CME INDIA Case Presentation by Dr Sikandar Singh, Deoghar.

CME INDIA Case Study

CASE: Is it Varicella (Chicken Pox) and Herpes Zoster in the same patient and at the same time?

Patient presented with history of painful eruption at left arm, upper chest and back 5 days ago. Then after 2days she develop fever, body ache and painless eruption over face and other part of body. No history of DM, pox or any immunocompromised condition in past.

CME INDIA Discussion:

Dr N. K. Singh: I have not seen both lesions in same patient. What the literature says? Lesions suggest both type in same patient occurring simultaneously. Must be a immunocompromised person needs further investigations. The chicken pox might have activated the zoster virus which was latent?? Do a covid test, nobody knows, it might be underplaying…. Reactivation of 2 Genetically Distinct Varicella-Zoster Viruses in the same individual.

Dr Anil Kumar, Pshy, Ranchi: I have seen 20years ago young girl having both

Dr Anil Motta, Max, Delhi: That’s possible… Immunodeficiency due to any cause needs to be looked at!

Dr Noni G Singha, Dibrugarh, Assam: Disseminated Herpes Zoster. 1-2% of HZ pts can present as disseminated one. If so one should look for any drugs causing immunosuppression like steroids, anti-cancer etc., any immunesuppression or immunocompromise related disorders. You do not think HZ and chicken pox coexisting.

Dr Basab Ghosh, Agartala: Chicken pox and Herpes.

Dr Noni G Singha: In this particular case, it is more fitting in disseminated HZ which is may be commoner than coexisting together. Here onset is HZ first, then she must have exposed earlier to VZ. If both would have come together or VZ followed by HZ then maybe we could have called VZ and HS together. Thats my understanding.

Dr BASAB Ghosh Agartala: Any possibilities for exaggerated “Shingles” in this case? Chicken pox is a type of Herpes.

Dr Amit Kumar, Dermatologist, Ranchi: I will go with Zoster with Disseminated Type 2 herpes. Better to get a PCR done. And also, rule out any other cause for immunocompromise. It is not types of disseminated but type of HSV causing disseminated herpes.

Case is open for further comments…

CME INDIA Learning Points:

  1.  Recurrent zoster in a young, immunocompetent individual is rare, literature exists that provide the evidence that recurrent zoster can be caused by 2 different strains of VZV. The finding needs further investigation but raises important questions about VZV pathogenesis.
  2. Latent persistence of 11 viral genotype has previously been suggested by the finding of wild-type viruses in 30% of US cases of zoster occurring in subjects immunized with the Oka vaccine. However, these cases could be explained either by undetected latent wild-type VZV infection preceding immunization or failure of the Oka vaccine strain to establish latency.
  3. Natural immunity following chickenpox is largely protective against clinical reinfection. Although recurrent chickenpox is difficult to prove, a study reported that 13% of children presenting with chickenpox had experienced a well-documented previous episode, suggesting that clinical recurrence may be more common than previously thought.
  4. At least 4 distinct genotypes of VZV have been described. Geographical segregation of genotypes is well described, and data from ourselves and others suggest that Bgl 1-positive viruses of genotype A are more prevalent in non-European populations. An increase in Bgl 1-positive viruses has occurred in east London with increasing immigration from Asia and Africa. This natural experiment of viral mixing has provided insights into the molecular epidemiology and pathogenesis of VZV, which might otherwise not have been possible in the highly homogeneous European viral population. Thus, reinfection and establishment of colatency may occur.
  5. Varicella-zoster viruses recovered from 2 episodes of herpes zoster in an immunocompetent man has been found to be different genotypes. The fact that the 2 isolates comes from the same individual has been confirmed by DNA fingerprinting. Immunity following chickenpox may not always protect against systemic reinfection. This finding raises questions about varicella-zoster virus pathogenesis and may have an impact on public health policy

[1302 • CID 2006:43 (15 November) • BRIEF REPORT, Reactivation of 2 Genetically Distinct Varicella-Zoster Viruses in the Same Individual Y. Taha et al.]

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