Herpes Zoster Ophthalmicus

in
Elderly

BENNY YOHANIS GAE

12/329227/KU/14996
 KELUHAN UTAMA

Nyeri terbakar di dahi sebelah kiri

Keadaan Umum : tampak sakit sedang, rawat diri cukup,

compos mentis
IDENTITAS PASIEN

• Nama : Ny H
• Usia : 58 thun
• Agama : Islam
• Masuk : 1 Februari 2018
RIWAYAT PENYAKIT SEKARANG

• 2 HSMRS os mengeluhkan muncul demam pada pagi

hari disertai plenting-plenting merah kecil berisi air (?) di
sebelah mata kiri. Plenting ditekan > pecah > meluas
sampai area dahi dan kepala atas bagian kiri. Os minum
paracetamol dan menggolesi minyak tawon pada lesi
kulit. Malam harinya demam turun namun lesi masih
terus menyebar disertai nyeri terbakar. Selain nyeri, os
juga mengeluhkan sakit kepala sebelah kiri, mata
gatal,dan sedikit kabur. Os juga mengeluhkan mual,
muntah. Sakit mata, digigit serangga disangkal oleh
pasien. Riwayat vaksin cacar air tidak diketahui.
• HSMRS : keluhan masih menetap dan menyebar. Os
memutuskan untuk ke poli KK RSUD Tirtrowardojo.
• Penyakit lainnya saat ini : Hipertensi terkontrol
Hiperkolesterol, Cervical spondilisis
 Riwayat Penyakit Dahulu
 CTS
 Riw transfusi (-)
 Keluhan serupa (-)
 Gatal di selangkangan
Asthma,alergi (-)
Cacar air (+)

Riwayat Penyakit Keluarga

Riwayat alergi (-)
Keluhan serupa (+)
Riwayat Sosial dan Lingkungan

• Pasien tinggal bersama dengan suami dan

3 anaknya.
• Penggunaan pakaian bersama disangkal
• Os mengatakan salah seorang anaknya
sakit dompo
Pemeriksaan

• TD : 100/60
• HR : 91
• RR : 20
• t : afebris
• VAS : 2-3

BB : 58 kg
TB : 160 cm
STATUS DERMATO VENEROLOGI
DIFFERENTIAL DIAGNOSIS

• Herpes Zooster Ophtalmicus

• Herpes Simpleks
• Varicella
• Dermatitis Kontak alergi
PEMERIKSAAN PENUNJANG

• Tzank Test

• Lainnya :
1. Isolasi virus dengan kultur jaringan dan identifikasi morfologi dengan
mikroskop elektron.
2. Pemeriksaan antigen dengan imunofluoresen
3. Test serologi dengan mengukur imunoglobulin spesifik.
DIAGNOSIS Kerja

• Herpes Zooster Ophtalmicus

TATA LAKSANA

• Asiklovir 5 x 800 mg
• Asam mefenamat 3 x 500 mg
• Salicyl talk 0,5-1 %
a. Preventif :
- Jangan menggaruk/memecahkan vesikel atau
mengoleskan obat-obatan/rempahrempah tradisional yang
tidak terjamin kebersihannya karena dapat menyebabkan
terjadinya infeksi sekunder.
- Istirahat yang cukup dengan tidur minimal 8 jam sehari
- Mengkonsumsi makanan dengan gizi seimbang dan
nutrisi yang cukup untuk meningkatkan daya tahan tubuh
seperti nasi, lontong, ikan, telur serta sayur dan buah-
buahan.
- Jaga kebersihan badan dengan cara mandi 2 kali sehari
dengan air bersih untuk mengurangi gatal-gatal dan
mencegah infeksi lain akibat bakteri (infeksi sekunder).
b. Promotif :
- Menjelaskan kepada pasien bahwa penyakit herpes zooster yang di
alami pasien merupakan penyakit kulit yang disebabkan oleh virus
yang sangat menular sehingga anggota keluarga pasien yang lain
harus menjaga ketahanan tubuh agar tidak tertular penyakit ini.
- Menjelaskan kepada pasien bahwa penyakit yang diderita pasien
adalah penyakit yang mudah menular melalui udara (inhalasi) dan
dianjurkan kepada pasien agar beristirahat dirumah.
- Menjelaskan kepada pasien bahwa lesi kulit tersebut mudah terinfeksi
apabila gelembung terpecah oleh karena itu hindari menggaruk/
memecahkan gelembung dan jangan mengoleskan obat-
obatan/rempah-rempah tradisional karena dapat menambah penyakit
lain di kulit tersebut.
- Menjelaskan kepada pasien bahwa penyakit yang diderita pasien ini
bisa menimbulkan komplikasi berupa nyeri pasca herpetik (Neuralgia
pasca herpetik) yang dapat terjadi walaupun lesi kulitnya telah sembuh.
- Minum obat selama 7-10 hari tergantung dari respon pengobatan,
minum obat tidak boleh putus, jika obat sudah habis sebelum
pengobatan selesai maka pasien harus kembali satu hari sebelum obat
habis.
- Menjelaskan kepada pasien bahwa dalam pengobatan nantinya
pasien akan diberikan obat antivirus yang diminum 5 kali sehari (setiap
5 jam), oleh karena itu diberikan anjuran jadwal meminum obat pada
pasien yaitu pada jam 05.00-10.00-15.00-20.00-24.00 agar pasien
lebih mudah mengingat jadwal minum obatnya.
C. Rehabilitatif :
- Kontrol kembali ke puskesmas bila obat-
obat sudah habis
- Jika terjadi nyeri pada wajah (neuralgia
pasca herpetik) atau terdapat nanah
(infeksi) pada lesi, segera kontrol ke
puskesmas untuk pengobatan.
Problems ????

