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A clinicomorphological study of childhood herpes

zoster at a rural based tertiary center, Gujarat, India
Rita V Vora, Rahul Krishna S Kota, Nidhi B Jivani
Department of Skin and VD, Shree Krishna Hospital, Anand, Gujarat, India


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.

Key words: Childhood, herpes zoster, immunosuppression

INTRODUCTION and then travels centripetally to sensory ganglia where

it remains in the latent stage.[2] On reactivation,

H erpes zoster(HZ) is a localized disease

characterized by unilateral radicular pain and
vesicular eruption limited to dermatome innervated
which is triggered by many factors, it travels back
along the sensory afferents to the skin associated with
hematogenous dissemination. Depending upon the
by a single spinal or cranial sensory ganglion. It is immune status of the patient, the presentation may
caused by the neurodermotropic virus called varicella vary from no clinical lesions to typical zoster, scattered
zoster virus(VZV) distributed worldwide. This vesicles, zoster sine herpete, or disseminated zoster.[3]
benign localized viral disease has been recognized
as a distinct entity since ancient times. It occurs as ADDRESS FOR CORRESPONDENCE
Dr.Rita V Vora,
a result of reactivation of VZV that is lying dormant
Skin OPD, Room No111, Shree Krishna Hospital, Karamsad, Anand388325,
in the sensory ganglion following an earlier attack of Gujarat, India.
varicella.[1] During varicella infection, VZV passes
from skin lesions into cutaneous sensory nerve endings
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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.

2016 Indian Journal of Paediatric Dermatology|Published by Wolters KluwerMedknow 273

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Vora, etal.: A clinicomorphological study of childhood herpes zoster

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)

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

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Vora, etal.: A clinicomorphological study of childhood herpes zoster

Figure1: Grouped vesicular lesions involving left T4 dermatomes in a

10yearold boy on day 2 Figure2: Grouped vesicular lesions involving right C8 dermatomes in a
6yearold girl on day 3
children with acquired cellular immune deficiency as in
patients on chemotherapy or with HIV.[9] HZ may also patients aged between 4 and 12years. Mean age of
occur in immunocompetent children as recent reports presentation was 9.26years in our study, whereas
show an increase in the number of cases in apparently Malik et al.[18] study showed mean age of 8.2years.
healthy children.[8] Several authors have studied the In our study, 55.9% patients had a history of
epidemiology and clinical patterns of this condition chicken pox in patient or chickenpox or HZ in close
in the pediatric population.[13] There is increased contact while in Malik et al. study, it was seen in
incidence of HZ with an increase in age which can be 31% patients.[18] In these cases, where the history of
explained by reduction of the cellmediated immune varicella was not obtained, it is suggested that the
response mechanism to VZV in older adult patients.[14] initial contact with the virus may result in zoster.[19]
The majority of cases of childhood zoster occur after None of our patients were vaccinated for varicella
the age of 5years.[15] Important factor in determining virus. Evidence of immunosuppression was seen
the onset of zoster in childhood is the immunological only in 1(2.94%) patient in our study, in contrast
status of the child at the time of primary infection. Low to Malik et al. study, in which 7 out of 42patients
levels of lymphocytes, natural killer, and cytokines, showed evidence of immunosuppression in the form
along with virusspecific immunoglobulins result in of hepatitis C virus infection in 3patients, pulmonary
early appearance of zoster in infants.[16] tuberculosis in 2patients, leukemia in one patient,
and the other patient was on steroid treatment.[18]
The diagnosis of HZ is mostly clinical, but when in Three children had shown hepatitis C positivity, this
doubt, laboratory investigations such as tzanck smear might be due to the second highest prevalence of
preparation of scrapings from the floor of the vesicles, hepatitis C in the world ranging from 4.5% to 8% in
which reveal multinucleated giant cells on direct Pakistan.[20] Historically, childhood HZ was thought
microscopy, or by direct fluorescent antibody tests, to be an indicator for an underlying malignancy or
presence of high or rising titers to VZV, or culture immunosuppression.[7] About 3% of pediatric zoster
studies can fetch the diagnosis.[17] HZ should be cases were associated with malignancies,[9] whereas
differentiated from zosteriform herpes simplex, which recent studies have shown no increase in the incidence
is more common in children, and can be done by direct of malignancy in children with HZ. Our study proves
fluorescent monoclonal antibody test or by detection the same. In Malik etals. study, only one patient had
of serum specific immunoglobulin M by the indirect malignancy(leukemia), whereas in our study, there
fluorescent antibody method. The other differential was not even a single case of malignancy.[18]
diagnosis for dermatomal vesicular eruptions in children
is bullous impetigo and bullous insect bite reaction. As In our study, there was leftsided preponderance similar
the abovementioned tests were not available to us, to Malik etal. study.[18] The thoracic dermatomes were
our diagnosis was mainly clinical or by tzanck smear most commonly affected dermatome in half of the
in doubtful cases. Rising incidence of HZ in otherwise patients followed by lumbar dermatome in 23.5%
healthy children can be attributed to acquiring primary patients. Similar findings were reported by Malik
varicella infection in utero, or in infancy, wherein the et al.[18] Prabhu et al.,[4] Bharija et al.[21] andHope-
immunity is not fully developed. Vaccination with live Simpsons[6] studies, and various other studies,[4,8,9,19]
attenuated virus may also contribute. whereas Leung etal.[22] noted predilection of cervical
and sacral dermatomes.
Our study showed male preponderance similar to
Malik etal. study[18] and in contrast to Prabhu etal.[4] Very few case reports of childhood HIV patients
study which showed female preponderance. All the acquiring zoster are reported.[4] In our study, an

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Vora, etal.: A clinicomorphological study of childhood herpes zoster

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