Herpes Zoster in Healthy Infants and Toddlers after Perinatal Exposure To Varicella-Zoster Virus: A Case Series and Review of the Literature

Xavier Rodríguez-Fanjul, MD; Antoni Noguera, MD, PhD; Asunción Vicente, MD; Maria Antònia González-Enseñat, MD; Rafael Jiménez, MD, PhD; Clàudia Fortuny, MD, PhD*


Pediatr Infect Dis J. 2010;29(6):574-576. 

In This Article

Case Reports

The main clinical characteristics of the patients are summarized in Table 1. In brief, most patients were male (12 of 16) and the median age at presentation was 22 months (range: 5 to 60 months). Five children had been exposed to VZV in utero, 6 patients developed mild chickenpox by the age of 4 months (none of them received acyclovir at that time), and the parents reported contact during the first months of life with siblings or other relatives affected with chickenpox for 3 children; VZV exposure source and age was unknown for 2 patients. None of the patients in our series had received the Oka vaccine strain of VZV. Apart from these data, the medical history was unremarkable in all cases.

All children presented with a 2- to 7-day history of progressive vesicular rash consistent with HZ in different regions (Fig., Supplemental Digital Content 1, http://links.lww.com/INF/A410; and Fig., Supplemental Digital Content 2, http://links.lww.com/INF/A411): in cranial nerve (9 of 16), in lumbosacral (5 of 16), and in cervical and thoracic dermatomes (one each); involvement of 2 adjacent dermatomes occurred in 6 children. Other complaints at presentation were irritability and/or pruritus (16 patients) and fever (6 patients; rectal temperature ranging from 38°C to 39.4°C); enlarged local lymph nodes were noted in 2 children. Clinical diagnosis was confirmed in all cases, by means of identification of multinucleated giant cells with eosinophilic intranuclear inclusion bodies on Tzanck smears and, most recently, by means of VZV-specific polymerase chain reaction assays in vesicular fluid in 9 children.

Patients with moderate-to-severe rash or irritability (n = 5) and those in whom ocular involvement could not be ruled out (n = 7) were admitted for intravenous administration of acyclovir (30 mg per kg of body weight per day, divided every 8 hours) and/or pain management; the rest of the children received oral acyclovir (80 mg per kg of body weight per day, divided every 6 hours). Patients 4, 12, 13, and 16 were not treated because the HZ lesions were healing by the time the children were first seen. All treated patients completed a sequential intravenous-oral 7- to 10-day course of acyclovir. Complete recovery after 1 to 3 weeks was observed in all cases.

The 8 patients with HZ affecting the ophthalmic division of the trigeminal nerve (V1) were referred to the ophthalmologist for evaluation. Only patient 10 showed ocular involvement. He showed neither discomfort nor decrease in vision, but examination of the left eye showed marginal keratitis (dendriform lesions) and mild anterior uveitis. The patient completed a 7-day regimen of intravenous acyclovir and a 2-week treatment with atropine and prednisone eye drops, with complete recovery.

No cases of post-HZ neuralgia occurred, but 4 children reported hypopigmentation in the affected area, that recovered within some months. HZ recurred in patients 14 and 15, 12 years and 3 months after the first episode, respectively, affecting the same dermatomes and healing completely within one week; again, ocular involvement was ruled out in both cases. Only patient 15, aged 8 months, received one week of oral acyclovir for the second episode. An immunologic work-up was undertaken in 10 children (including those with recurrent HZ) which consisted of a complete blood count, lymphocyte subset count and percentage, mitogen stimulation tests, serum immunoglobulin (IgG, IgA, and IgM) and IgG subclass values, humoral response to tetanus and rubella antigens, and human immunodeficiency virus antibodies. A primary or secondary immunodeficiency was not identified in any of the patients. After a median follow-up of 5 years (only one patient was lost to follow-up) all patients have remained well.


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