HERPES ZOSTER DUPLEX BILATERALIS IN AN IMMUNOCOMPETENT ADOLESCENT GIRL AT KOSHI ZONAL HOSPITAL , MORANG Affiliation

Herpes Zoster (HZ) is a segmental erup on of grouped vesicles that are confined to a dermatome. There is dermatomal distribu on of skin rash, which is unilateral. When two non contagious dermatomes are involved, if affected bilaterally, it is called HZ duplex bilateralis; if unilaterally, unilateralis. HZ duplex bilateralis is extremely rare in immunocompetent children. This report describes a 12-year old girl with bilateral HZ. She had no features of immunosupression. She was treated with oral acyclovir for one week. No complica ons, including post herpe c neuralgia, were observed during the follow up period of three months.


INTRODUCTION
Varicella Zoster Virus (VZV) remains latent in dorsal root ganglion cells a er an a ack of varicella or vaccina on.Herpes Zoster, also known as shingles, occurs as the result of reac va on of the latent VZV.HZ is characterized by unilateral vesicular rash and pain limited to a single dermatome.It is a common disease in older people with rela ve compromise in cell mediated immunity.Below the age of 45, the annual incidence of HZ is less than 1 in 1000 1 popula on.Bilateral HZ is extremely rare, with incidence of less than 0.1 percent of all HZ cases, and usually develops in 2 immunocompromised pa ents.

CASE REPORT
A 12-year-old girl, from Katari, Morang, presented with complaints of fluid filled lesions on her abdomen, sides of trunk and back for 3 days.Two days prior to the erup on of vesicles, she had felt mild pain and burning sensa on over the affected area.The lesions were sudden in onset, erupted ini ally as vesicles in erythematous base.The lesions had burning sensa on and were mildly painful.She no ced few grouped vesicles ini ally over her le hypochondriac region.The very next day, the lesions spread to the sides and back with simultaneous appearance of vesicles over right side of the chest and back.There was no history sugges ve of immunosupressed status.On examina on, there were grouped vesicles on erythematous skin.The lesions had bilateral dermatomal distribu on (Le : T8,9, and Right: T6,7 ).(Figure 1) The rest of the physical findings were unremarkable.Mucosal involvement was absent.Her complete blood count, hemoglobin, liver func on tests and renal func on tests showed values within normal limits.Her HIV status was nega ve.Serologic test for an -varicella-zoster virus immunoglobulin G (IgG) showed posi ve (37.91 Units), (Biological Reference range: 9-11 Units), but an -VZV IgM was nega ve.We performed T-Zanck smear from a vesicle.It showed acantholy c cells along with mul nucleated giant cells.She was diagnosed with HZ duplex bilateralis.She was treated with oral acyclovir 800 mg 5 mes a day for 7 days.The vesicles got resolved, leaving behind crust in 10 days.In the three months follow up period, she had no any complica ons including the post herpe c neuralgia, except the post inflammatory hypopigmenta on over the site of the lesions.

DISCUSSION
Herpes Zoster occurs due to reac va on of Varicella Zoster Virus (VZV) that remains latent a er the primary infec on of varicella.It is characterized by grouped vesicles, distributed 3 unilaterally, usually over one or two adjacent dermatomes.Usually, the ini al manifesta on of zoster is pain that is sharply localized to skin area supplied by one or more dermatomes.When zoster occurs in two non con guous dermatomes, the condi on is termed as HZ duplex unilateralis or bilateralis, on the basis of whether one half or both halves of the body are involved.In cases of immunosupression, VZV can get reac vated in mul ple dorsal root ganglia and result mul dermatomal HZ.This may present with lesions Baskota R et al  HZ duplex bilateralis has been reported worldwide.Most of the cases had immunosupression, leukemia, malignancy or HIV infec on.Among them, there were just five cases of HZ duplex bilateralis or unilateralis in immunocompetent cases.Most of the previously described cases occurred in context of primary immunodeficiency, acquired immunodeficiency, old age or persons in immunosuppressive medica ons.In our case, the pa ent was young and was immunocompetent.
The diagnosis of HZ is mainly clinical, based on the dis nc ve distribu on of lesions.T-Zanck smear is a very useful diagnos c 7 test, confirming the diagnosis in 80% of the cases.In HZ, the levels of IgG an body increase rapidly and reach a higher ter than during the primary infec on.
Treatment for HZ duplex bilateralis remains the same as the common treatment for HZ, which includes an an viral drug, management of pain and care of skin lesions.It usually resolves without sequel in children and young adults with intact immune systems.In our case, her immune response was normal and she had no complica ons associated with herpes zoster.HZ duplex bilateralis showed prognosis similar to that for HZ with only one nerve ganglion involved.It seemed that HZ duplex bilateralis is not a risk factor for poor prognosis and post herpe c neuralgia.

CONCLUSION
Herpes zoster duplex bilateralis is a rare presenta on in immunocompetent adolescences.However, possibility should be suspected even in immunocompetent children who present with characteris c history and skin findings.There is high chance of clinical misdiagnosis as it can also occur in children with no underlying factors for immunosupreession.