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The clinical diagnosis, etiology and predisposing factors of these common viral skin diseases are discussed with special emphasis on new therapeutic approaches.
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Herpes zoster ophthalmicus is not an uncommon disease and is more prevalent among debilitated and seriously ill patients. It is caused by the same virus causing varicella. The exact trigger mechanism is unknown, as well as much of the pathogenesis. The disease is more uncommon among the elderly and usually runs a benign course. Approximately 50% of the patients develop ocular complications ,the most frequent of these being keratitis, iritis, secondary glaucoma and extraocular muscle involvement. The most striking pathologic features are the lymphocytic infiltration of the long ciliary nerves and the vasculitis of the vessels accompanying them. The most controversial aspect of the disease is that of treatment. Almost every therapeutic regimen has been attempted in a disease whose natural course is self-limited. The future will add more to our knowledge of the pathogenesis of the disease and shed more light on the efficacy of various treatments.
Herpes zoster virus DNA was isolated from infected human embryo lung cells because it is released into the "Hirt supernatant". The buoyant density of the virus DNA was found to be slightly higher than that of cellular DNA. The molecular weight of this DNA was estimated to be 92 x 10(6) daltons by cosedimentation with T4 DNA in neutral sucrose gradients. As with the DNA of other herpesviruses, the DNA of herpes zoster virus is fragmented when denatured under alkaline conditions and is therefore "alkali-labile". Studies of virus DNA using reassociation kinetics reveal that the kinetic complexity of the DNA correlates with the genome size as estimated by sucrose gradient sedimentation.
Herpes zoster has rarely been noted to occur during pregnancy. We report the case of a woman at 37 weeks' gestation who developed herpes zoster and 3 weeks later delivered a normal infant. A 6-month follow-up has revealed no sequelae in the child. Pertinent clinical aspects of herpes zoster and a review of the literature indicating a favorable prognosis for infants exposed in utero are presented.
Herpes zoster is a self-limited disorder which in most cases resolves without complications. The specific defect in host immunity that permits activation of latent V-Z virus and the occurrence of herpes zoster in both healthy and debilitated individuals has not yet been identified. In some patients, particularly the aged, complications occur during the acute phase of the disease or there are sequelae that may incapacitate the patient later. The most important of these is postherpetic neuralgia. In the elderly the chance of developing neuralgia following herpes zoster is about 50%. Involvement of the eye may produce minimal scarring or permanent blindness. There is an increasing incidence and severity of herpes zoster in association with malignant disease and in particular with Hodgkin's disease. Treatment of herpes zoster in the elderly should be determined by presenting symptoms. Topical medication such as the basic shake lotion is helpful. Personal experience and published reports suggest that early systemic administration of corticosteroids to healthy patients with severe herpes zoster pain with lessen the occurrence of postherpetic neuralgia. Administration of herpes zoster immune globulin is only effective in reducing the morbidity or preventing varicella in high risk individuals. ZIG does not affect the clinical course of herpes zoster.
Epidemiological and statistical data of herpes zoster and chickenpox by such indices as morbidity level, periodicity and month-by-month changes in the incidence of these diseases were compared. The study included 2345 herpes zoster and 11116 chickenpox cases in the course of 5 years (1972--1976). In comparison with herpes zoster, the intensity of chickenpox spread among the population was on the average 4.7 times greater. Of the total number of chickenpox cases the percentage of herpes zoster contituted 21.0. Chickenpox morbidity had marked seasonal cyclic nature with the amplitude of seasonal variations of about 8; as to herpes zoster--there was no annual or seasonal cyclicity. Thus, in the development of chickenpox and herpes zoster epidemic process there was revealed a peculiar tendency inherent to each of these infections; no common epidemiological and statistical regularities in the spread intensity, annual periodicity and seasonal cyclicity were detected.
A case of herpes zoster limited to the right palate and the edentulous alveolar ridge in the absence of concurrent skin lesions or predisposing systemic disease is presented. Because of the relative rarity of isolated mucous membrane lesions of this viral disease, the tendency for intraoral vesicles to break down and ulcerate early, and, in this patient, the additional clinical findings of marked swelling and induration, malignancy rather than herpes zoster was suspected; cytologic smear furthered the suggestion of the former. A biopsy provided the definitive diagnosis.
Chicken pox and herpes zoster represent afraid complications in patients with malignant diseases which may take a noxious course. During the sequence of two chicken pox epidemias in 1973 in children with acute lymphoblastic leukaemias, the prevention and therapeutic possibilities were checked again. Chicken pox or herpes zoster convalescent sera being compatible for blood groups and zoster-immunoglobulin were not available. At the time of the epidemia the first reports on the effect of cytarabine (Alexan) were published. Moreover, we received an information on the therapeutic application of small pox vaccine inactivated with formaldehyde (vaccinia antigen) in adults with herpes zoster and herpes labialis. From 10 children with leukaemias, who were affected with chicken pox or herpes zoster, 7 received up to 1.0 ml of inactivated small pox vaccine intramuscularly on the first day of manifestation. In 6 of the patients there were no new efflorescences on the third day. A third child died. First of all it seems probable that this influence may be due to an induction of interferon formation. Further studies will have to elucidate to what extent this mechanism will also be efficient in severe cases of immunosuppression.
