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ORIGINAL ARTICLE

A clinicomorphological study of childhood herpes

zoster at a rural based tertiary center, Gujarat, India
Rita V Vora, Rahul Krishna S Kota, Nidhi B Jivani
Department of Skin and VD, Shree Krishna Hospital, Anand, Gujarat, India

ABSTRACT

Aims and Objectives: To study the clinical features of herpes zoster (HZ) in childhood along with prevalence of human
immunodeficiency virus (HIV) seropositivity.

Materials and Methods: The study was carried out in the Department of Dermatology at a Tertiary Care Centre of Gujarat,
India, for 6 years. Children aged ≤12 years with a diagnosis of HZ seen in the Departments of Dermatology were enrolled in
a predesigned pro forma. Diagnosis of HZ was made on clinical grounds, confirmed by tzanck smear as and when required.
Sera of all cases were tested for HIV.

Results: Total of 34 children aged ≤12 years were enrolled in the study. Nineteen (55.88%) were boys and 15 (44.12%)
were girls. The mean age was 9.26  years. In 97.06% patient have localized dermatomal involvement. Most common
symptom was burning pain seen in 30  (88.24%) patients. Previous history of chickenpox was present in 19  (55.88%)
patients. Evidence of immunosuppression on history, clinical examination, and investigations was present only in one
patient, who had HIV infection.

Conclusion: Although there is increased incidence of HZ in childhood, atypical presentations are rare, multidermatomal
involvement is not commonly seen. Majority of these children do not show immunosuppression. Hence, we conclude HZ
in childhood occurs as a relatively mild and self‑limiting disease.

Key words: Childhood, herpes zoster, immunosuppression

INTRODUCTION and then travels centripetally to sensory ganglia where

it remains in the latent stage.[2] On reactivation,

H erpes zoster (HZ) is a localized disease

characterized by unilateral radicular pain and
vesicular eruption limited to dermatome innervated
by a single spinal or cranial sensory ganglion. It is
caused by the neurodermotropic virus called “varicella
zoster virus” (VZV) distributed worldwide. This
benign localized viral disease has been recognized
as a distinct entity since ancient times. It occurs as
a result of reactivation of VZV that is lying dormant
in the sensory ganglion following an earlier attack of
varicella.[1] During varicella infection, VZV passes
from skin lesions into cutaneous sensory nerve endings
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which is triggered by many factors, it travels back
along the sensory afferents to the skin associated with
hematogenous dissemination. Depending upon the
immune status of the patient, the presentation may
vary from no clinical lesions to typical zoster, scattered
vesicles, zoster sine herpete, or disseminated zoster.[3]
ADDRESS FOR CORRESPONDENCE
Dr. Rita V Vora,
Skin OPD, Room No 111, Shree Krishna Hospital, Karamsad, Anand ‑ 388 325,
Gujarat, India.
E‑mail: ritavv@charutarhealth.org
This is an open access article distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as
the author is credited and the new creations are licensed under the identical
terms.
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Vora RV, Kota RK, Jivani NB. A clinicomorphological
10.4103/2319-7250.179505 study of childhood herpes zoster at a rural based tertiary center, Gujarat,
India. Indian J Paediatr Dermatol 2016;17:273-6.

© 2016 Indian Journal of Paediatric Dermatology | Published by Wolters Kluwer ‑ Medknow 273

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Vora, et al.: A clinicomorphological study of childhood herpes zoster

