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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 28  |  Issue : 1  |  Page : 49-51

Herpes zoster ophthalmicus in pregnancy: A rare presentation


Department of Skin and Venereal Disease, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Warud, Wardha, Maharashtra, India

Date of Web Publication24-Jun-2014

Correspondence Address:
Dr. Sonia Jain
Department of Skin and Venereal Disease, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Warud, Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-4958.135236

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  Abstract 

Herpes zoster ophthalmicus (HZO) is caused by the varicella-zoster virus, the human herpes virus-3 (HHV-3). HZO is an ocular disease which manifests as unilateral painful skin rash in a dermatomal distribution of the ophthalmic branch of the trigeminal nerve shared by the eye and ocular adnexa. There are many risk factors for HZO like advancing age, immunosupression, and psychological stress. HZO during pregnancy is rare. Although HZ during pregnancy is less likely to cause harm to the unborn child, it is necessary to treat the mother to prevent complications. We report this case as rare because two divisions of trigeminal nerve are involved simultaneously in the form of HZO (ophthalmic nerve) and orocutaneous lesions (maxillary nerve, i.e., maxillary zoster) in an immunocompetent multigravida nullipara pregnant female.

Keywords: Herpes zoster ophthalmicus, Immunocompetent, Maxillary nerve, Pregnant woman


How to cite this article:
Jain S, Jakhar P. Herpes zoster ophthalmicus in pregnancy: A rare presentation. J Med Soc 2014;28:49-51

How to cite this URL:
Jain S, Jakhar P. Herpes zoster ophthalmicus in pregnancy: A rare presentation. J Med Soc [serial online] 2014 [cited 2020 Sep 23];28:49-51. Available from: http://www.jmedsoc.org/text.asp?2014/28/1/49/135236


  Introduction Top


Both chickenpox (varicella) and herpes zoster (HZ; shingles) are caused by varicella-zoster virus (VZV). After primary infection (chickenpox) which usually occurs in childhood, the virus lies dormant for many years. Virulence of the VZV and the immune status of the host are primary factors leading to the development of HZ ophthalmicus (HZO). The lifetime risk of developing HZ is about 20-30%. [1] However, the risk rises markedly with age, approximately doubling for each decade after 50 years of age. [1] In a study, the incidence of HZ increased with advancing age; 32.8 per 10,000 for <60 year olds; 93.1 per 10,000 for 60-64 year olds, and 113.2 per 10,000 for >65 year olds. [2]

The gender factor may also act as a risk factor. According to a study, female gender was an independent risk factor for HZ in the 25-64-year-old age groups. [3] Patients who are immunocompromised are more prone to HZ. The incidence of zoster is considerably increased in human immunodeficiency virus (HIV)-positive adults and children; and in AIDS patients, zoster is often recurrent and more protracted. [4] HZO represents approximately 10-25% of all cases of HZ. [5]

On reactivation, from the sensory ganglion the virus travels along neurons to the sensory axons of the skin to form vesicular eruption of epithelium of the forehead, the nose, eyelids, and sometimes the cornea according to the affected dermatome. A minority of patients may have only ophthalmic findings, limited mainly to the cornea. The vesicles rupture, leaving hemorrhagic areas that heal in several weeks. A minority of patients may also develop conjunctivitis, keratitis, uveitis, and ocular cranial nerve palsies. Permanent sequelae of ophthalmic zoster infection may include chronic ocular inflammation, loss of vision, and debilitating pain. HZ during pregnancy is rare. It is possible that the stress created by the pregnancy on the mother's body could weaken the immune system, allowing the virus to become reactivated. The mainstay of treatment for HZ is antiviral drugs. Studies report better results if the antiviral drug is taken within the first 3 days of rash and has a favorable effect on postherpetic neuralgia. [5] It hastens resolution of skin lesions, reduce viral shedding, and decrease the incidence of dendritic and stromal keratitis as well as anterior uveitis. [5]


  Case Report Top


A 25-year-old female who was multigravida with history of two abortions (G 3 A 2 ) had amenorrhea of 21.5 weeks, came with chief complaints of multiple fluid filled lesions over right side of forehead and right eye. The lesions were associated with burning type of pain, swelling, and watering from the right eye. She had applied some homemade preparation over these lesions to relieve the pain, which led to an increase in the symptoms. There was no history of fever or insect bite. She also did not suffer from chickenpox in the past or in the childhood. She was multigravida with history of two spontaneous abortions in last year. She had no history suggestive of high risk behavior and any addiction. Her husband was farmer by occupation and did not have any history of high risk behavior.

On cutaneous examination, she had multiple vesicles over erythematous base present over the right side of forehead, nasal root, right eyelid, extending to the right side of frontal and parietal regions of scalp, and there was single vesicle over the right side of philtrum of nose [Figure 1] and [Figure 2]. On eye examination, there was conjunctival congestion with erythema and tenderness of both upper and lower eyelids. Mucosal involvement in the form of multiple erosions on the right side of buccal mucosa was present, which was tender on touch. Systemic examinations were within normal limits. She had uterus size of approximately 20 weeks with normal fetal movements. Her blood parameters were within normal limit. She was found nonreactive for HIV testing by Combi-AIDS kit. Ultrasonography (USG) abdomen as advised by her obstetrician showed single live fetus of 20 weeks gestation. Tzanck smear showed multinucleate giant cells with few acantholytic cells.
Figure 1: Multiple vesicles over right forehead and eye with vesicles on lateral side of right nostril and cheek (shown with the help of arrow)

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Figure 2: Periorbital puffiness with vesicles of right eye

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  Discussion Top


Trigeminal nerve is fifth cranial nerve with three branches: Ophthalmic, maxillary, and mandibular nerves. Ophthalmic nerve supplies skin of forehead, upper eyelid, conjunctiva, and side of nose and maxillary nerve supplies skin of posterior part of side of the nose, lower eyelid, cheek, upper lip, and lateral side of orbit were involved in this case. Since the mandibular nerve carries sensory information from the lower lip, the lower teeth and gums, the chin and jaw (except the angle of the jaw, which is supplied by C 2-3 ), parts of the external ear, and parts of the meninges; there was no clinical involvement of it.