Systemic treatment of herpes zoster becomes possible by cytarabine. Complications of herpes zoster ophthalmicus such as relapsing corneal ulceration, perforation or scarring, secondary glaucoma, Argyll Robertson pupils, extraocular muscle palsies, and optic atrophy, as well as postherpetic neuralgia can be prevented by the use of this drug. For this reason the authors believe treatment with cytarabine to be the therapy of choice in herpes zoster.
Difference in antibody responses between varicella and herpes zoster was reconfirmed by complement fixation (CF) test and by platelet aggregation (PA) test. Rise in PA antibody level was observed only in patients with herpes zoster, but not in patients with varicella, while the increase in CF antibody was demonstrated in both types of the diseases. Among 235 healthy children, CF antibody was detected in 42 children and out of these 25 also had PA antibody. Sera of 116 individuals who were vaccinated with a live vaccine comprised of varicella-herpes zoster virus (VZV) were tested for CF and PA antibodies. Within six months after vaccination, 81.3 per cent of the vaccinees demonstrated the rise in CF antibody alone, and only one vaccinee possessed low level of PA antibody. Six months to 1 year after vaccination, CF antibody in 12 out of 13 vaccinees fell to undetectable level. Later than 1 year after vaccination, 9 out of 28 vaccinees possessed CF antibody. Two out of these 9 vaccinees also had PA antibody. The PA antigens prepared from viruses isolated either from a varicella patient or a herpes zoster patient responded similarly to the sera of herpes zoster patients, but no response was detected with sera of varicella patients. PA and CF antibody titers of herpes zoster patients showed a high degree of correlation.
Herpes zoster is a viral disease with cutaneous and mucous manifestations. They occur in 30% cases in the trigeminal area and in 7.2% cases in other parts of the head. Typical manifestations are nevralgias simulating dental pain, also vesicles with an erythematous halo located in the territory of the second and third trigemial branch. They erupt on the skin, the lips, tongue, palate and cheeks. Zosteric nevralgia may extend into the territory of the first trigeminal. There is no known causal therapy and local treatments are but unsatisfactory pallatives.
The lesions of herpes zoster of the colon were observed in three cases. Small polygonal mucosal blebs or small ulcerations involving a short segment of the colon and appearing in a reasonable time relationship with the cutaneous manifestations either in a corresponding or noncorresponding dermatome should enable diagnosis of this unusual condition. Recognition of this entity in the presence of these skin lesions should be obvious and therefore helpful in avoiding more aggressive and invasive diagnostic procedures.
A case of herpes zoster complicated by acute arthritis with effusions is described. The white cell count in the synovial fluid was low, with a predominance of neutrophils. The synovium showed superficial deposits of fibrin, slight intimal hyperplasia, and subintimal polymorph infiltration. Varicella virus was not detected by culture or electron microscopy, but varicella antigen was demonstrated in the cytoplasm of macrophages in the effusion. Other findings did not determine whether the antigen had appeared in the joint from circulating immune complexes, or following synovial phagocytosis or proliferation of virus.
Herpes zoster of the larynx is considered to be rare, but on reviewing the literature it is noted that some authors considered it to be more common than already acclaimed. Herpes may prove to be a common cause of cord palsies presently labelled as idiopathic and serological tests for herpes should be asked for. Of note is the fact that the cord palsy of a herpetic lesion can be short-lived and that earache is a common symptom. In this paper four cases of herpes laryngis are presented. It is advised that the larynx should be examined in all cases of herpes zoster of the head and neck.
The literature on complicated herpes zoster is summarized in this paper. The case histories of 18 patients with herpes zoster are presented. Two patients had encephalitis, 2 had myelitis and the other 14 patients had various types of lower motor neurone disturbance. Both patients with encephalitis--one of who developed choreo-athetosis during the illness--recovered fully. Only 1 of the 2 patients with myelitis recovered fully; the other remains severely paraparetic and the reason for her incomplete recovery may be related to the presence of generalized arteriolar disease associated with seronegative rheumatoid disease. One patient developed a Guillain-Barre syndrome 3 weeks after the onset of herpes zoster. Recovery in the 15 patients with lower motor neurone involvement has been slow butcomplete--or almost complete--in all but 1, a patient with persistent facial weakness as part of the Ramsay Hunt syndrome and who also had weakness of one upper limb. Seven other patients had lower limb weakness. In 2 patients the weakness was confined to abdominal myotomes and 2 other patients had urinary retention. Electromyographic abnormalities were found in the muscles which were weak and frequently also in muscles which appeared strong. It is emphasized that neurological disturbances other than sensory abnormalities may be found in patients with herpes zoster. Motor complications of various types are not uncommon.
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