CASE REPORT Identity of patient Name Sex Registration number !ge !

$$ress P'one number Examination $ate History The Chief Complain : +esi,les -it' *ain on t'e le.t si$e o. t'orax sin,e 2 $a#s be.ore a$mission. History of present illness: Patient ,ame to t'e 'os*ital ,om*laine$ /esi,les $e/elo*s u*on t'e er#t'ematous base -it' *ain0 it,'# an$ burning sensation o. t'e le.t si$e o. t'e t'orax sin,e 2 $a#s be.ore a$mission. !t .irst0 *atient .oun$ re$$is' ras' aroun$ 'er le.t t'orax t'en a.ter " $a# s'e .oun$ t'e same /esi,les -it' er#t'ematous base -it' *ain0 it,'# an$ burning sensation aroun$ 'er le.t in .ront an$ ba,& si$e o. t'orax. 1'e ras' be,ome more it,'# an$ *ain. Patient also .elt 'er bo$# be,omes -ea& an$ ,on/in,e$ o. .e/er. Fe/er -as .elt a.ter t'e ras' a**ear. Patient ,on.esses t'at s'e 'as a lot o. a,ti/it# an$ a$mitte$ .atigue ) $a#s be.ore t'e /esi,les a**ears. Patient $enie$ s'e got an# inse,t bite or 'a$ a ras' a.ter ,onsume$ an# .oo$ ,onsist o. -'eat an$ #o$ium. History of previous illness: Patient ne/er ,om*laine$ li&e t'is be.ore. S'e e/er got /ari,ella -'en s'e -as 5 #ears ol$. History of Family disease : None o. 'er .amil# 'a$ t'is &in$ o. $isease : Ms. EPD : Female : 96-85-2 : "8 #ears ol$ : %ing&e : 856688( ")"
t'

: Se*tember "

2 ")

History of Treatment: Patient 'a$ Caladine *o-$er. History of Social Habits: Patient 'a$ a lot o. a,ti/it# 5 $a#s be.ore a$mission Physical Examination +ital Sign : Not ,'e,&e$ Dermatological status:

Figure ". First /isit at Se*tember " t' 0 2 "). 3rou* /esi,les on an er#t'ematous base -it' lesion in t'e le.t 1) $ermatomes le.t si$e t'orax. !. %esion on le.t si$e t'orax. 2. %esion on ba,& si$e t'orax. a4r 1'ora,'alis sinistra et anterior an$ *osterior .oun$ grou* /esi,les on an er#t'ematous base0 5osteri.orm arrangement0 some lesion are ,on.luens an$ t'ere is normal s&in among t'e lesion0 milier to lenti&uler si5e0 an$ unilateral $istribution in t'e le.t 1) $ermatomes. Clinical Test No ,lini,al test a/ailable Differential Diagnosis ". 6er*es 7oster at regio t'ora,'alis anterior an$ *osterior sinistra in t'e le.t 1) $ermatomes 4

2. Dermatitis +enenata ). Dermatitis 6er*eti.ormis Planning Diagnosis 15an& smear0 but not ,'e,&e$. 8. t'is t5an& test being ,'e,&e$ a result is a multinu,leate$ giant ,ell -ill be .oun$ in mi,ros,o*i, examination. Diagnosis 6er*es 7oster at regio t'ora,'alis anterior an$ *osterior sinistra in t'e le.t 1) $ermatomes Treatment S#stemi, Me$i,ation : !nti/iral : !,#,lo/ir 5 x 8 mg 9.or : $a#s; mg !nalgeti, : Me.enami, a,i$ ) x 5 1o*i,al Me$i,ation : !**l# sali,il tal, 2< o/er t'e lesion Education ". Do not tou,' or s,rat,' o/er t'e lesion. 2. 1a&e a rest an$ $on=t $o a lot o. a,ti/it# $uring " -ee& ). Don=t a.rai$ i. t'e lesion a**ear more t'an be.ore0 be,ause t'e a,ti/e *'ase o. t'e in.e,tion t'at -ill be least in " -ee&. (. !.ter " -ee& lesion -ill be ,ruste$ an$ 'eals normall# an$ sometimes -ill get a *ain an$ burn sensation o/er t'e lesion 5. 1a&e a me$i,ine routinel# as *res,ribe$. Prognosis >uo !$ +itam >uo !$ Fun,tionam >uo !$ Sana,tionam : Dubia at bonam : Dubia at bonam : Dubia at bonam