The annual incidence of HZ worldwide is approximately 1.2-3.4 cases per 1,000 persons. [6] HZ is less common in women under 30 years of age, but may be underreported in pregnancy as the fetus is rarely infected. [7] HZ infection during pregnancy carries same risk as general population of developing congenital varicella syndrome (CVS) in the unborn child. [8]

In a study, out of 474 women diagnosed with HZ during pregnancy, 466 had live births and other eight had miscarriages and therapeutic abortions. There was no serologic evidence of intrauterine infection. A smaller prospective report had 14 cases of pregnancy complicated with HZ, without adverse outcomes or CVS. [8] There is a theoretical risk of intrauterine infection following HZ involving T 10 to L 1 dermatomes (as sensory nerves to the uterus originate from these segments) in pregnancy. However, no such reports have been documented. [8] There was a case of congenital malformations consistent with CVS in a child whose mother had disseminated zoster at 12 weeks of gestation, indicating the possibility of infection caused by maternal viremia. [8] There is no clinical or serologic evidence of VZV infection in infants whose mothers developed perinatal zoster. [8] Newborns do not appear to be at risk of infection if maternal zoster occurs near delivery. [8]

After reviewing the literature, in one of the studies multidermatomal HZ occurred only in HIV-infected patients; [9] whereas yet in another report, female patient showed involvement of multiple cranial and spinal nerve segments in the form of multidermatomal HZ with facial palsy without skin lesions over VII nerve area, although she neither suffered from HIV or any immunosuppression. [10] On further reports, it was observed that if HIV-infected individuals had VZV reactivation with either multidermatomal or disseminated presentation or a trigeminal localization or both; the complication rate was quite high. [11] In another report, multidermatomal HZ occurred in HIV infected patients at lower CD 4 level than zoster involving single dermatome. [12]


  Conclusion Top


HZO in younger age commonly affects the immunocompromised host. We report this case as rare because two divisions of trigeminal nerve are involved simultaneously in the form of HZO (ophthalmic branch) and orocutaneous lesions (maxillary nerve, that is, maxillary zoster) in an immunocompetent multigravida nullipara pregnant female.

 
  References Top

1.Gialloreti LE, Merito M, Pezzotti P, Naldi L, Gatti A, Beillat M, et al. Epidemiology and economic burden of herpes zoster and post-herpetic neuralgia in Italy: A retrospective, population-based study. BMC Infect Dis 2010;10:230.  Back to cited text no. 1
    
2.Pierik JG, Gumbs PD, Fortanier SA, Van Steenwijk PC, Postma MJ. Epidemiological characteristics and societal burden of varicella zoster virus in the Netherlands. BMC Infect Dis 2012;12:110.  Back to cited text no. 2
    
3.Opstelten W, Van Essen GA, Schellevis F, Verheij TJ, Moons KG. Gender as an independent risk factor for herpes zoster: A population-based prospective study. Ann Epidemiol 2006;16:692-5.  Back to cited text no. 3
    
4.Birlea M, Arendt G, Orhan E, Schmid DS, Bellini WJ, Schmidt C, et al. Subclinical reactivation of varicella zoster virus in all stages of HIV infection. J Neurol Sci 2011;304:22-4.  Back to cited text no. 4
    
5.Shaikh S, Ta CN. Evaluation and management of herpes zoster ophthalmicus. Am Fam Physician 2002;66:1723-30.  Back to cited text no. 5
    
6.Chen YH, Rau RH, Keller JJ, Lin HC. Possible effects of anaesthetic management on the 1 yr followed-up risk of herpes zoster after Caesarean deliveries. Br J Anaesth 2012;108:278-82.  Back to cited text no. 6
    
7.McKinlay WJ. Herpes zoster in pregnancy. Br Med J 1980;280:561-2.  Back to cited text no. 7
    
8.Pupco A, Bozzo P, Koren G. Herpes zoster during pregnancy. Can Fam Physician 2011;57:1133.  Back to cited text no. 8
    
9.Nithyanandam S, Joseph M, Stephen J. Ocular complications and loss of vision due to herpes zoster ophthalmicus in patients with HIV infection and a comparison with HIV-negative patients. Int J STD AIDS 2013;24:106-9.  Back to cited text no. 9
    
10.Gupta LK, Kuldeep CM, Mittal A, Singhal H. Multidermatomal herpes zoster in an immunocompetent female. Indian J Dermatol Venereol Leprol 2005;71:210-1.  Back to cited text no. 10
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11.Veenstra J, van Praag RM, Krol A, Wertheim van Dillen PM, Weigel HM, Schellekens PT, et al. Complications of varicella zoster virus reactivation in HIV-infected homosexual men. AIDS 1996;10:393-9.  Back to cited text no. 11
    
12.Lidhoo P, Unemori P, Leslie KS, Maurer T. Disseminated herpes zoster with increased CD 4 counts in 3 HIV-infected patients. J Am Acad Dermatol 2009;61:345-7.  Back to cited text no. 12
    


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