1. How bout the epidemiology and risk

factors in elderly?
2. How do you manage this patient?
3. Is PNH common in elderly? How to
predict it?
• Herpes zoster virus involves the ophthalmic branch of the
trigeminal nerve by recurrence of virus that has persisted in
the sensory nerve ganglia in a latent form. The virus
produces herpes zoster with a typical vesicular rash in the
distribution of one or more cutaneous dermatomes.
Decreased cellular immunity is likely the leading cause of
VZV reactivation, while humoral immunity remains intact in
most patients.
EPIDEMIOLOGY
• Varicella often occurs in childhood, whereas zoster is
most commonly seen among the elderly who have a less
robust cell-mediated immune response associated with
advancing age. Because of this, herpes zoster is not
common in children; however, it can occur when a child
has experienced varicella infection prior to one year of
age.
• The interval between varicella infection and childhood
zoster averages 3.8 years if varicella infection occurs
during the first year of life, but averages 6.2 years if
infection occurs after the age of one year
• The incidence of HZ increases sharply among patients
aged ∼50–60 years and continues an upward course in
the decades 160 years. In the Duke Established
Populations for Epidemiological Studies of the Elderly
[4], the lifetime risk of having HZ increased significantly
with age even among elderly patients (OR, 1.20 for
every 5-year interval in patients 165 years old; 95% CI,
1.10–1.31). Extrapolating from HZ epidemiological
studies, experts calculate the lifetime incidence rate of
HZ to be 10%–20% in the general population and as
high as 50% of a cohort surviving to age 85 years.
investigators estimate an annual incidence of 600,000 to
850,000 cases of HZ in the United States.
• Cellular immune dysfunction in certain disease states is
another potent trigger for HZ. The types of
immunosuppressed patients at great risk for HZ include
those with HIV infection, Hodgkin’s disease, non-
Hodgkin’s lymphomas, leukemias, bone marrow and
other organ transplants, systemic lupus erythematosus,
and those who take immunosuppressive medications.

• Other potentially important risk factors include white

race, psychological stress, and physical trauma. Sex,
marital status, educational level, season, or urban versus
rural residence do not affect HZ risk. There are no
controlled studies indicating that exposure of a latently
infected patient to an individual with HZ or varicella
causes HZ
CLINICAL FEATURES
• Optic nerve involvement is a very rare sequelae
of childhood HZO. In comparison, optic nerve
involvement of HZO in adults has been
frequently reported. This condition may present
as papillitis, optic neuritis, or optic nerve
infarction
• Eventually the virus infects cells in the dermis
and epidermis, produces the characteristic rash,
and reveals the reason for the patient’s pain.
The unilateral, dermatomal rash begins as a
red,maculopapular eruption, usually develops
vesicles,
• During the vesicular stage, the patient poses no threat to
latently infected people but may transmit VZV to a
susceptible person (usually a child) and cause varicella.

• Typically, the vesicles crust over in 7–10 days. During

nonvesicular stages, the patient is not contagious. These
simple facts can allay the worries of family and friends of
patients with HZ who may avoid the patient for fear of
infection. Along with the rash, most patients experience a
dermatomal pain syndrome caused by acute neuritis.
The neuritis is described as burning, deep aching,
tingling, itching, or stabbing pain, and ranges from mild
to severe.
• This pain continues after the rash has
healed in as many as 60%–70% of people
aged 160 years and develops into PHN. In
addition to older age, greater acute pain
severity and rash severity are risk factors
for PHN
DIAGNOSIS

