Herpes zoster (HZ) in children is very rare. We report a case of HZ in an infant which responded well to the treatment. HZ shouldalso be considered in an infant with vesiculo-bullous lesion in a dermatomal distribution

James, Jemila

Nair, P M C

Soumya, S

English

Atharva Scientific Publications (E-Jounals)

Vol 3 | Issue 4 | Oct - Dec 2016 Indian J Child Health 346
Case Report
A rare presentation of shingles (herpes zoster) in an infant
P M C Nair1, Jemila James2, S Soumya2
From 1Department of Neonatology, Sree Gokulam Medical College, Trivandrum, Kerala, India, 2Department of Pediatrics, Sree Gokulam Medical 
College, Trivandrum, Kerala, India
Correspondence to: Dr. P M C Nair, Chaithanya, TC 25/1847, Thampanoor, Trivandrum - 695 001, Kerala, India. 
E-mail: drpmc50@gmail.com
Received – 18 April 2016 Initial Review – 20 May 2016 Published Online – 24 September 2016
Primary varicella tends to occur in childhood, whereas herpes zoster (HZ) is a disease of adults, with most of the patients being older than 45 years [1,2]. It is very rare 
in healthy children <5 years with the exception of infants who 
are infected in utero. In literature, very few cases of shingles 
have been reported in infants. We report a case of an infant who 
presented to us with shingles.
CASE REPORT
A 1-year-old boy presented with fever and grouped vesiculo-
bullous lesions over left axilla, left side of upper chest, and back 
of 5 days duration. Mother had varicella infection during the 
4th month of gestation treated with oral acyclovir and resolved 
completely. All antenatal ultrasonograms were normal. Baby 
was born by full term lower segment cesarean section delivery 
(indication: Failed induction) with birth weight of 2.7 kg. No 
anomalies were present at birth. Postnatal period was uneventful 
with no history of varicella or contact with varicella. The child 
had normal development history.
Physical examination revealed grouped vesiculo-bullous 
lesions with an erythematous base and serous discharge in the left 
side of chest, axilla, and back in the dermatomal distribution of 
T4, associated with itching (Fig. 1). Systemic examination was 
within normal limits. Blood examination revealed leukocytosis. 
Tzanck smear showed multinucleated giant cells. Varicella zoster 
virus (VZV) IgG report awaited. The child was treated with oral 
acyclovir 80 mg/kg day in 5 divided doses for 7 days, and other 
supportive measures and child improved (Figs. 2 and 3a and b).
DISCUSSION
VZV causes primary infection, manifested as varicella 
(chickenpox), and can reactivate after establishing latency in the 
dorsal (spinal) sensory ganglia or cranial nerve ganglia to cause 
reactivated infection, manifested as HZ [3,4]. The development of 
HZ is associated with a decline in cell-mediated immunity due to 
aging, an immunosuppressive illness or treatment, or an immature 
cell-mediated immune system [4,5]. HZ is more common in older 
adults; however, it can occur in healthy infants, children, and 
young adults, in whom the disease is usually milder [6].
HZ is uncommon among children. In classic studies, its 
incidence in the pediatric age ranged from 0.2 to 0.74 cases/1000 
person-years [7,8]. A large population-based study from Iceland in 
the early 90s reported a higher incidence rate up to 1.6 cases/1000 
person-years [9].
Antigen-specific T-cells are believed to be the principal 
gatekeepers of latent VZV. Conditions in which cellular responses 
were lost or diminished by immunosuppression pose a risk for 
reactivation of VZV and acquisition of HZ in healthy immune-
competent children in early childhood or during intrauterine 
exposure has been attributed to the immaturity of the immune 
system [10].
Terada et al. [10] observed that immunological status 
before primary infection with VZV is important and affects 
the reactivation of VZV. They noticed that, 6-7 weeks after 
primary varicella, infants had a lower response of VZV-specific 
cellular and humoral immunity compared with children who 
had an infection at older ages (>1 year). In another study [11], 
the peak levels of IgG antibodies after primary varicella were 
lower in infants compared with older children. Low response in 
specific VZV immunity is a valid reason to consider varicella in 
the 1st year of life as a risk factor for the development of HZ in 
otherwise healthy children.
Terada et al. showed that healthy immunocompetent 
children who had primary VZV before 1 year of age remained 
positive for VZV (as determined by polymerase chain reaction) 
