50%. The condition is benign and common prodromal symptom seen in 15(44.12%)
selflimiting in patients with normal immunological patients[Table1]. Most common presenting complaint
status. Although extensive data regarding HZ in was burning type of pain seen in 30(88.24%) patients
adults is available, studies regarding this disease in followed by throbbing pain and itching in 5(14.71%)
children are limited. Studies have shown an increasing and 4(11.76%) patients, respectively. Previous
incidence of childhood zoster.[4] Overall rate of history of chicken pox in patient or chicken pox or HZ
occurrence of HZ is 3.40cases per 1000 persons while in close contact was present in 19(55.88%) patients
in children<10years, it is 0.74/1000.[5] The attack rate while 2patients do not remember and rest deny
during the seventh decade is approximately 7times the chicken pox in the past. All the patients had unilateral
attack rate in the first two decades of life.[6] Historically, involvement. Leftsided dermatomes were involved in
childhood HZ was thought to be an indicator for an 20patients(58.82%), whereas rightsided dermatomes
underlying malignancy or immunosuppression.[7] were involved in 14patients(41.18%). Thirtythree
HZ may also occur in immunocompetent children, patients(97.06%) had localized involvement,
and recent reports show an increase in the number whereas 1(2.94%) patient had multiple dermatomal
of cases in apparently healthy children.[8] This study involvement. Most common dermatome involved was
was conducted to study the clinicoepidemiology, thoracic in 20(50%) patients followed by lumbar
association of immunosuppressive states, and dermatome in 8(23.53%) patients[Table 2 and
prevalence of seropositivity in children with HZ. Figures 1 and 2]. All the 34patients screened for HIV
infection, one patient was found to be HIV positive;
subsequently, it was confirmed by Western blot. No
MATERIALS AND METHODS child has been immunized against varicella virus.
The study was carried out in the Department of
Dermatology in a teaching institute at a ruralbased DISCUSSION
Tertiary Care Centre of Gujarat from June 2008 to
May 2014 after getting ethical approval from HREC HZ is a viral infection caused by reactivation of
department of the institute. This was a crosssectional, the VZV, a doublestranded DNA virus belonging
observational study. The study population included all to alpha Herpesviridae family. The virus lies latent
the patients with a diagnosis of HZ, who were seen in sensory ganglia after primary varicella exposure
in the dermatology department, aged 12 years. (chicken pox).[9] HZ can arise years or decades following
Detailed history regarding precipitating factors, primary infection with VZV.[10] Generally, reactivation
preexisting illness, drug history, chief complaints, occurs in the elderly and is associated with loss of cellular
dermatome involved, type of pain, prodromal immunity which is varicella zoster virusspecific.[11] HZ
symptoms, and detailed clinical examination was occurs less frequently among children, typically causing
entered in a predesigned pro forma. The diagnosis of mild disease with minimal pain.[12] It may be seen in
HZ was made on clinical grounds and confirmed by
Table1: Prodromal symptoms
tzanck smear as and when required. Sera of all cases
Prodrome Number of patients(%)
were tested for antibody to human immunodeficiency
Paresthesia 5(14.71)
virus(HIV) after taking written informed consent from Itching 15(44.12)
the parent of the child, using a commercially available Burning 9(26.47)
immunocomb test. Subsequently, seropositivity was Tingling 2(5.88)
Watering of eyes 1(2.94)
confirmed by Western blot assay.
Fever 1(2.94)
No prodrome 1(2.94)
RESULTS
Table2: Dermatome involved
A total of 34 children with HZ were enrolled during Dermatome Number of patients(%)
6years in our study. Nineteen(55.88%) were Cervical 6(17.65)
boys and 15(44.12%) were girls. The mean age Thoracic 17(50)
Lumbar 8(23.53)
of presentation was 9.26years ranging from 4 to Sacral 1(2.94)
12years. Twenty(58.82%) patients presented to us Ophthalmic 3
within 3days of the appearance of zoster, whereas Maxillary 0
11(32.35%) patients presented between 3 and Mandibular 0
11yearold girl diagnosed to be HIV positive 1year 3. TalwarS. Herpes zoster associated with varicelliform eruption.
ago, who had blood transfusion for anemia 2years Indian J Dermatol Venereol Leprol 1991;57:52.
back presented to us with typical presentation of HZ 4. PrabhuS, SripathiH, GuptaS, PrabhuM. Childhood
herpes zoster: A clustering of ten cases. Indian J Dermatol
involving leftsided single cervical dermatome(C6). 2009;54:624.