Se,on$ /isit at Se*tember ":t' 0 2 ") The Chief Complain sin,e ( $a#s ago. History of present illness: Patient ,om*laine$ it,'# an$ burning sensation o. t'e *re/ious lesion. Some o. t'e lesion alrea$# ,ruste$0 but anot'er lesion still *rominent. " $a# a.ter a$mission to 'os*ital0 *atient also .oun$ a ne- lesion on t'e le.t arm. 1'e lesion -as same -it' t'e *re/ious lesion on t'e le.t t'orax. !t .irst0 *atient .oun$ re$$is' ras' aroun$ 'er le.t arm t'en a.ter " $a# s'e .oun$ t'e same /esi,les -it' er#t'ematous base -it' *ain0 it,'# an$ burning sensation aroun$ 'er le.t in .ront an$ ba,& si$e arm. No- t'e lesion on arm -as alrea$# ,ruste$ too. Patient also ,on.ess t'at s'e routinel# ta&e a me$i,ine as *res,ribe$ an$ .eel more better t'an be.ore. Dermatologi, status : : 8t,'# an$ burning sensation o. t'e *re/ious lesion an$ arise ne- lesion on t'e le.t arm

Figure 2. Se,on$ /isit at Se*tember ":t'0 2 "). 3rou* /esi,les an$ bullous on an er#t'ematous base -it' lesion in t'e le.t 1) $ermatomes le.t si$e t'orax an$ ma,ula er#t'ematous base -it' ,ruste$ lesion in t'e le.t 12 $ermatomes. !. %esion on le.t si$e t'orax. 2. %esion on ba,& si$e t'orax. ?0 D. Ne- lesion on .ront an$ ba,& arm. Dermatologi, status : a4r 1'ora,'alis sinistra et anterior an$ *osterior .oun$ grou* /esi,les an$ bullous on an er#t'ematous base -it' some lesion alrea$# ,ruste$0 5osteri.orm arrangement0 some lesion are ,on.luens an$ t'ere is normal s&in among t'e lesion0 milier to lenti&uler si5e0 an$ unilateral $istribution in t'e le.t 1) $ermatomes. a4r 6umerus sinistra et anterior an$ *osterior .oun$ ma,ula er#t'ematous -it' ,ruste$ lesion0 5osteri.orm arrangement0 some lesion are ,on.luens0 milier si5e an$ unilateral $istribution in t'e le.t 12 $ermatomes. Treatment S#stemi, Me$i,ation : !nalgeti, : Me.enami, a,i$ ) x 5 1o*i,al Me$i,ation : !**l# Mu*ira,in oint o/er t'e lesion ) x " mg

DISC SSIO! 6er*es 5oster 9s'ingles; is an a,ute0 sel.-limiting0 /esi,ular eru*tion o,,urring in a $ermatomal $istribution -'i,' is ,ause$ b# a re,ru$es,en,e o. Varicella zoster /irus. 1'e ,'ara,teristi, ras' an$ asso,iate$ *ain o,,ur -'en /ari,ella-5oster/irus0 -'i,' be,omes $ormant in sensor# ganglia .ollo-ing *rimar# /ari,ella-5oster /irus in.e,tion is rea,ti/ate$0 o.ten in asso,iation -it' $e,lining ,elular immunit# asso,iate$ -it' a$/an,ing age.60: 1'e in,i$en,e o. 'er*es 5oster is ".5 to ). *er " in all ages an$ : to "" *er " in " *er #ear in *erson #ears *er #ear in *ersons o/er 6 #ears o. age in Euro*ean

an$ Nort' !meri,an stu$ies.2elo- t'e age o. (50 t'e annual in,i$en,e is less t'an " *ersons6.1'e ma@or ris& .a,tor .or 'er*es 5oster is in,reasing age0 unli&e le/els o. /irus s*e,i.i, antibo$ies ,orrelates -it' *rote,tion against 'er*es 5oster. 1'e ris& is 'ig'er .or -omen t'an man0 an$ .or *ersons -it' a .amil# 'istor# o. 'er*es 5oster t'an .or t'ose -it'out su,' ba,&groun$ 8. !,,or$ing to t'e ,ase0 *atient is .emale in ages "8 #ears -'i,' is $oes not .it -it' in,i$en,e o. 'er*es 5oster base$ on t'e t'eor#. Varisella zoster virus passes from lesions in the skin and mucosal surfaces into contagious endings of sensory nerves and is transported centripetally up the sensory fibers to the sensory ganglia. In the ganglia, the virus establishes a latent infection that persists for life. Herpes zoster occurs most often dermatomes in which the rash of varicella achieves the highest density division of the trigeminal nerve and by spinal sensory ganglia from T1 to L2. Although the latent virus in the ganglia retains its potential for full infectivity, re-activation is sporadic and infrequent, and infectious virus doesnt appear to be present during latency. The mechanisms involved in reactivation has been associated with immunosuppression, emotional stress, irradiation of the spinal column, tumor involvement in the cord, local trauma, surgical of spine and frontal sinusitis. VZV may also reactivate and would be expected to stimulate and sustain host immunity to VZV6. The incubating infection is partially contained by innate host defenses (interferon, natural killer cells) and by developing VZV- specific immune responses. In most individuals, virus replication eventually overwhelms these developing host defenses, so that approximately 2 weeks after infection, a much larger (secondary) 8

