2012.1-1.HZ

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Our Dermatol Online. 2012; 3(1): 5-8
Date of submission: 14.09.2011 / acceptance: 28.10.2011
Conflicts of interest: None
 

HERPES ZOSTER OPHTHALMICUS: CLINICAL PROFILE IN ADULTS LESS THAN 30 YEARS OF AGE

HERPES ZOSTER OPHTHALMICUS: KLINICZNY PROFIL U DOROSŁYCH PONIŻEJ 30-go ROKU ŻYCIA

Vijayalekshmi Sujatha1, Mudianur Subrahmanyam Padmajothi1, Hariharasubramony Ambika2, Chankramath Sujatha2

1Department of Ophthalmology, M.V.J.Medical College & Research Hospital, Hoskote, Bangalore, India
2Department of Dermatology, M.V.J.Medical College & Research Hospital, Hoskote, Bangalore, India
 

Corresponding author: Dr. Vijayalekshmi Sujatha   e-mail: drsujatha2006@yahoo.co.in


 

Abstract
Introduction: To establish the clinical profile of Herpes Zoster Ophthalmicus (HZO) in individuals less than 30 years of age and to correlate clinical manifestation with their immune status.
Materials and methods: A retrospective chart review was performed of patients younger than 30 years of age who presented with HZO from June 2010 to June 2011. Data was collected on their demographics, medical history, clinical presentation, results of serological investigations, and visual outcome. A detailed evaluation of clinical profile with ocular implications and a sequel was done in each case.
Results: The mean age of the patients was 23.25 years. Ophthalmic features presented included lid edema, ptosis, keratitis, and superficial punctate keratitis with dry eye, optic neuritis. None of them was found to be HIV positive. Final visual acuity was 20/40 or better in 90% of the subjects.
Conclusion: Immunocompetent young adults do present with features of HZO. However, the disease spectrum in HIV-negative patients is localized, less severe, and more amenable to therapy.
 
Streszczenie
Wstęp: Celem pracy było stworzenie klinicznego profilu postaci ocznej półpaśca u osób poni?ej 30-go roku ?ycia oraz skorelowanie objawów klinicznych z poziomem odporności tych osób.
Materiał i metody: Wykonano retrospektywną analizę historii chorób u pacjentów poni?ej 30-go roku ?ycia z rozpoznaniem ocznej postaci półpaśca. Zebrano dane dotyczące demografii, przebytych chorób, klinicznych objawów, wyników badań serologicznych oraz badań okulistycznych. Dokładna ocena klinicznego profilu z implikacjami okulistycznymi i dalszymi ich następstwami była przeprowadzona w ka?dym przypadku.
Rezultaty: Średnia wieku pacjentów wynosiła 23,25 lat. Prezentowane objawy okulistyczne obejmowały obrzęk powiek, opadanie górnej powieki, zapalenie rogówki oraz powierzchowne, punktowane zapalenie rogówki z zespołem suchego oka a tak?e zapalenie nerwu wzrokowego. śaden z pacjentów nie był HIV- pozytywny. Końcowa ostrość widzenia wynosiła 20/40 lub powy?ej u 90% pacjentów.
Podsumowanie: Młodzi immunokompetentni dorośli tak?e zapadają na oczną postać półpaśca. Jednak?e spektrum choroby u osób HIV-negatywnych jest ograniczone, mniej cię?kie i bardziej podatne dla terapii.
 
Key words:  herpes zoster ophthalmicus; Human Immunodeficiency Virus infection; immune status; young adults
Słowa klucze:  herpes zoster ophthalmicus; infekcja ludzkim wirusem niedoboru odporności; stan odporności; młody dorosły

 

Introduction
Herpes Zoster Ophthalmicus (HZO) is a serious infection because of its implications on vision and the cosmetic blemish it leaves in addition to the distressing post herpetic neuralgia. Herpes Zoster is caused by the reactivation of the Varicella–Zoster virus lying dormant in the spinal or cerebral sensory ganglia and is commonly seen in patients with depressed cellular immunity, such as the elderly, patients on immunosuppressive therapy, and patients with lymphoma or positive HIV status [1,2]. The incidence and severity of Herpes Zoster increases with advancing age, especially after the seventh decade [3]. The pain associated with Herpes Zoster can be debilitating, with a serious impact on the quality of life, and the economic costs of managing the disease represent an important burden on both health services and society [4]. With the emergence of the Acquired Immune Deficiency Syndrome (AIDS) pandemic, adults younger than 45 years of age are increasingly presenting with Herpes Zoster due to HIV [5]. The relative risk of Herpes Zoster is at least fifteen times greater in patients with HIV than in patients without HIV [6]. Studies indicate that the occurrence of HZO in young individuals correlates strongly with immunosuppression. The present study was undertaken to highlight the clinical profile of (HZO) in young adults who are less than 30 years of age.
 