In HIV patients, progressive primary varicella, a 5. JainA, SingalA, BaruahMC. Herpes zoster in a 9 month old
syndrome with persistent new lesion formation infant. Indian J Dermatol Venereol Leprol 1999;65:2945.
and visceral dissemination, may occur and may be 6. HopeSimpsonRE. The nature of herpes zoster: Alongterm
lifethreatening.[23] study and a new hypothesis. Proc R Soc Med 1965;58:920.
7. KakourouT, TheodoridouM, MostrouG, SyriopoulouV,
Clinical features included pain, itching, and fever. PapadogeorgakiH, ConstantopoulosA. Herpes zoster in
children. JAm Acad Dermatol 1998;39(2 Pt 1):20710.
Itching was seen as prodromal symptom in 44.1%
patients, whereas it was present in active disease 8. TeradaK, KawanoS, YoshihiroK, MiyashimaH, MoritaT.
Characteristics of herpes zoster in otherwise normal children.
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complaint was burning type of pain in 88.2% patients, 9. TakayamaN, YamadaH, KakuH, MinamitaniM. Herpes
whereas in Malik etal. study,[18] itching was the most zoster in immunocompetent and immunocompromised
common presenting complaint. In Malik etal. study,[18] Japanese children. Pediatr Int 2000;42:2759.
69% patients showed one dermatome involvement 10. Gnann JW Jr., WhitleyRJ. Clinical practice. Herpes zoster.
and 28.6% showed involvement of 2 dermatomes. NEngl J Med 2002;347:3406.
More than 2 dermatomes were involved in only 11. BergerR, FlorentG, JustM. Decrease of the lymphoproliferative
response to varicellazoster virus antigen in the aged. Infect
1(2.4%) patient, whereas in our study, only 1(2.94%) Immun 1981;32:247.
patient had multidermatomal involvement. Incidence
12. WhitleyRJ. Varicellazoster virus. In: MandellGL, BennettJE,
of postherpetic neuralgia in childhood is rare.[8,24] DolinR, editors. Principles and Practice on Infectious Diseases.
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therapy is reserved usually for immunocompromised 13. GuessHA, BroughtonDD, Melton LJ 3rd, KurlandLT.
Epidemiology of herpes zoster in children and adolescents: A
or children with disseminated disease.
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14. PapadopoulosAJ, BirnkrantAP, SchwartzRA, JannigerCK.
CONCLUSION Childhood herpes zoster. Cutis 2001;68:213.
15. GuptaLK, KhareAK, MittalA, KuldeepCM. Herpes zoster in
HZ is increasingly being observed in children. Most infancy. Indian Dermatol Online J 2013;4:2524.
of them show no evidence of immunosuppression and 16. TeradaK, TanakaH, KawanoS, KataokaN. Specific cellular
immunity in immunocompetent children with herpes zoster.
the disease is generally mild and of shorter duration
Acta Paediatr 1998;87:6924.
than its adult variety. Previous exposure to varicella
17. SolomonAR. New diagnostic tests for herpes simplex
is seen only in about half of the patients. Most and varicella zoster infections. JAm Acad Dermatol
common dermatome involved is thoracic dermatome 1988;18(1 Pt 2):21821.
in children. Atypical presentations are very rare when 18. MalikLM, AzfarNA, Rahim KhanA, IjazH, JahangirM.
compared to adults and elderly patients. Herpes zoster in children. JPak Assoc Dermatologists
2013;23:226771.
Financial Support and Sponsorship 19. LatifR, ShopeTC. Herpes zoster in normal and
immunocompromised children. Am J Dis Child 1983;137:8012.
Nil.
20. KhattakMF, SalamatN, BhattiFA, QureshiTZ. Seroprevalence
of hepatitis B, C and HIV in blood donors in Northern Pakistan.
Conflicts of Interest JPak Med Assoc 2002;52:398402.
There are no conflicts of interest. 21. BharijaSC, KanwarAJ, BelhajMS. Herpes zoster. Indian J
Pediatr 1988;55:3013.