Herpes zoster case history infection. Case history - herpes - infectious diseases. Clinical observation of the patient

Clinical diagnosis:

Accompanying illnesses:

IHD, NK I, hypertension stage II, non-insulin-dependent diabetes mellitus type II, chronic atrophic gastritis, chronic cholecystitis, prostate adenoma

I. Passport part

Full Name: -

Age: 76 (11/14/1931)

Permanent residence: Moscow

Profession: pensioner

Date of receipt: 06.12.2007

Curation date: 10/19/2007 – 10/21/2007

II.Complaints

For pain, hyperemia and multiple rashes in the forehead on the right, swelling of the upper eyelid of the right eye, headache.

III. History of the present disease (Anamnesis morbi)

He considers himself ill since December 6, 2007, when for the first time, at night, a headache and swelling of the upper eyelid of the right eye appeared. The next morning, the edema intensified, hyperemia and a rash in the form of multiple vesicles were noted in the area of the right half of the forehead. Body temperature 38.2°C. Regarding the above symptoms, he called an ambulance, an injection of analgin was made. On the evening of December 6, 2007, the patient was hospitalized at the Central Clinical Hospital of the UD RF No. 1.

IV. Life history (Anamnesis vitae)

He grew and developed normally. Higher education. Living conditions are satisfactory, nutrition is full-fledged regular.

Bad habits: smoking, drinking alcohol, drugs denies.

Past illnesses: childhood infections do not remember.

Chronic diseases: coronary artery disease, NK I, hypertension stage II, non-insulin-dependent diabetes mellitus type II, chronic atrophic gastritis, chronic cholecystitis, prostate adenoma

Allergic history: no intolerance to food, drugs, vaccines and serums.

V.Heredity

In the family, the presence of mental, endocrine, cardiovascular, oncological diseases, tuberculosis, diabetes, alcoholism denies.

VI. Present status (Status praesens)

General inspection

The state of moderate severity, consciousness is clear, position is active, physique is correct, constitutional type is asthenic, height is 170 cm, weight is 71 kg, BMI is 24.6. Body temperature 36.7°C.

Healthy skin is pale pink. The skin is moderately moist, the turgor is preserved. Male pattern hair. The nails are oblong in shape, without striation and brittleness, there is no symptom of "watch glasses". Visible mucous membranes are pale pink in color, moistened, there are no rashes on the mucous membranes (enanthems).

Subcutaneous fat is moderately developed, the deposition is uniform. There are no edema.

The parotid lymph nodes on the right are palpable in the form of rounded, soft-elastic consistency, painful, mobile formations, 1 x 0.8 cm in size. elbow, inguinal, popliteal lymph nodes are not palpated.

The muscles are developed satisfactorily, the tone is symmetrical, preserved. The bones are not deformed, painless on palpation and tapping, there is no symptom of "drum sticks". The joints are not changed, there is no pain, hyperemia of the skin, swelling over the joints.

Respiratory system

The shape of the nose is not changed, breathing through both nasal passages is free. Voice - hoarseness, no aphonia. The chest is symmetrical, there is no curvature of the spine. Breathing is vesicular, chest movements are symmetrical. NPV = 18/min. Breathing is rhythmic. The chest is painless on palpation, elastic. Voice trembling is carried out in the same way on symmetrical sections. A clear pulmonary percussion sound is detected over the entire surface of the chest.

Circulatory system

The apex beat is not visually determined, there are no other pulsations in the region of the heart. The boundaries of absolute and relative stupidity are not shifted. Heart sounds are rhythmic, muffled, the number of heartbeats is 74 per 1 minute. Additional tones are not heard. are not heard. The pulsation of the temporal, carotid, radial, popliteal arteries and arteries of the dorsal foot is preserved. Arterial pulse on the radial arteries is the same on the right and left, increased filling and tension, 74 per 1 minute.

Blood pressure - 140/105 mm Hg.

Digestive system

The tongue is pale pink, moist, the papillary layer is preserved, there are no raids, cracks, ulcers. Shchetkin-Blumberg's symptom is negative. On palpation, the abdomen is soft and painless. The size of the liver according to Kurlov: 9-8-7 cm The edge of the liver is pointed, soft, painless. Gallbladder, spleen is not palpable.

Urinary system

The symptom of tapping is negative. Urination free, painless.

Nervous system and sense organs

Consciousness is not disturbed, oriented in the environment, place and time. Intelligence saved. Rough neurological symptoms are not detected. There are no meningeal symptoms, no changes in muscle tone and symmetry. Visual acuity is reduced.

VII. Local Status

Skin process of an acute inflammatory nature in the region of the right half of the forehead, right eyebrow, upper right eyelid. Eruptions are multiple, grouped, not merging, evolutionarily polymorphic, asymmetrical, located along the first branch of the right trigeminal nerve.

The primary morphological elements are pale pink vesicles protruding above the surface of the hyperemic skin, 0.2 mm in diameter, hemispherical in shape, with rounded outlines, the borders are not sharp. The vesicles are filled with serous contents, the lid is dense, the surface is smooth.

Secondary morphological elements - crusts, small, rounded, 0.3 cm in diameter, serous, yellow-brown in color, weeping erosions remain after removal.

Rashes are not accompanied by subjective sensations.

There are no diagnostic phenomena.

Hairline without visible changes. Visible mucous membranes are pale pink, moist, no rashes. The nails of the hands and feet are not changed.

