Case #11

The patient first noted the ulcerations approximately one week earlier. He reported that the lesions were painful and did not appear to be resolving. When questioned about other signs and symptoms, the patient claimed the affected area became painful prior to the appearance of the ulcerations. In addition, fever and malaise were also noted. No previous episodes were reported.

Oct 1st, 1997

A 60-year-old male visited a dentist for evaluation of multiple, painful oral ulcerations.

Joen Iannucci Haring, DDS, MS

History

The patient first noted the ulcerations approximately one week earlier. He reported that the lesions were painful and did not appear to be resolving. When questioned about other signs and symptoms, the patient claimed the affected area became painful prior to the appearance of the ulcerations. In addition, fever and malaise were also noted. No previous episodes were reported.

A review of the patient`s medical history revealed no significant positive findings. At the time of the dental visit, the patient was taking an over-the-counter pain reliever to alleviate symptoms. No other medications were reported.

Examinations

Examination of the head and neck region revealed several enlarged and tender lymph nodes. The patient`s blood pressure and temperature were found to be within normal limits. Oral examination revealed multiple small, shallow ulcerations on the hard and soft palates, alveolar mucosa and buccal mucosa. The distribution of the lesions appeared unique; the ulcerations did not cross the midline (see photo).

Clinical diagnosis

Based on the clinical information presented, which of the following is the most likely clinical diagnosis?

* Benign mucous membrane pemphigoid

* Pemphigus vulgaris

* Secondary varicella zoster

* Erosive lichen planus

* Allergic mucositis

Diagnosis

_ Secondary varicella zoster

Discussion

Secondary varicella zoster, or shingles, is caused by the varicella zoster virus (VZV). Following the initial or primary infection with VZV known as chickenpox, the virus is not eliminated from the body. Instead, the virus travels along the sensory nerve fibers and resides in the nerve ganglia until it is reactivated. It is the "reactivation" of this latent virus that causes the secondary or recurrent infection known as shingles.

Stimuli that trigger this reactivation include the following: immunosuppression, treatment with cytotoxic drugs, radiation, presence of malignancies, old age, trauma, alcohol abuse and manipulation of tissues during dental treatment. It is important to note that every individual with shingles has previously had chickenpox.

A person with shingles is capable of transmitting VZV to a person who has not had chickenpox (a person without antibodies to VZV). In such an instance, VZV is transmitted by direct contact with the vesicular fluid of the skin lesions of shingles.

It is important to note the following: a person without antibodies to VZV can only contract chickenpox (not shingles) from a person with shingles. Shingles is not transmitted from one person to another.

Clinical features

Although approximately 95 percent of the United States population has been infected with VZV, only 10 to 20 percent of those individuals experience recurrent disease in the form of shingles.

Shingles is more common in the elderly adult population, and an increased incidence is noted with increased age. As the average age of the United States population increases, an increase in the number of cases of shingles is expected.

A recurrent VZV infection begins with prodromal pain in the area of skin or mucosa that is inneravated by the affected sensory nerve. In addition to pain, fever, malaise, and headache may also be present. The prodromal period lasts one to four days prior to the appearance of the skin or oral lesions. Numbness or itching may also be noted in the affected area.

With shingles, the distribution of lesions follows the path of the affected nerve and stops at the midline; this pattern is unique. The skin lesions appear as clustered vesicles on an erythematous background. Within three to four days, the vesicles ulcerate. Crusts typically form within seven to 10 days. Scarring may result. In healthy individuals, these lesions usually resolve in two to three weeks.

In some instances, the vesicular skin lesions are absent and the clinical presentation involves extreme pain and hyperesthesia over a specific dermatome. This pattern is known as zoster sine herpete. Fever, malaise, and lymphadenopathy may or may not accompany this presentation.

In some people, pain persisting longer than one month occurs after an episode of shingles. This pain is termed postherpetic neuralgia and occurs in up to 14 percent of people with shingles, especially those age 60 and older. Most of the neuralgias resolve within one year, and 50 percent of the cases resolve within two months. Other significant morbidity associated with shingles includes blindness that results from ocular involvement.

If the trigeminal nerve is involved, oral lesions occur. Both non-movable and movable tissues may be involved. Tiny vesicles appear and then rupture, resulting in small, shallow ulcerations. The distribution of the lesions is characteristic and stop at the midline. The number of lesions present is variable; with larger number of lesions, difficulty in eating and drinking is more likely.

Diagnosis

The diagnosis of shingles is usually established based on the clinical presentation and history of recurrence. In atypical cases, other procedures may be required. For example, viral culture or cytology can be used to confirm the presence of VZV and establish a definitive diagnosis.

Treatment

High doses of systemic acyclovir are recommended to treat shingles in an attempt to decrease the duration of the exanthem and the severity of the pain. This medication is typically prescribed for immunocompromised patients and patients with severe or disseminated disease.

Other therapies are directed toward supportive and symptomatic measures. Fever should be treated with non-aspirin type antipyretics. Topical or systemic antipruritics such as Benadryl can be used to decrease itching. After the lesions heal, the pain associated with the area can be lessened through the use of topical analgesics. In the absence of specific contraindications, consideration should be given to prescribing short term, high-dose corticosteroid medications (prednisone, for example) in an attempt to prevent postherpetic neuralgia.

Joen Iannucci Haring, DDS, MS, is an associate professor of clinical dentistry, Section of Primary Care, The Ohio State University College of Dentistry.

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