HZ has traditionally affected persons with more than
60 years of age. Lifetime risk in people who survive
to 85 years is 50%. The condition is benign and
self‑limiting in patients with normal immunological
status. Although extensive data regarding HZ in
adults is available, studies regarding this disease in
children are limited. Studies have shown an increasing
incidence of childhood zoster.[4] Overall rate of
occurrence of HZ is 3.40 cases per 1000 persons while
in children <10 years, it is 0.74/1000.[5] The attack rate
during the seventh decade is approximately 7 times the
attack rate in the first two decades of life.[6] Historically,
childhood HZ was thought to be an indicator for an
underlying malignancy or immunosuppression.[7]
HZ may also occur in immunocompetent children,
and recent reports show an increase in the number
of cases in apparently healthy children.[8] This study
was conducted to study the clinicoepidemiology,
association of immunosuppressive states, and
prevalence of seropositivity in children with HZ.
MATERIALS AND METHODS
The study was carried out in the Department of
Dermatology in a teaching institute at a rural‑based
Tertiary Care Centre of Gujarat from June 2008 to
May 2014 after getting ethical approval from HREC
department of the institute. This was a cross‑sectional,
observational study. The study population included all
the patients with a diagnosis of HZ, who were seen
in the dermatology department, aged  ≤12  years.
Detailed history regarding precipitating factors,
preexisting illness, drug history, chief complaints,
dermatome involved, type of pain, prodromal
symptoms, and detailed clinical examination was
entered in a predesigned pro forma. The diagnosis of
HZ was made on clinical grounds and confirmed by
tzanck smear as and when required. Sera of all cases
were tested for antibody to human immunodeficiency
virus (HIV) after taking written informed consent from
the parent of the child, using a commercially available
immunocomb test. Subsequently, seropositivity was
confirmed by Western blot assay.
6 days, and 3 (8.82%) patients presented 6 days
after developing lesions of HZ. Itching was the most
common prodromal symptom seen in 15 (44.12%)
patients [Table 1]. Most common presenting complaint
was burning type of pain seen in 30 (88.24%) patients
followed by throbbing pain and itching in 5 (14.71%)
and 4 (11.76%) patients, respectively. Previous
history of chicken pox in patient or chicken pox or HZ
in close contact was present in 19 (55.88%) patients
while 2 patients do not remember and rest deny
chicken pox in the past. All the patients had unilateral
involvement. Left‑sided dermatomes were involved in
20 patients (58.82%), whereas right‑sided dermatomes
were involved in 14 patients (41.18%). Thirty‑three
patients (97.06%) had localized involvement,
whereas 1 (2.94%) patient had multiple dermatomal
involvement. Most common dermatome involved was
thoracic in 20 (50%) patients followed by lumbar
dermatome in 8 (23.53%) patients [Table 2 and
Figures 1 and 2]. All the 34 patients screened for HIV
infection, one patient was found to be HIV positive;
subsequently, it was confirmed by Western blot. No
child has been immunized against varicella virus.
DISCUSSION
HZ is a viral infection caused by reactivation of
the VZV, a double‑stranded DNA virus belonging
to alpha Herpesviridae family. The virus lies latent
in sensory ganglia after primary varicella exposure
(chicken pox).[9] HZ can arise years or decades following
primary infection with VZV.[10] Generally, reactivation
occurs in the elderly and is associated with loss of cellular
immunity which is varicella zoster virus‑specific.[11] HZ
occurs less frequently among children, typically causing
mild disease with minimal pain.[12] It may be seen in
Table 1: Prodromal symptoms
Prodrome Number of patients (%)
Paresthesia 5 (14.71)
Itching 15 (44.12)
Burning 9 (26.47)
Tingling 2 (5.88)
Watering of eyes 1 (2.94)
Fever 1 (2.94)
No prodrome 1 (2.94)

RESULTS
Table 2: Dermatome involved
A total of 34 children with HZ were enrolled during Dermatome Number of patients (%)
6 years in our study. Nineteen (55.88%) were Cervical 6 (17.65)
boys and 15 (44.12%) were girls. The mean age Thoracic 17 (50)
Lumbar 8 (23.53)
of presentation was 9.26 years ranging from 4 to Sacral 1 (2.94)
12 years. Twenty (58.82%) patients presented to us Ophthalmic 3
within 3 days of the appearance of zoster, whereas Maxillary 0
11 (32.35%) patients presented between 3 and Mandibular 0