Material and Methods
A retrospective analysis of available records of young adults (less than 30 years of age) with HZO was performed. Clinical features, results of blood laboratory workup, and treatment prescribed were noted. The median duration of follow up was nine months.
 
Results
The clinical data of eight young adults presenting with features of HZO were evaluated. Their average age was 23.25 years (range, 13-28 years). There was a predominance of males (62.8%) among the young adults presenting with HZO (Tabl. I). None of the subjects in our study had a history of varicella vaccination. All of them had a history of chicken pox in childhood. The clinical features are summarized in (Tabl. II). All subjects presented with skin lesions consistent with zoster involving the ophthalmic division of the trigeminal nerve on the affected side (right side affected in 75% subjects) of the face and head. It was limited to the ophthalmic division in all subjects. Results of other systemic investigations including a complete hemogram with peripheral smear, blood sugar profile, and serological tests for HIV,VDRL and Hepatitis B and C were negative for the all the subjects. There was no evidence of any co-existing systemic disease in any of the individuals. Serological tests were repeated in four previously negative subjects six months after their first test. The repeat test was negative in each case. Visual acuity was impaired in all subjects, the extent of impairment ranging from 20/400 to 20/60. Conjunctival hyperemia and lid edema ranging from mild to severe was observed in all subjects in the acute phase. Corneal involvement was seen in 7(87.5%) of the 8 subjects in the form of dendritic keratitis (25%), punctate keratopathy (50%) and stromal keratitis (12.5%). Corneal sensitivity was abnormal in 75% of the cases. One of the eight patients (12.5%) presented with uveal inflammation. Evaluation of the posterior segment showed optic neuritis in12.5%(1/8) of the patients. Nebulomacular corneal opacities was seen in 50% (4/8) of the patients. All the subjects with active HZO were prescribed 800mg of oral acyclovir five times a day for 2 weeks.
 

Age
Gender
Occupation
13
Female
Student
22
Male
Shop keeper
28
Male
Labourer
26
Male
Truck driver
28
Male
Farmer
25
Male
Farmer
22
Female
Housewife
23
Female
Housewife
Table I. Demographic profile and immune status of young patients with HZO
 

Case
Initial
BCVA

Lid
edema

Corneal
findings

Corneal
sensation

Uveiitis
Posterior
segment
findings
Final
BCVA

1
20/60
+
Punctate
keratitis

20/20
2
20/60
+
Dendritic
keratitis

+
20/20
3
20/400
Optic
neuritis
20/30
4
20/400
Optic
neuritis
20/60
5
20/80
Dendritic
keratitis

+
20/20
6
20/60
Punctate
keratitis

20/20
7
20/60
Punctate
keratitis

20/20
8
20/400
Punctate
keratitis

++
20/30
Table II. Ocular features at presentation and final visual acuity in young adults with HZO