viremia and associated symptoms and lesion occur. Skin lesions appear in successive crops, reflecting a cyclic viremia, which in the normal host is terminated after approximately 3 days by VZV-specific humeral and cellular immune responses. VZV may also reactivate without producing overt disease. The small quantity of viral antigens released during such contained re-activations would be expected to stimulate and sustain host immunity to VZV6. A'en +7+-s*esi.i, ,ellular immunit# .alls belo- some ,riti,al le/el0 rea,ti/ate$ /irus ,an no longer be ,ontaine$. +irus multi*lies an$ s*rea$s -it'in t'e ganglion0 ,ausing neuronal ne,rosis an$ intense in.lammation0 a *ro,ess t'at is o.ten a,,om*anie$ b# se/ere neuralgia. 8n.e,tious +7+ t'en s*rea$s $o-n t'e sensor# ner/es0 ,ausing intense neuritis an$ is release$ .rom t'e sensor# ner/e en$ings in t'e s&in0 -'ere its *ro$u,e t'e ,'ara,teristi, ,luster o. 5oster /esi,les6.

Figure ). Pat'o*'#siolog# o. 'er*es 5oster in.e,tion6 1'e ,lini,al .eatures o. a,ute 5oster is /ariable. 6er*es 5oster usuall# begins -it' a *ro$rome su,' as *ain0 it,'ing or tingling on t'e area t'at be,omes a..e,te$. 1#*i,all#0 *atients ex*erien,e 'ea$a,'e0 malaise an$ sometimes *'oto*'obia or .e/er. !bnormal sensation or *ain0 o.ten $es,ribe$ as burning0 t'robbing or stabbing0 o,,urs in a**roximatel# :5< o. *atients an$ ma# be t'e .irst noti,eable .eature. B.ten 9

*ruritus in t'e a..e,te$ region is t'e most *rominent .eature. : ?utaneous in/ol/ement ma# be *at,'# or ,on.luent0 -it' s&in ,'anges beginning -it' re$ness an$ in.lammation .ollo-e$ b# t'e $e/elo*ment o. ,luster o. small or ,lear /esi,les.9 !,,or$ing to t'e ,ase0 *atient e/er .elt 'er bo$# be,oming .atigue an$ also get .e/er .or a .e- $a# t'at in$i,ate *ro$romal state o. 'er*es 5oster ,lini,al .eatures. S'e also ex*erien,e$ 'ea$a,'e0 *ain an$ it,'# on t'e lesion. 1'is ,on$ition *resumabl# be,ause o. *atient 'a$ a lot o. a,ti/it# an$ be,ome -ea& in last t'ree $a#s. 1'e ras' o. 'er*es 5oster o.ten *re,e$e$ b# tingling0 it,'ing0 or *ain 9or a ,ombination o. t'ese; .or 2 to ) $a#s0 an$ t'ese s#m*toms ,an be ,ontinuous or e*iso$i,. 1'e ras' begins as ma,ules an$ *a*ules0 -'i,' e/ol/e into /esi,les an$ t'en *ustules. Ne- lesions a**ear o/er a *erio$ o. ) to 5 $a#s0 o.ten -it' .illing in o. t'e $ermatome $es*ite anti/iral treatment. 1'e ras' usuall# $ries -it' ,rusting in : to " $a#s. ?'ara,teristi,s o. *ain asso,iate$ -it' 'er*es 5oster /ar#. Patients ma# 'a/e *arest'esias 9e.g.0 burning an$ tingling;0 $#sest'esia 9altere$ or *ain.ul sensiti/it# to tou,';0 allo$#nia 9*ain asso,iate$ -it' non*ain.ul stimuli;0 or '#*erest'esia 9exaggerate$ or *rolonge$ res*onse to *ain;. Pruritus is also ,ommonl# asso,iate$ -it' 'er*es 5oster.5 2ase$ on t'is ,onsi$eration *atient also .eel *ain0 .e/er0 an$ malaise o,,ur be.ore er#t'ematous *a*ules $e/elo* in t'e area o. t'e a..e,te$ $ermatome. 1'e /esi,les $e/elo* o/er se/eral $a#s0 ,rusting o/er as : $a# an$ nelesion -as a**ear at least ) $a#s a.ter *re/ious lesion. 8t be,ause t'e in,ubation *erio$ o. 'er*es 5oster is :-" $a#s6. 1'e ras' o. 'er*es 5oster is $ermatomal an$ $oes not ,ross t'e mi$line0 a .eature t'at is ,onsistent -it' rea,ti/ation .rom a single $orsal-root or ,ranial-ner/e ganglion. 1'e t'ora,i, 95)<;0 ,er/i,al 92 <;0 trigeminal 9"5<; an$ lumbar9""<; $ermatomes are t'e most .reCuent sites o. ras'0 alt'oug' an# area o. t'e s&in ,an be in/ol/e$. 8n non immuno,om*romise$ *ersons0 a .e- s,attere$ lesions outsi$e t'e a..e,te$ $ermatome are not unex*e,te$. :0" 2ase$ on t'e ,ase0 t'e lesions a**ear on t'e le.t si$e o. t'orax -'i,' re.ers to 1) an$ in t'e le.t arm -'i,' re.ers to 12 $ermatomes t'at ,om*lian,e as t'e most ,ommonl# in/ol/e$ $ermatomes in 'er*es 5oster.

