Shingles in a Healthy Child: A Case Report

Haya Majed AlBaqami^1*, Manal Saeed AlAseeri², AbdulElah Ayed AlQahtani³, Yara Saeed AlGhamdi⁴, Turki Abdullah Alsulami⁵ and Ibrahim Hadi Tawhari⁶

^*Correspondence: Haya Majed AlBaqami, Department of Dermatology, King Abdulaziz Hospital, Saudi Arabia, Email:

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Introduction

Shingles, also known as herpes zoster, often affects elderly patients and is caused by the reactivation of Varicella-Zoster virus (VZV) [1,2]. It rarely affects immunocompromised and immunocompetent children [3,4]. Majority of shingles patients have a prior history of chickenpox; however, a proportion of patients who are otherwise healthy may present with shingles despite the absence of prior varicella infection [5]. Live attenuated varicella vaccine is included in the Saudi National Vaccination Program and is administered at the age of 18 months and at school age [6]. Some studies have linked the history of varicella vaccination to the afterward development of shingles [5]. Here, we report a case of a healthy 3-year-old child who developed shingles without a prior history of chickenpox.

Case Report

A 3-year-old healthy boy was brought to the emergency department having a 6-day-history of itchy and mildly painful fluid-filled skin lesions over the right upper extremity. The lesions had initially started at the right hand and progressed to involve the right forearm and arm. The patient’s parents denied recent fever, contact with sick patients, a similar presentation in the past, an application of topical formulation, recent outdoor activities, a recent trauma, or allergies. They also denied a history of chickenpox in the past, recurrent infections, or a family history of immunodeficiency. The patient received his varicella vaccine at the age of 18 months, and the BCG vaccination at birth. Review of systems was otherwise negative. On examination, the patient was conscious, alert, vitally stable, and interacting playfully with his parents. There were multiple grouped vesicles on erythematous bases following the dermatomal distribution of C5-C6 (Figure 1). A normal-looking BCG scar was seen over the left upper arm. Complete blood count, liver function tests, and renal profile were all within normal limits. Human Immunodeficiency Virus (HIV) was negative. Varicella-zoster virus (VZV) IgM and IgG antibodies were both positive. A diagnosis of shingles was made, and the patient was started on oral acyclovir as well as paracetamol and topical fusidic acid ointment. We continued to monitor the patient closely as he made a remarkable recovery. After one week, the child had no additional symptoms of pain or discomfort. Post-inflammatory hyperpigmentation was noticed over the areas of the resolved shingles.

Figure 1. Multiple grouped vesicles on erythematous bases following a dermatomal distribution over the right hand, forearm and arm.

Discussion

Shingles has become a rare disorder following the introduction of the live attenuated varicella vaccine and is estimated to inflict 14 per 100,000 person-years [7]. Less than 1% of shingles cases are in the pediatric age group [8]. Immunosuppressed and immunocompromised patients hold the major proportion of pediatric patients who develop shingles [9]. The immune status of children during the contraction of the infection is believed to play a role in the early activation of the infection [10]. Varicella infection in the first year of life is considered a risk factor for the development of pediatric shingles [4]. Pruritus is a common symptom in the pediatric age group [11]. Thoracic and lumbar dermatomes are typically involved in the patients who are 10 years and older while younger patients have tendency to develop shingles in cervical, trigeminal, and sacral dermatomes [11]. Cranial nerves involvement and disseminated disease are less frequent in the pediatric population when compared with adults [12]. Prior trauma has been linked to the development of zoster at the trauma site within one month after the incident [13]. Varicella-zoster vaccine has the potential to induce a latent infection of the virus and also reactivation as demonstrated in a group of immunocompetent children who had had shingles that was triggered by the vaccine viral strain [14]. Vaccinestrain shingles predominantly manifests in the cervical and lumbar dermatomes, possibly owing to the site of vaccination in the upper arms or thighs [15]. Zoster may also arise from subclinical infection of varicella as reported in another group of healthy children whose zoster strain was found to be a wild-type varicella-zoster virus (VZV) and did not have a prior history suggestive of varicella and were not in contact with zoster or varicella patients [14]. Pediatric zoster, particularly the wildtype VZV, may culminate in meningitis or encephalitis as reported in some cases [14]. Secondary bacterial infection is the most common complication whereas post-herpetic neuralgia is an uncommon complication [16]. Prognosis is overall excellent in healthy children and usually, they would completely recover on their own [8]. In this report, we present zoster following the right cervical dermatomal distribution in a healthy child who had recovered without subsequent complications except for post-inflammatory hyperpigmentation.

Conclusion

Shingles results from reactivation of the latent varicellazoster virus. It occurs rarely in healthy children and possesses an excellent prognosis. Risk factors need to be identified, such as immuno compromising states, early contraction of chickenpox, trauma and chickenpox vaccination. Albeit rarely, zoster in children may be complicated by meningitis or encephalitis. We aim to raise awareness of pediatric shingles and to emphasize the fact that it may present in children who are otherwise healthy and do not have a prior history of chickenpox.

Funding Sources

None.

Conflicts of Interest

None declared.

IRB Approval Status

Reviewed and approved by the Directorate of Health Affairs, Ministry of Health, Jeddah, Saudi Arabia.

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