Dermatology Online Journal

Dermatomal vesicular eruption in an asymptomatic infant
Premnashu Bhushan¹, Kabir Sardana², Supriya Mahajan¹
Dermatology Online Journal 11 (3): 26

1. Department Of Dermatology and STD Lady Hardinge Medical college and Associated KSCH hospital ,New Delhi India ,110001 2. Department Of Dermatology & STD Maulana Azad Medical College & Chacha Nehru Super Speciality Childrens Hospital Delhi. kabir_sardana1@rediffmail.com

---

Abstract

We present a case of infantile herpes zoster without clinical evidence of varicella infection in the mother or apparent exposure in the child; our patient's diagnosis was confirmed by serology and by Tzanck smear. We briefly review the etiopathogenesis factors of this condition. We emphasize the benign course and spontaneous uneventful resolution.

---

Introduction

Herpes zoster is a dermatomal vesicular eruption of viral etiology associated with the reactivation of latent varicella zoster virus (VZV) in the posterior root ganglia. Herpes zoster is rare in infancy, owing to the protection offered by the maternal immunoglobulins against the virus. The incidence of zoster in first decade of life is reported to be nearly 0.74 cases per thousand per year [1]. We present a case of infantile herpes zoster, a condition that can be occasionally misdiagnosed by the attending physician.

Clinical synopsis

The patient was a seven and a half month old girl, born at full term with a normal vaginal delivery, and with a birth weight of 2800 g. The milestones of the child were normal for her age. She presented to our outpatient department with a 4-day history of multiple fluid-filled blisters involving the left upper back; the blisters progressed to involve the left upper arm. The eruption was not associated with fever, irritability, or excess crying of the baby; there was no history of varicella-like eruption involving the patient, the mother (during or after pregnancy), or any close family member.

Figure 1
Grouped vesiculo-papular eruption over an erythematous base on left upper back, corresponding to left T 1-2 dermatomes

Physical examination revealed a healthy, smiling child with a temperature of 38° C, pulse 106 per minute, and respiratory rate of 18 per minute. The infant's weight was 7.4 kg and length was 68 cm. Cutaneous examination revealed unilateral, grouped vesiculo-papular eruption with hemorrhagic crusts over an erythematous base involving the left upper back and extending onto left upper arm but not crossing the midline, corresponding to left T 1-2 dermatomes (Fig. 1). Tzanck smear demonstrated multiple multinucleated giant cells. Hemogram was within normal limits. Serology for HIV I and II and HSV 1 and 2 were negative. The VZV IgM antibody was 700 × by indirect immunofluorescence (normal 0-10) and the IgG was negative; the serology of the mother was negative. The child was prescribed calamine lotion twice a day and she improved in 2 weeks with no cutaneous sequelae.

Discussion

The occurrence of zoster in childhood is related to intra-uterine and perinatal exposure to varicella. The incidence of varicella infection in utero secondary to maternal varicella during pregnancy is about 24 percent and only 50 percent of these develop clinical symptoms [2]. If the infection develops in early pregnancy (< 20 weeks), congenital varicella syndrome may result with abnormalities including dermatomal cutaneous scars, limb and eye defects, and neurological disturbances [3]. Exposure late in pregnancy or perinatal period may lead to a severe and life-threatening varicella-like disease or zoster in early childhood [4]. Herpes zoster in children probably represents the result of an immature immune response to the transplacentally acquired VZV [4]. Low levels of lymphocytes, natural killer cells, cytokines characterize this poor response, and virus-specific immunoglobulins may result in inability to maintain the latency of VZV leading to early appearance of zoster in children [4].

The majority of cases of childhood zoster occur after the age of 5 years [5]. In one study of twenty-two patients, only one (4.5 %) was younger than 1 year, and the mean age at the onset was 8.9 years (2 months to 18 years) [5]. A detailed literature search revealed twenty-five cases of infantile herpes zoster [5, 6, 7, 8, 9]. Of these, fifteen cases had intrauterine exposure to VZV, five infants had documented chicken pox, and in only five cases no history of prior VZV exposure was elicited [6, 7]. Our patient also had no history of intrauterine or postnatal exposure. The possibility of asymptomatic infection in the mother during pregnancy is contemplated as a cause of exposure of the fetus in utero [8], although this could not be confirmed in our case. There was no evidence of any immunocompromised state and some occult trigger may be responsible for the reactivation of virus. There was no history of exposure to any other source of varicella in our case and the uncommon possibility of herpes simplex in a dermatomal pattern [9] was ruled out by serology.

Infantile herpes zoster is more commonly seen in girls and is usually not accompanied by pain or post-herpetic neuralgia. However; fever, headache, and regional lymphadenopathy may occur [5, 9]. Studies have demonstrated that herpes zoster in children is a benign, self-limited illness with short duration and excellent prognosis; concerns that it may herald an immunocompromised state or malignancy have been allayed [5, 9].

The other vesicular dermatoses in the differential diagnosis include incontinentia pigmenti, irritant contact dermatitis, insect bite, and phytodermatitis [5, 8, 9, 10]. This case report emphasizes the rare occurrence of infantile herpes zoster without clinical evidence of VZV infection in the mother or apparent exposure in the child. This case also serves to emphasize the role of dermatology referral in diagnosis of infantile dermatoses.

References

1. Winkelmann RK, Perry HO. Herpes zoster in children. JAMA 1959;171:876-880.

2. Payani SG, Arvin AM. Intrauterine infections with varicella zoster virus after maternal varicella. N Eng J Med 1986;814:1542-6.

3. Alkalay AL, Pomerance JJ, Rimoin DL. Fetal varicella syndrome. J Pediatr 1987;111:320-3.

4. Huang JL, sun PC, Hung IJ. Herpes zoster in infancy after intrauterine exposure to varicella zoster virus: report of two cases. J Formos Med Assoc 1994 Jan;93(1):75-7.

5. Wurzel CL, Kahan J, Heitler M, Rubin LG. Prognosis of herpes zoster in healthy children. Am J Dis Child 1986 May;140(5):477-8.

6. Kashima M. A rather rare encounter with herpes zoster in a male infant. J Dermatol 2003 Apr;30(4):348-9.

7. Brar BK, Pall A, Gupta RR. Herpes zoster neonatorum. J Dermatol 2003 Apr;30(4):346-7.

8. Nikkels AF, Nikkels-Tassoudji N, Pierard GE. Revisiting childhood herpes zoster. Pediatr Dermatol 2004 Jan-Feb;21(1):18-23

9. Guess Ha, Broughton DD, Melton LJ3rd, Kurland IT. Epidemiology of herpes zoster in children and adolescents: a population-based study. Pediatrics 1985 Oct;76(4):512-7.

10. Fromer ES, Lynch PJ. Neonatal herpes simplex and incontinentia pigmenti. Pediatr Dermatol 2001 Jan-Feb;18(1):86-7.

© 2005 Dermatology Online Journal