10

Figure 2. Dermatomes in/ol/e$ in 'er*es 5oster" 2# its ,lasi,,al mani.estation0 t'e signs an$ s#m*toms o. 5oster are usuall# $istin,ti/e enoug' to ma&e an a,,urate ,lini,al $iagnosis on,e t'e ras' 'as a**eare$. 5 t'us0 *atient on t'is ,ase is $iagnose$ -it' 'er*es 5oster at region t'ora,alis sinistra in t'e le.t 1) $ermatomes. ?urrentl# t'e treatment o. 'er*es 5oster in mil$ s'ingles is s#m*tomati,0 -it' rest0 analgesia an$ blan$ $r#ing *re*arations su,' as ,alamine lotion. Se,on$ar# ba,terial in.e,tion ma# reCuire a to*i,al antise*ti, or antibioti,. More se/ere ,ases ma# be treate$0 i. seen -it'in (8 'ours o. onset0 -it' oral a,i,lo/ir 98 mg 5 times *er $a# .or : $a#s; or .am,i,lo/ir9:5 mg on,e $ail# .or : $a#s; -'i,' *romote resolution0 re$u,e t'e /iral s'e$$ing time an$ ma# re$u,e *ost-'er*eti, neuralgia. Similarl#0 t'e *atients as in t'is ,ase is gi/en an anti/iral me$i,ation0 -'i,' is oral !,#,lo/ir .i/e times $ail# -it' $oses 8 mg .or : $a#s6. !nti/iral t'era*# is t'e ,ornerstone in t'e management o. 'er*es 5oster. Sin,e anti/iral t'era*# $oes not re$u,e t'e rate o. 5osterasso,iate$ *ain0 ,lini,ians ma# un$era**re,iate t'e tremen$ous bene.it t'ese anti/iral $rugs *ro/i$e. 1'e main bene.it o. t'era*# is in re$u,tion o. t'e $uration an$ se/erit# o. 5osterasso,iate$ *ain9. 1'e *rognosis o. 'er*es 5oster in t'is ,ase is $ubia at bonam. 6er*es 5oster ma# be atten$e$ b# neurologi, ,om*li,ations o. -'i,' P6N 9Post 6er*eti, Neuralgia; is 11

t'e most ,ommon an$ im*ortant. Patiens -it' P6N ma# su..er .rom ,onstant *ain 9$es,ribe$ as burning0 a,'ing0 t'robbing;0 intermittent *ain 9 stabing0 s'ooting;0 or stimulus-e/o&e$ *ain0 in,lu$ing allo$#nia 9ten$er0 burning0 stabbing;. P6N 'as been /ariabl# $e.ine$ as an# *ain a.ter 'ealing or an# *ain " mont'0 ) mont's0 ( mont's or 6 mont's a.ter ras' onset0 -it' most re,ent $e.initions .o,using on 9 to "2 a.ter ras' onset. !ge is t'e most signi.i,ant ris& .a,tor .or P6N. ?lini,all# signi.i,ant *ain lasting ) mont's or more is rare in immuno,om*etent *ersons #ounger t'an 5 #ears o. age6. 2ase$ on t'is ,ase0 *atient also $on=t 'a/e P6N -'i,' is in/ol/e$ b# ol$er age t'an #ounger. Most *eo*le re,o/er ,om*letel# .rom an a,ute e*iso$e -it' no *ain an$ s&in ,olor returns to normal. 6er*es 5oster ,omes ba,& in onl# about 2< o. *eo*le0 but in u* 2 < o. *eo*le -it' 68+ !8DS. %ong term ,om*li,ations su,' as *ost-'er*eti, neuralgia0 ma# ,ontinue .or mont's an$ man# #ears. 1'e $isease also ma# ,ause /ar#ing $egrees o. s&in $is,oloration0 *rimaril# $ar&ening.

12