Pediatric Herpes Zoster Clinical Presentation

  • Author: Camila K Janniger, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: May 11, 2011
 

History

Children commonly experience systemic symptoms of zoster before cutaneous manifestations erupt. Acute phase symptoms include the following:

  • Unilateral pain
  • Localized unilateral pruritus
  • Low-grade fever
  • Malaise
  • Headache
  • Regional lymphadenopathy

Approximately 4-5 days before the eruption appears, the patient may experience pre-eruptive pain, itching, or burning along the affected dermatome. The pain may occasionally be so severe that it mimics appendicitis, pleuritic chest pain, renal calculi, or biliary colic.

Patients with multiple myeloma and colon cancer treated with arsenic trioxide may have a propensity to develop herpes zoster (shingles). Arsenic compounds have been suggested as a possible predisposing factor for herpes viral reactivation in these patients.[8]

The reactivation of varicella zoster virus (VZV) is seen with increased frequency in otherwise healthy children who acquire VZV (chickenpox) either in utero or within the first year of life.

Ambilateral reactivation of herpes zoster V2 following cataract operation of both eyes has been described.[9]

Herpes zoster virus reactivation may occur secondary to localized immunosuppression from corticosteroid injection.[10]

As previously mentioned, herpes zoster oticus may produce an acute jugular foramen syndrome.[4] It is characterized by acute-onset dysphagia and dysphonia, often accompanied or preceded by cranial, cervical, or pharyngeal pain. Herpetic vesicles on the skin or mucosa may or may not occur, may be noted late after onset, or may go undetected.

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Physical Examination

Patients present with a vesicular rash that generally involves the skin of a single, unilateral dermatome.

Approximately 17-35% of patients with herpes zoster also have a few scattered vesicles in sites remote from the primary dermatome. This is likely secondary to viremia and should not be confused with generalized herpes zoster. The generalized form occurs in 2-10% of patients with herpes zoster.

Zoster sine herpete appears as a tender, erythematous, unilateral patch or plaque without vesicle or bullae formation. It tends to be preceded by dysesthesias, as is typical herpes zoster (shingles).

Herpes zoster ophthalmicus can be initially evident in the eyelids.[2] Lesions that appear on the tip of the nose indicate the presence of dendritic corneal lesions of herpetic keratitis along the course of the nasociliary nerve. Immediately refer children with zoster that involves the first branch of the trigeminal nerve to an ophthalmologist.

Go to Herpes Zoster, Herpes Zoster Ophthalmicus, and Herpes Zoster Oticus for complete information on these topics.

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Contributor Information and Disclosures
Author

Camila K Janniger, MD  Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, New Jersey Medical School

Camila K Janniger, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Andrea N Driano, MD  Consulting Staff, Department of Emergency Medicine, Children's Hospital and Medical Center, Seattle WA

Disclosure: Nothing to disclose.

Specialty Editor Board

Kevin P Connelly, DO  Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University School of Medicine; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center

Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH  Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Department of Dermatology, Geisinger Medical Center

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

  1. [Guideline] Dworkin RH, Johnson RW, Breuer J, Gnann JW, Levin MJ, Backonja M, et al. Recommendations for the management of herpes zoster. Clin Infect Dis. Jan 1 2007;44 Suppl 1:S1-26. [Medline].

  2. Najjar DM, Youssef OH, Flanagan JC. Palpebral subconjunctival hemorrhages in herpes zoster ophthalmicus. Ophthal Plast Reconstr Surg. Mar-Apr 2008;24(2):162-4. [Medline].

  3. Ogita S, Terada K, Niizuma T, Kosaka Y, Kataoka N. Characteristics of facial nerve palsy during childhood in Japan: frequency of varicella-zoster virus association. Pediatr Int. Jun 2006;48(3):245-9. [Medline].

  4. Ono N, Sakabe A, Nakajima M. [Herpes zoster oticus-associated jugular foramen syndrome]. Brain Nerve. Jan 2010;62(1):81-4. [Medline].

