Journal of Pakistan Association of Dermatologists 2013;23 (3):2267-271.

Original Article
Herpes zoster in children
Lamees Mahmood Malik*, Nadia Ali Azfar*, Abdur Rahim Khan*, Ijaz Hussain**,
Muhammad Jahangir

*Department of Dermatology, Unit 1, Allama Iqbal Medical College/Jinnah Hospital, Lahore

**Department of Dermatology, Postgraduate Medical Institute, Lahore General Hospital, Lahore

Abstract Objective To study the epidemiology and clinical features of childhood herpes zoster.
Patients and methods The study was carried out from March 2008 till February 2012. Forty two
cases of herpes zoster in children less than 12 years of age were enrolled from the outpatient
departments of Lahore General Hospital and Jinnah Hospital Lahore. Patients were subjected to
detailed history, physical examination and relevant investigations.

Results Out of 42 patients with herpes zoster, 57.1 % were males and 42.9 % were females. The
mean age was 8 years with an age range of 18 days to 12 years. In most patients a single dermatome
was involved (69%) and thoracic dermatome was involved in the majority (40.4%). The most
common symptom was pruritus in 52%, followed by pain in 12%. A positive history of previous
exposure to varicella was present in 31% patients only, and out of these 61% were exposed before
the age of two years. Six patients gave history of chickenpox in mother during pregnancy. Majority
of patients i.e. 83.3% showed no evidence of immunosuppression on history, examination and
investigations. Three patients were anti-HCV positive (7.1%), two (4.6%) had tuberculosis, one
(2.3%) patient was taking steroids and one (2.3%) was diagnosed as leukemia.

Conclusion Most of the children with herpes zoster had no obvious evidence of
immunosuppression. History of previous exposure to varicella was found in only 31% with majority
being exposed below two years of age. Herpes zoster is a relatively mild disease in children with
pruritus being the main symptom in 52% and pain occurred in only 12% of cases.

Key words
Herpes zoster, shingles, varicella, children.

Introduction years is only 0.45 per 1000 persons while in the

age group of 75 years and above it is up to 4.5
Herpes zoster is a viral illness caused by per 1000 persons.1
reactivation of previously acquired varicella-
zoster virus occurring in a dermatomal pattern. Although childhood herpes zoster is considered
.The primary infection i.e. chickenpox usually to be rare, many studies have shown an
occurs in childhood whereas herpes zoster is increasing incidence.2 It is frequently seen in
considered to be an ailment of the elderly. The children with acquired cellular immune
age adjusted incidence rate in children below 14 deficiency as in patients on chemotherapy or
with HIV.3 Herpes zoster may also occur in
Address for correspondence
Dr. Lamees Mahmood Malik immunocompetent children and recent reports
Associate Professor, show an increase in the number of cases in
Dermatology Department Unit 1, apparently healthy children.4
Jinnah Hospital, Lahore.
Email: [email protected]

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Journal of Pakistan Association of Dermatologists 2013;23 (3):2267-271.

Extensive data regarding herpes zoster in adults

are available but studies regarding this disease in
children are limited. The present study was
undertaken to study the epidemiological and
clinical features of herpes zoster occurring in
children below 12 years of age presenting at a
tertiary care unit.

Patients and methods

The data presented in this study were collected

at the departments of dermatology, Lahore Figure 1 Herpes zoster affecting the right ophthalmic
division of trigeminal nerve.
General Hospital and Jinnah hospital Lahore
respectively, over a period of four years from Results
March 2008 till February 2012. A total of 42
children below 12 years of age both male and A total of 42 patients were enrolled in the study.
female, presenting with a clinical diagnosis of There were 24 (57.1%) males and 18 (42.9%)
herpes zoster were enrolled in the study. An females. The ages ranged from less than a month
informed consent was obtained from the parents to 12 years, the youngest patient being 18 days
and all information was recorded on a pre- of age. Mean age was 8.2±2.4 years. Most of the
designed pro forma. A detailed history included patients belonged to the age group of 6 to 12
history of chickenpox in the past, both in the years followed by the age group of 1 to below 6
patient and in other family members, history of years.
chickenpox or herpes zoster in the mother at the
time she was pregnant with the patient and Dermatomal involvement was thoracic in 17
history pertaining to any evidence of (40.4%), cervical in 12 (28.6%), cranial
immunosuppression. Clinical examination to (ophthalmic) in 7 (16.7%) [Figure 1] and
ascertain the dermatome involved, any evidence lumbar in 5 (11.9%) patients. Dissemination was
of dissemination, and any other manifestation of seen in only one patient (2.4%). Sixty nine
immunosuppression was carried out. In majority percent patients showed one dermatome
of the patients the diagnosis was clinical. involvement and 28.6% showed involvement of
However, in a few doubtful cases Tzanck smear 2 dermatomes. More than 2 dermatomes were
for viral giant cells was carried out. Other involved in only 1 (2.4%) patient. The
investigations such as complete blood count, involvement was right-sided in 20 and left sided
ESR, liver function tests, HBsAg, anti-HCV in 22 patients. Most of the patients presented
antibodies and renal function tests were done in with mild to moderate pruritus i.e. 52 %. Only
all patients. Chest X rays were done in 9 patients 12 % had pain which was mild in 4%, moderate
with history of chronic cough with in 3% and severe pain was present in 5 % of the
expectoration. Abdominal ultrasonography was patients. Presence or absence of symptoms was
done in 3 patients with positive anti-HCV assessed in patients above two years of age only.
antibody. Eleven (26%) patients had secondary bacterial
infection at the time of presentation.