for the longest period [12]. From these data, Terada et al. [12] 
ABSTRACT
Herpes zoster (HZ) in children is very rare. We report a case of HZ in an infant which responded well to the treatment. HZ should 
also be considered in an infant with vesiculo-bullous lesion in a dermatomal distribution.
Key words: Dermatome, Herpes zoster, Immunity, Infant
Vol 3 | Issue 4 | Oct - Dec 2016 Indian J Child Health 347
Nair et al. Herpes Zoster in an infant
hypothesized that a “subclinical reactivation” puts infants with a 
history of primary varicella at risk for HZ. In 69% of infantile HZ 
cases (i.e., <12 months of age) reported in the literature, the initial 
event could be traced to maternal varicella during pregnancy. 
Dobrev [13] observed that maternal varicella during the first 
trimester is likely to produce congenital varicella syndrome; 
when women have the disease later in pregnancy, the fetus can 
develop asymptomatic congenital infection and subsequently 
present clinically with HZ within the 1st year of life. Newborns 
of VZV-immune mothers can also develop subclinical varicella 
within the first 6 months of life. In these cases, maternal VZV 
antibodies passively transferred to the infant may modify the 
disease into a subclinical form. In general, infants with primary 
varicella infection are at high risk for HZ within the 1st year of 
life [13].
In infant, however, HZ typically demonstrates the skin lesions 
only, without acute pain or postherpetic neuralgia [14,15]. In 
both, the skin lesions typically develop from central to peripheral 
and do not cross the midline [16]. During this vesicular stage, the 
condition is contagious, as virus is found at the lesion sites [16] 
and vesicles and erosions are susceptible to bacterial super-
infection. After several days, the vesicles will erode and crust, 
heralding resolution [16].
HZ is usually diagnosed clinically by the characteristic 
presentation of the disease, and laboratory testing is not usually 
necessary [15]. However, it has been shown that herpes simplex 
infections may have a zosteriform presentation. Two situations in 
which laboratory confirmation can provide helpful information are 
to confirm the diagnosis of varicella before initiation of antiviral 
therapy in a patient who presents with unusual symptoms and to 
confirm susceptibility or immunity in exposed pregnant women. 
A common confirmatory laboratory test, Tzanck smear, can be 
done to support the clinical diagnosis, demonstrating a viral cause. 
However, to differentiate a possible HZV infection from that of 
herpes simplex, cultures or other antigen-based testing must be 
done [4]. In general, the treatment of HZ is indicated to limit the 
spread, duration, and bacterial super-infection of the skin lesions, 
to reduce the acute symptoms of pain and malaise, and to prevent 
the development of postherpetic neuralgia and ophthalmological 
complications in HZ ophthalmicus whenever these complications 
exist or are likely to develop.
Infants do not suffer postherpetic neuralgia, so oral antiviral 
use has been questioned. Some authors have recommended 
that oral antiviral use in immunocompetent children with 
HZ be reserved for the more severe cases, as with ophthalmic 
involvement [14]. Other authors have used oral antivirals as a 
general approach [15]. In the uncomplicated infant case, whether 
treated with antivirals or not, resolution of the condition is quick 
and free of sequelae [14,15].
CONCLUSION
The incidence of infantile HZ is very rare. However, the possibility 
of HZ also should be considered in an infant with vesiculo-
bullous lesion in a dermatomal distribution, even if history is not 
available.
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Figure 1: Vesiculo-bullous lesions of herpes zoster in the T4 
dermatomal distribution
Figure 2: Crusting lesions
Figure 3: (a and b) Healed lesions after acyclovir treatment
a b
Vol 3 | Issue 4 | Oct - Dec 2016 Indian J Child Health 348
Nair et al. Herpes Zoster in an infant
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Funding: None; Conflict of Interest: None Stated.
How to cite this article: Nair PMC, James J, Soumya S. A rare presentation 
of shingles (herpes zoster) in an infant. Indian J Child Health. 2016; 
3(4):346-348.


A rare presentation of shingles (herpes zoster) in an infant

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A rare presentation of shingles (herpes zoster) in an infant

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