 
Discussion
Herpes zoster is uncommon in adults younger than 30 years of age and the peak incidence occurs in the fifth to the seventh decade of life. The annual incidence of Herpes Zoster in adults 20–40 years old is 1.2 per 1000 person year compared with 9.4 per 1000 personyear in adults above 80 years of age in the United States [7] Similarly, the incidence of Herpes Zoster in the European primary care population was the lowest in young adults (1.9/1000 person-years in persons less than forty four years old) [8]. The disease spectrum and clinical features in adults younger than 30 years of age has not been extensively described. Our study highlights the clinical and demographic profile of HZO in this age group and also aims to correlate the clinical manifestations and final outcome of vision with the immune status. Clinically, many believe that the occurrence of HZO at such a young age is associated with an underlying HIV infection [9]. The normal spectrum of HZO in immunocompetent individuals has been described by Zaal et al [10] where 23 patients were younger than 50 years of age and 50 patients were older than 50 years. In the prospective study by Zaal et al [10]. immunocompetent young adults (<50 years) formed 31% of the study group, but their unique clinical features and disease spectrum were not highlighted. HZO has also been reported in immunocompetent, healthy children with a favorable outcome [11]. In the study by Gupta et. al [12], 56% of the cases had no clinical evidence of immunosuppression. In our study none of the subjects had any immunosuppression or any systemic disease. Half of them had exposure to chickenpox virus. All the patients presented with a localized, less severe form of the disease with better response to medical therapy. The main cause of moderate to severe visual loss at presentation in the young, patients was optic neuritis and stromal keratitis, but it was reversible with an early course of pulse intravenous steroids and aggressive antiviral therapy. Some degree of reduced corneal sensitivity was present in the majority (70%) of the immunocompetent patients without any associated long-term morbidity. This hypesthetic corneal surface, often with impaired tear secretion, predisposes the cornea to secondary infections. However, no superimposed bacterial infection was found in the group despite the diminution of corneal sensation in 70% of these subjects. None of the subjects presented with Post Herpetic Neuralgia (PHN). This correlates with the study from Iceland [13], which demonstrated variations in risk of developing PHN with different age groups and in that study patients younger than 50 years never developed severe pain at any time.
 
Conclusion
Our study outlines the spectrum of HZO in young adults who are immunocompetent. No study has been reported of HZO in young immunocompetent adults less than 30 years of age. The lack of Cell Mediated Immunity (CMI) is a significant factor in triggering Herpes zoster. While CMI is definitely compromised in immunocompromised individuals, several other factors such as malnutrition or prior infection (such as typhoid) can also lower CMI and increase the risk of virus reactivation even in young adults who are otherwise clinically healthy. Yet another trend observed was that prompt diagnosis and early intervention is effective in healthy patients.
 
REFERENCES
1. Miller AE: Selective decline in cellular immune response to varicella-zoster in the elderly. Neurology. 1980; 30: 582– 587. 2. Kestelyn P, Stevens AM, Bakkers E, Rouvroy D, Van de Perre P: Severe herpes zoster ophthalmicus in young African adults: A marker for HTLV- III seropositivity. Br J Ophthalmol. 1987; 71: 806–809. 3. Cooper M: The epidemiology of herpes zoster. Eye. 1987; 1: 413–421. 4 Whitley RJ: Varicella Zoster. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases,6th ed.Philadelphia: Elsevier Churchill Livingstone, 2004. 5. Bayu S, Alemayehu W: Clinical profile of herpes zoster ophthalmicus in Ethiopians. Clin Infect Dis. 1997; 24: 1256–1260. 6. Buchbinder SP, Katz MH, Hessol NA, Liu JY, O’Malley PM, Underwood R, et al: Herpes zoster and human immunodeficiency virus infection. J Infect Dis. 1992; 166: 1153–1156. 7. Insinga RP, Itzler RF, Pellissier JM, Saddier P, Nikas AA: The Incidence of herpes zoster in a United States administrative database. J Gen Intern Med. 2005; 20: 748– 753. 8. Opstelten W, Mauritz JW, de Wit NJ, van Wijck AJ, Stalman WA, van Essen GA: Herpes zoster and postherpetic neuralgia: Incidence and risk indicators using a general practice research database. Fam Pract. 2002; 19: 471–475. 9. Hodge WG, Seiff SR, Margolis TP: Ocular opportunistic infection incidences among patients who are HIV positive compared to patients who are HIV negative. Ophthalmology. 1998; 105: 895–900. 10. Zaal MJ, Volker-Dieben HJ, D’Amaro J: Visual prognosis in immunocompetent patients with herpes zoster ophthalmicus. Acta Ophthalmol Scand. 2003; 81: 216-220. 11. De Freitas D, Martins EN, Adan C, Alvarenga LS, Pavan-Langston D: Herpes zoster ophthalmicus in otherwise healthy children. Am J Ophthalmol. 2006; 142: 393–399. 12 Gupta N, Sachdev R, Sinha R, Titiyal JS, Tandon R: Herpes Zoster Ophthalmicus: Disease Spectrum in Young Adults iddle East Afr J Ophthalmol. 2011; 18: 178–182. 13. Helgason S, Petursson G, Gudmundsson S, Sigerddson JA: Prevalence of postherpetic neuralgia after a first episode of herpes zoster: prospective study with long term follow up. BMJ. 2000; 321: 794–796.


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