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Journal of Pakistan Association of Dermatologists 2013;23 (3):2267-271.

Out of the total 42 patients, 29 (69%) gave no cells on microscopy in case of viral infection.
history of previous chickenpox in patient or However it is imperative that herpes zoster be
chickenpox or herpes zoster in family member differentiated from zosteriform herpes simplex
or close contact. Out of these only 6 (20%) by direct fluorescent monoclonal antibody test,
patients gave a positive history of chickenpox in serum specific IgM by indirect fluorescent
the mother while she was pregnant carrying the antibody method or more definitely viral
patient. No mother gave history of herpes zoster cultures.7 Unfortunately these tests were not
during pregnancy. Out of the 13 patients available to us so our diagnosis was mainly
previously exposed to varicella, 8 (61%) were clinical or by Tzanck smear in doubtful cases.
exposed below 2 years of age. None of the
children gave history of immunization against Herpes zoster although thought to be a disease
varicella. of the elderly is increasingly being seen in the
younger age groups. Various authors have
Majority of the patients i.e. 35 (83.3%) showed studied the epidemiology and clinical patterns of
no evidence of immunosuppression on history, this condition in the pediatric population.8 Out of
examination and investigations. Three patients our 42 patients there was a slight male
were anti-HCV positive, 2 were diagnosed as predominance i.e. 57% and the mean age was
having pulmonary tuberculosis, one patient was 8.2 years which was consistent with other
taking systemic corticosteroids for chronic studies.3,9 Although our youngest patient was 18
bullous disease of childhood and one patient was days old, majority of the patients were between
recently diagnosed as leukemia although 6 to 12 years of age i.e. 54%. Infants below one
chemotherapy had not yet been started. year amounted to only 14% of the total cases.
The immunological status of the child at the
Discussion time of acquiring the primary infection is very
important in determining the onset of childhood
Primary varicella-zoster infection occurs in the zoster. In infants, low levels of lymphocytes,
form of chickenpox, usually in early childhood. natural killer and cytokines, along with virus-
The virus remains dormant in the dorsal root specific immunoglobulins result in early
ganglia till activated when it produces the appearance of zoster.10 Of our patients who gave
clinical picture of herpes zoster. This history of varicella exposure in the past more
reactivation generally occurs in the elderly and than half i.e. 61% were exposed below 2 years
is associated with loss of varicella-zoster virus of age. Terada et al.11 showed that healthy
specific cellular immunity.5 Similarly herpes immunocompetent children who had primary
zoster in patients on chemotherapy is due to varicella infection before one year remained
suppression of cellular immunity and in HIV positive for VZV for the longest period as
infected individuals it is due to viral destruction determined by PCR reaction.
of T cells.6
Herpes zoster in otherwise healthy children may
A diagnosis of herpes zoster is mainly clinical. be due to acquiring primary varicella infection in
Common differentials include zosteriform utero or in infancy when the immunity is not
herpes simplex, bullous impetigo and bullous fully developed. Vaccination with live
insect bite reaction. A simple bed side test of attenuated virus may also contribute. However,
Tzanck smear may reveal multinucleated giant none of our patients was previously vaccinated.

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Journal of Pakistan Association of Dermatologists 2013;23 (3):2267-271.