• HZ is instantly recognizable when an

elderly patient presents with the typical
dermatomal rash and pain. The main
consideration in the differential diagnosis
is zosteriform herpes simplex. Herpes
simplex commonly recurs many times,
most often affects younger adults, and
usually does not generate chronic pain.
• Therefore, clinical diagnosis is sufficient in the typical case of HZ,
but laboratory diagnostic testing is useful for differentiating herpes
HZ from herpes simplex, for suspected organ involvement, and for
atypical presentations.
• Immunofluorescence antigen detection of VZV antigens in vesicle
scrapings or other specimens (i.e., tissue biopsy or cerebrospinal
fluid) is an excellent test because it is rapid, specific, and sensitive
(∼90%). VZV culture is slower and less sensitive (∼40%), but it
remains a standard in making the virological diagnosis.
• Tzanck smears may suggest VZV infection if multinucleated giant
cells and intranuclear inclusions are demonstrated in stained vesicle
scrapings, but the technique cannot differentiate VZV from herpes
simplex virus infections.
TREATMENT OF ACUTE HZ

• Antiviral therapy.
Acyclovir, famciclovir, and valacyclovir are guanosine analogs that are
phosphorylated by viral thymidine kinase and cellular kinases to a
triphosphate form that inhibits VZV DNA polymerase

Randomized, controlled trials indicate that orally administered acyclovir

(800 mg 5 times a day for 7 days), famciclovir (500 mg q8h for 7 days),
and valacyclovir (1 g t.i.d. for 7 days) reduce acute pain and the
duration of chronic pain in elderly patients with HZ who are treated
within 72 h of the onset of rash.
• Anti-inflammatory therapy.
• Two well-designed clinical trials with data on corticosteroids versus placebo in older
patients with HZ showed equal rates of chronic pain in the 2 groups. In addition, 2
recent, well-designed clinical trials of acyclovir with or without corticosteroids
demonstrated that corticosteroids added nothing to acyclovir in the prevention of PHN
The most common adverse effects in these trials were gastrointestinal symptoms
(dyspepsia, nausea, and vomiting), edema, and granulocytosis

• Therefore, some experts advocate orally administered corticosteroids for otherwise

healthy older adults with moderate to severe pain and no contraindications to
corticosteroids. Prednisone was administered orally at 60 mg/day for days 1–7, 30
mg/day for days 8–14, and 15 mg/d for days 15–21. Some clinicians use
corticosteroids for VZV-induced facial paralysis and cranial polyneuritis to improve
motor outcomes and pain
• Analgesic therapy.
Clinicians should employ analgesic therapy to reduce acute HZ pain
regardless of effects on chronic HZ pain. The choice of nonopiate or
opiate analgesic drugs depends on the patient’s pain severity,
underlying conditions, and response to the drug.

Although there are no randomized controlled trials of this approach for

the treatment of acute pain or the prevention of PHN, several case
series have consistently reported acute pain relief from a variety of
anesthetic techniques.
In elderly patients with age-related comorbid diseases and
polypharmacy, occurrence of HZ and progression to PHN
causes an additional burden on top of pharmacological
treatment and comorbid adverse events. Quality of life is
greatly affected and activities of daily life are diminished in
patients who may already have health problems to cope
with in everyday life. Information on HZ, which is a very
common infectious disease, and its possible complications
should be provided more widely to the elderly population.
HZ prophylaxis by vaccination is today a valuable option
that could prevent the added burdens of HZ, long-standing
persistent PHN, extra medications and impaired quality of
life in an immunocompetent but frail elderly population
Dworkin and Portenoy proposed a definition that was
widely accepted: they set the diagnosis of PHN at 3 months
after rash healing, referring to pain persisting at earlier time
points as zoster-associated pain (ZAP).
More recently, this definition has been revised, with a
further distinction: pain present within 30 days from the
onset of rash is defined as acute herpetic neuralgia; pain
present between 30 and 120 days is defined as subacute
herpetic neuralgia; pain persisting after 120 days from the
onset of HZ is defined as PHN.
Moreover, other authors introduced the concept that only
clinically relevant pain should be defined as PHN, to avoid
overestimation of the problem: they proposed PHN to be
defined as pain 3 on a 10-point scale persisting 120 days
after rash healing
HOW TO PREDICT PHN?

No systematic reviews, meta-analyses, or

RCTs had evidence pertaining to the
prediction of PHN. However, 14 cohort
studies did.
Older age is one factor associated with PHN
in almost all studies
Pain at presentation is the second best-
established risk factor for PHN
Severity of rash, assessed as the number of lesions
appearing on the patients’ skin at presentation, suggests a
relationship between the extent of neural damage and
PHN.

The presence and duration of symptoms prodromal to HZ

rash (pain, dysesthesia, and allodynia) have been reported
as tightly predictive of PHN in several studies. This
association may reflect a more intense involvement of
nerve fibers by viral reactivation in the early phases of HZ,
leading to extended damage and PHN.
In a few reports, PHN has been reported as
more frequent in ophthalmic and thoracic
zoster patients