  5. Wung PK, Holbrook JT, Hoffman GS, et al. Herpes zoster in immunocompromised patients: incidence, timing, and risk factors. Am J Med. Dec 2005;118(12):1416. [Medline].

  6. Strangfeld A, Listing J, Herzer P, et al. Risk of herpes zoster in patients with rheumatoid arthritis treated with anti-TNF-alpha agents. JAMA. Feb 18 2009;301(7):737-44. [Medline].

  7. Sharma A, Makrandi S, Modi M, Sharma A, Marfatia Y. Immune reconstitution inflammatory syndrome. Indian J Dermatol Venereol Leprol. Nov-Dec 2008;74(6):619-21. [Medline].

  8. Nouri K, Ricotti CA Jr, Bouzari N, Chen H, Ahn E, Bach A. The incidence of recurrent herpes simplex and herpes zoster infection during treatment with arsenic trioxide. J Drugs Dermatol. Feb 2006;5(2):182-5. [Medline].

  9. Korber A, Franckson T, Grabbe S, Dissemond J. Ambilateral reactivation of herpes zoster V2 following cataract operation of both eyes. J Eur Acad Dermatol Venereol. May 2007;21(5):712-3. [Medline].

  10. Fernandes NF, Malliah R, Stitik TP, Rozdeba P, Lambert WC, Schwartz RA. Herpes zoster following intra-articular corticosteroid injection. Acta Dermatovenerol Alp Panonica Adriat. Mar 2009;18(1):28-30. [Medline].

  11. Koh MJ, Seah PP, Teo RY. Zosteriform herpes simplex. Singapore Med J. Feb 2008;49(2):e59-60. [Medline].

  12. Patel GA, Siperstein RD, Ragi G, Schwartz RA. Zosteriform lymphangioma circumscriptum. Acta Dermatovenerol Alp Panonica Adriat. Dec 2009;18(4):179-82. [Medline].

  13. Kalpoe JS, Kroes AC, Verkerk S, et al. Clinical relevance of quantitative varicella-zoster virus (VZV) DNA detection in plasma after stem cell transplantation. Bone Marrow Transplant. Jul 2006;38(1):41-6. [Medline].

  14. Boer A, Herder N, Blodorn-Schlicht N, Falk T. Herpes incognito most commonly is herpes zoster and its histopathologic pattern is distinctive!. Am J Dermatopathol. Apr 2006;28(2):181-6. [Medline].

  15. Sanford M, Keating GM. Zoster vaccine (Zostavax): a review of its use in preventing herpes zoster and postherpetic neuralgia in older adults. Drugs Aging. 2010;27(2):159-76. [Medline].

  16. Caple J. Varicella-zoster virus vaccine: a review of its use in the prevention of herpes zoster in older adults. Drugs Today (Barc). Apr 2006;42(4):249-54. [Medline].

  17. van Hoek AJ, Gay N, Melegaro A, Opstelten W, Edmunds WJ. Estimating the cost-effectiveness of vaccination against herpes zoster in England and Wales. Vaccine. Feb 25 2009;27(9):1454-67. [Medline].

  18. Schmader K, Levin M, Gnann J, McNeil S, Vesikari T, et al. Efficacy, immunogenicity, safety, and tolerability of zoster vaccine (ZV) in subjects 50 to 59 years of age (Poster/Abstract). Infectious Diseases Society of America. The 48th Annual Meeting of the Infectious Diseases Society of America. 10-21-2010;Vancouver, British Columbia, Canada:Ref Type: Abstract: 3363.

  19. Khaliq W, Alam S, Puri N. Topical lidocaine for the treatment of postherpetic neuralgia. Cochrane Database Syst Rev. 2007;(2):CD004846. [Medline].

  20. Paster Z, Morris CM. Treatment of the localized pain of postherpetic neuralgia. Postgrad Med. Jan 2010;122(1):91-107. [Medline].

  21. Quan D, Hammack BN, Kittelson J, Gilden DH. Improvement of postherpetic neuralgia after treatment with intravenous acyclovir followed by oral valacyclovir. Arch Neurol. Jul 2006;63(7):940-2. [Medline].

 
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