A large number of our patients i.e. 69% gave no Clinical features include pruritus, pain, burning,
history of exposure to varicella in the past. Of fever and lymphadenopathy. Fifty two percent of
these only 20% gave history of maternal our patients had pruritus as a symptom while
vesicular eruption likely to be chickenpox in 12% had pain which was severe in only 5%.
pregnancy. However, in literature, in 69% of Dermatomal involvement was predominantly
infantile herpes zoster cases, the initial event thoracic (40%) and this was comparable with
could be traced to maternal varicella during other studies.2,3,4,9 Dissemination was seen in
pregnancy.12,13 The reason of this difference only one patient who otherwise had no evidence
could be a larger number of subclinical of immunosuppression. However, more than two
infections that go unnoticed in our population. dermatomes were involved in one patient who
was diagnosed with leukemia. Incidence of
Historically, childhood herpes zoster was postherpetic neuralgia is reported to be very rare
thought to be an indicator of underlying in childhood cases.4,16 Only 17 out of our 42
malignancy or immunosuppression.14 However, patients reported for follow up after 6 weeks of
studies indicate that only 3% of pediatric herpes the eruption and none of them had pain as a
zoster cases are associated with malignancies.3,9 symptom.
In our patients, majority (83%) showed no
evidence of immunosuppression on history, Due to the mild nature of disease in otherwise
examination and investigations. Ideally in healthy children, antiviral therapy is usually
childhood herpes zoster, lymphocyte counts, reserved for immunocompromised children or
CD4/CD8 ratio and serum immunoglobulin children with evidence of dissemination of
levels should be estimated to rule out undetected disease. Majority of patient respond well to
concurrent immunosuppression. It was our symptomatic treatment. Patients with HIV
limitation in not being able to perform these infection are at a risk of developing severe
tests. However, of the 7 patients with underlying illness from either varicella or zoster.
immunocompromised state, 3 had infection with Progressive primary varicella, a syndrome with
hepatitis C virus, 2 were diagnosed as persistent new lesion formation and visceral
pulmonary tuberculosis. One patient was taking dissemination, may occur in HIV infected
long-term steroids and one had recently been patients and may be life threatening.17.
diagnosed with leukemia. Only one of these 7
patients gave a positive history of previous Conclusion
exposure to varicella infection. The anti-HCV
positive patients had normal liver functions and Herpes zoster is increasingly being observed in
size and texture of liver on sonography. The children. Majority of these children show no
reason for lower number of evidence of immunosuppression and generally
immunocompromised patients in our study the disease is mild and of shorter duration than
could be that our study population consisted of its adult variety.
general dermatology OPD cases and patients
from oncology and more sick pediatric patients References
were not included.
1. Ragozzino MW, Melton L J III, Kurland LT
et al. Population-based study of herpes
Generally, childhood herpes zoster is milder and zoster and its sequelae. Medicine
shorter in duration than the adult variety.15 (Baltimore).1982;61:310-6.

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Journal of Pakistan Association of Dermatologists 2013;23 (3):2267-271.

2. Prabhu S, Sripathi H, Gupta S, Prabhu M. 10. Terada K, Tanaka H, Kawano S, Kataoka N.

Childhood herpes zoster: A clustering of ten Specific cellular immunity in
cases. Indian J Dermatol. 2009;54:62-4. immunocompetent children with herpes
3. Takayama N, Yamada H, Kaku H, zoster. Acta Paediatr. 1998;87:692-4.
Minamitani M. Herpes zoster in 11. Terada K, Kawano S, Yoshihiro K, Morita
immunocompetent and T. Varicella-zoster virus (VZV) reactivation
immunocompromised Japanese children. is related to the low response of VZV-
Pediatr Int. 2000;42:275-9. specific immunity after chickenpox in
4. Terada K. Characteristics of herpes zoster in infancy. J Infect Dis. 1994;169:650-2.
otherwise normal children. Pediatr Infect 12. Lewkonia IK, Jackson AA. Infantile herpes
Dis J. 1993;12:960-961 zoster after intrauterine exposure to
5. Berger R, Florent G, Just M. Decrease in the varicella. BMJ. 1973;3:149.
lymphoproliferative response to varicella- 13. Enders G, Miller E, Cradock-Watson J et al.
zoster virus antigen in the aged. Infect Consequences of varicella and herpes zoster
Immun.1981;32:24-7. in pregnancy: prospective study of 1739
6. Kurlan JG, Connelly BL, Lucky AW. cases. Lancet. 1994;343:1548-51
Herpes zoster in the first year of life 14. Kakourou T, Theodoridou M, Mostrou G et
following postnatal exposure to varicella- al. Herpes zoster in children. J Am Acad
zoster virus: Four case reports and a review Dermatol. 1998;39:207-10.
of infantile herpes zoster. Arch Dermatol. 15. Smith CG, Glaser DA. Herpes zoster in
2004;140:1268-72. childhood: case report and review of the
7. Solomon AR. New diagnostic tests for literature. Pediatr Dermatol. 1996;13:226-9.
herpes simplex and varicella zoster 16. Baba K, Yabuuchi H, Takahashi M, Ogra
infection. J Am Acad Dermatol. PL. Increased incidence of herpes zoster in
1988;18:218-21. normal children infected with varicella
8. Guess HA, Broughton DD, Melton L J III, zoster virus during infancy: community-
Kurland LT. Epidemiology of herpes zoster based follow-up study. J Pediatr.
in children and adolescents: a population- 1986;108:372-7.
based study. Pediatrics. 1985;76:512-7. 17. von Seidlin L, Gillette SG, Bryson MD et al.
9. Latif R, Shope TC. Herpes zoster in normal Frequent recurrence and persistence of
and immunocompromised children. Am J varicella zoster virus infection in children
Dis Child. 1983;137:801-2. infected with human immunodeficiency
virus type 1. J Pediatr. 1996;128:52-7.

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