Varicella zoster virus

ByDr.Noreen

Mohammed

Varicella-zoster virus (VZV)Varicella-zoster virus (VZV) like other herpes viruses causes both primary and recurrent infections and remains latent neurons present in the sensory ganglia.

VZV is associated with two major clinical infections of humans: Chickenpox (varicella) and shingles (HZ)

Herpes zoster (HZ) (shingles)Herpes zoster is a well-known viral disease which results due to reactivation of the latent Varicella-zoster virus that is present because of a previous exposure to varicella infection (chicken pox)

1st division of the trigeminal nerve are the most commonly affected nerves; the involvement of 2nd and 3rd division of trigeminal nerve is a rarity

The elderly and those with an immunecompromised status such as HIV/AIDS stand at a greater risk to develop HZ .

Clinical features-:

Patients with HZ may progress through three stages ;1 .Prodromal

2 .Active 3.Chronic

1 )The prodromal stage:

characterized by sensations such as burning, tingling, itching, pricking, occurring along the cutaneous distribution of dermatome.

Odontalgia and pulpal necrosis may result if branches of the trigeminal nerve are involved, during this phase.

These symptoms may be present up to 1-month in advance of the acute mucocutaneous lesions, and hence, this stage is difficult to diagnose

2 )The active stageDescribed by the appearance of the rash with along with the systemic upset .

The skin rash is very characteristic and progresses from erythematous papules, edema to vesicles, and finally to pustules within 1-7 days .

Later, these pustules dry, crust, and are exfoliated over the next 2-3 weeks leaving erythematous macular lesions that may scar

3 )The chronic stage Approximately 10% of all patients advances to the chronic stage of HZ, and is known as PHN which is defined as a short-lived, deep, shooting, and recurrent pain remaining for over a month or 3 months after the healing of the mucocutaneous lesions.

Risk of occurrence of PHN increases significantly after sixth decade, which may be because of decline of cell-mediated immunity

Oral manifestations-:

Oral manifestations of HZ appear when the second and third divisions of the trigeminal nerve are affected5 .

Dental and osseous manifestations such as

1)non-vital teeth2)internal resorption of teeth

3)abnormal development of permanent teeth4 )spontaneous exfoliation of teeth

Treatment -:In majority of the HZ patients, the condition is self-limiting, and healing is usually complete

Aim of treatment-: 1 )To alleviate the symptoms of pain and malaise

2 )To restrict the spread as well as duration of the skin lesions and

3 )To prevent the development of PHN and ophthalmological complications

Case according to :-Journal of Dental & Oro-facial Research

Vol 11, Issue 1. Jan-Jun 2015 we present 42-year-old male patient with HZ involving the maxillary

division of the trigeminal nerve. reported to our department (Department of oral and maxillofacial

pathology, K. M Shah Dental College and Hospital, Vadodara

Chief complain: complaining of painful ulcers in the mouth and not able to eat food

History of present illness

Pain since 3 days which was mild, continuous, and radiating in nature, and was associated with fever of low grade since 5 days.

After 2 days patient developed fluid-filled blisters distributed over the left half of the face

Past medical history

The patient gave a history of chickenpox infection in childhood

No relevant drug, dental, and family history was recorded

General examination:

1 )the patient was of normally built and no abnormality was detected in the nails, gait, upper, and lower limbs .

2 )Clinical signs of icterus, pallor, clubbing, edema, cyanosis, and lymphadenopathy were absent.

3 )On evaluation of vital signs ,temperature was noted to be 100°F and blood pressure 140/80 mm of Hg

Extraoral examination No abnormality was detected in the eyes, nose, and temporomandibular

joint .

Clusters of vesicles were present on the left half of face involving ala of the nose and upper lip

Intraoral examination

Multiple ulcers were seen on left half of hard palate and soft palate

The shape of the ulcers was irregular, measured approximately 3 mm × 4 mm in size .

Margins of the ulcer were erythematous and edges were sloped

Diagnosis

Based on the history and clinical findings, a provisional diagnosis of HZ affecting the left side of face involving maxillary branch of the trigeminal nerve was made

Labratorty investigation: 1-Routine hematological and serological investigations were done for

the patient

2-Complete blood count was found to be within normal limits except erythrocyte sedimentation rate and red blood cell which were slightly raised

3-The cytological examination was done after obtaining the smear from the lesions presented intraorally and extraorally.

4-Acantholytic cells with few exfoliated squamous cells and

inflammatory cells were revealed in the cytological smear

Treatment-: 1-Aceclofenac 500 mg thrice daily was prescribed for symptomatic relief of

pain. 2-Betadine mouthwash was also advised to improve oral hygiene .

3-Antiviral drug therapy was started with acyclovir 800 mg 5 times per day for 10 days.

Instructions :- we advised the patient to be in isolation, so as to prevent the viral transmission to the healthy individuals. The cutaneous lesions were kept clean and dry to reduce the risk of superinfection with bacteria

On examination of the patient after 2 weeks, regression of a number of extraoral

Intraoral lesions were noted with the formation of scar tissue and hypopigmented areas.

No fresh vesicles were reported. The patient was then reviewed after 1-week and tremendous improvement was noticed regarding the HZ lesions .

After 1month follow-up, the patient was totally devoid of symptoms. The lesions healed with scarring, but post therapeutic complications were not reported .

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