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Vora, et al.: A clinicomorphological study of childhood herpes zoster
Figure 1: Grouped vesicular lesions involving left T4 dermatomes in a
10‑year‑old boy on day 2
children with acquired cellular immune deficiency as in
patients on chemotherapy or with HIV.[9] HZ may also
occur in immunocompetent children as recent reports
show an increase in the number of cases in apparently
healthy children.[8] Several authors have studied the
epidemiology and clinical patterns of this condition
in the pediatric population.[13] There is increased
incidence of HZ with an increase in age which can be
explained by reduction of the cell‑mediated immune
response mechanism to VZV in older adult patients.[14]
The majority of cases of childhood zoster occur after
the age of 5 years.[15] Important factor in determining
the onset of zoster in childhood is the immunological
status of the child at the time of primary infection. Low
levels of lymphocytes, natural killer, and cytokines,
along with virus‑specific immunoglobulins result in
early appearance of zoster in infants.[16]
The diagnosis of HZ is mostly clinical, but when in
doubt, laboratory investigations such as tzanck smear
preparation of scrapings from the floor of the vesicles,
which reveal multinucleated giant cells on direct
microscopy, or by direct fluorescent antibody tests,
presence of high or rising titers to VZV, or culture
studies can fetch the diagnosis.[17] HZ should be
differentiated from zosteriform herpes simplex, which
is more common in children, and can be done by direct
fluorescent monoclonal antibody test or by detection
of serum specific immunoglobulin M by the indirect
fluorescent antibody method. The other differential
diagnosis for dermatomal vesicular eruptions in children
is bullous impetigo and bullous insect bite reaction. As
the above‑mentioned tests were not available to us,
our diagnosis was mainly clinical or by tzanck smear
in doubtful cases. Rising incidence of HZ in otherwise
healthy children can be attributed to acquiring primary
varicella infection in utero, or in infancy, wherein the
immunity is not fully developed. Vaccination with live
attenuated virus may also contribute.
Our study showed male preponderance similar to
Malik et al. study[18] and in contrast to Prabhu et al.[4]
study which showed female preponderance. All the
Indian Journal of Paediatric Dermatology | Vol 17 | Issue 4 | Oct-Dec 2016
Figure 2: Grouped vesicular lesions involving right C8 dermatomes in a
6‑year‑old girl on day 3
patients aged between 4 and 12 years. Mean age of
presentation was 9.26 years in our study, whereas
Malik et  al.[18] study showed mean age of 8.2 years.
In our study, 55.9% patients had a history of
chicken pox in patient or chickenpox or HZ in close
contact while in Malik et  al. study, it was seen in
31% patients.[18] In these cases, where the history of
varicella was not obtained, it is suggested that the
initial contact with the virus may result in zoster.[19]
None of our patients were vaccinated for varicella
virus. Evidence of immunosuppression was seen
only in 1 (2.94%) patient in our study, in contrast
to Malik et  al. study, in which 7 out of 42 patients
showed evidence of immunosuppression in the form
of hepatitis C virus infection in 3 patients, pulmonary
tuberculosis in 2 patients, leukemia in one patient,
and the other patient was on steroid treatment.[18]
Three children had shown hepatitis C positivity, this
might be due to the second highest prevalence of
hepatitis C in the world ranging from 4.5% to 8% in
Pakistan.[20] Historically, childhood HZ was thought
to be an indicator for an underlying malignancy or
immunosuppression.[7] About 3% of pediatric zoster
cases were associated with malignancies,[9] whereas
recent studies have shown no increase in the incidence
of malignancy in children with HZ. Our study proves
the same. In Malik et al’s. study, only one patient had
malignancy (leukemia), whereas in our study, there
was not even a single case of malignancy.[18]
In our study, there was left‑sided preponderance similar
to Malik et al. study.[18] The thoracic dermatomes were
most commonly affected dermatome in half of the
patients followed by lumbar dermatome in 23.5%
patients. Similar findings were reported by Malik
et  al.[18] Prabhu et  al.,[4] Bharija et  al.[21] and  Hope-
Simpson’s[6] studies, and various other studies,[4,8,9,19]
whereas Leung et al.[22] noted predilection of cervical
and sacral dermatomes.
Very few case reports of childhood HIV patients
acquiring zoster are reported.[4] In our study, an
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Vora, et al.: A clinicomorphological study of childhood herpes zoster
11‑year‑old girl diagnosed to be HIV positive 1 year
ago, who had blood transfusion for anemia 2 years
back presented to us with typical presentation of HZ
involving left‑sided single cervical dermatome (C6).
In HIV patients, progressive primary varicella, a
syndrome with persistent new lesion formation
and visceral dissemination, may occur and may be
life‑threatening.[23]
Clinical features included pain, itching, and fever.
Itching was seen as prodromal symptom in 44.1%
patients, whereas it was present in active disease
only in 4 (11.8%) patients. Most common presenting
complaint was burning type of pain in 88.2% patients,
whereas in Malik et al. study,[18] itching was the most
common presenting complaint. In Malik et al. study,[18]
69% patients showed one dermatome involvement
and 28.6% showed involvement of 2 dermatomes.
More than 2 dermatomes were involved in only
1 (2.4%) patient, whereas in our study, only 1 (2.94%)
patient had multidermatomal involvement. Incidence
of postherpetic neuralgia in childhood is rare.[8,24]
As the nature of HZ in children is mild, treatment
among healthy children is symptomatic, and antiviral
therapy is reserved usually for immunocompromised
or children with disseminated disease.
CONCLUSION
HZ is increasingly being observed in children. Most
of them show no evidence of immunosuppression and
the disease is generally mild and of shorter duration
than its adult variety. Previous exposure to varicella
is seen only in about half of the patients. Most
common dermatome involved is thoracic dermatome
in children. Atypical presentations are very rare when
compared to adults and elderly patients.
Financial Support and Sponsorship
Nil.
Conflicts of Interest
There are no conflicts of interest.
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