VIII. Data from laboratory and instrumental studies

1. Complete blood count dated 07.12.2007: moderate leukocytopenia and thrombocytopenia

2. Urinalysis dated 12/07/2007: within normal limits

3.Biochemical blood test dated 12/12/2007: within normal limits

4. Wasserman's reaction from 10/12/2007 is negative

IX. Clinical diagnosis and justification

Clinical diagnosis: Shingles of the 1st branch of the right trigeminal nerve

The diagnosis was made on the basis of:

1. The patient complains of pain, hyperemia and multiple rashes in the forehead on the right, swelling of the upper eyelid of the right eye

2. Anamnesis: acute onset of the disease, accompanied by symptoms of general intoxication (fever, headache)

3. Clinical picture: Multiple vesicles are located on the hyperemic skin along the first branch of the right trigeminal nerve, as a result of the evolution of which crusts are formed.

4. The presence of somatic diseases - diabetes mellitus, leading to impaired peripheral circulation and a decrease in local immunity

X. Differential diagnosis

Differential diagnosis is carried out with the following diseases:

1. Herpes simplex. Herpes simplex is characterized by relapses, and not by an acute, sudden onset. As a rule, the age of manifestation of the disease is up to 40 years. The severity of symptoms in herpes simplex is less. With herpes simplex, there are fewer rashes and their location along the nerve fibers is not typical.

2. Dermatitis herpetiformis Dühring. With Dühring's dermatitis herpetiformis, polymorphism of elements is observed, there are urticarial and papular elements that are not characteristic of herpes zoster. Duhring's dermatitis herpetiformis is a chronic relapsing disease. The pain syndrome and the location of the elements along the nerve fibers are not characteristic

3. Erysipelas. With erysipelas, the rashes are distinguished by more pronounced redness, greater delimitation of edema from healthy skin, roller-shaped edges, uneven edges. The lesions are continuous, the skin is dense, the rashes are not located along the nerves.

4. Secondary syphilis. With secondary syphilis, the Wasserman reaction is positive, the rashes are generalized, painless, true polymorphism is observed.

XI. Treatment

1. General mode. It is necessary to consult a neurologist to determine the degree of damage to the first branch of the trigeminal nerve on the right.

Exclusion of irritating foods (alcohol, spicy, smoked, salty and fried foods, canned food, chocolate, strong tea and coffee, citrus fruits).

3. General therapy

3.1. Famvir (Famciclovir), 250 mg, 3 times a day for 7 days. Etiotropic antiviral treatment.

3.2. Sodium salicylic, 500 mg, 2 times a day. To relieve perineural edema.

3.3. Antiviral gamma globulin. 3 ml IM for 3 days. Immunostimulating, antiviral action.

4.Local therapy

Virolex (acyclovir) - eye ointment. Apply a thin layer on the affected eyelid 5 times a day for 7 days

5.Physiotherapy

5.1. Diathermy 10 sessions of 20 min. current strength 0.5A. Decreased irritation of the affected nerve

5.2. Laser therapy. Wavelength 0.89 µm (IR radiation, pulsed mode, laser emitting head LO2, output power 10 W, frequency 80 Hz). The distance between the emitter and the skin is 0.5–1 cm. The first 3 procedures: the time of exposure to one field is 1.5–2 minutes. Then 9 procedures: the time of exposure to one field is 1 min.

Stimulation of the immune system and reduction of irritation of the affected nerve

6.Sanatorium-resort treatment Consolidation of the results of therapy

XII. Forecast

Favorable for recovery

Favorable for life

… in human infectious pathology, herpesviruses play an important role due to their wide distribution in the population, their tendency to lifelong persistence in the body and the ability to cause an acute, chronic and latent form of the disease.

Shingles(syn. "shingles", "herpes zoster") is caused by the Varicella Zoster virus, which is also the causative agent of chickenpox. The incidence of herpes zoster is sporadic and occurs more often in the autumn-winter period of the year. Sick mainly older people with a history of chicken pox. Histopathological painting skin is the same as with herpes simplex. Herpes zoster is differentiated from eczema, chicken pox, herpes simplex, streptococcal impetigo.

Infection is possible

primary;
may be due to the reactivation of a latent virus that is in the body after chicken pox (it occurs under the influence of various endogenous and exogenous factors that reduce immunity, including hypothermia, systemic diseases, metabolic disorders, malignant neoplasms, HIV infection, etc.).

Clinically, the disease manifests itself

common infectious symptoms: fever, chills, intoxication;
skin lesions: blistering rashes;
severe pain syndrome (which is explained by the fact that Varicella Zoster, being a dermatoneurotropic virus, penetrates through the skin and mucous membranes, affects the spinal and cerebral ganglia, in severe cases, the anterior and posterior horns of the spinal cord and the brain - sections of the spinal cord, including responsible for pain sensitivity).
there are several clinical varieties herpes zoster

Herpes zoster (SH) may have a typical or atypical clinical presentation. A typical form of OH is characterized, as a rule, by unilateral localization within one dermatome. Lesions are represented by edematous erythema and vesicles with serous contents grouped against its background. A typical localization of rashes is most often the skin innervation zone from the II thoracic to the II lumbar segment, but in children, areas innervated by the cranial and sacral nerves may be involved in the process. With the defeat of the fifth pair of cranial nerves (trigeminal nerve), its branches may be affected. When the upper branch is involved, skin changes are observed on the scalp, in the forehead, nose, eyes, with damage to the middle branch - in the area of the cheeks, palate, with damage to the lower branch - in the region of the lower jaw, on the tongue. With damage to the VII pair of cranial nerves (facial), rashes are observed in the external auditory canal. The occurrence of atypical forms of OH is due to pronounced disorders of immune reactivity and is accompanied by the appearance of hemorrhagic, ulcerative necrotic (chronic ulcerative lesions), gangrenous, bullous elements, as well as a tendency to dissemination - generalization.

Herpes zoster treatment carried out on an outpatient basis, it should be comprehensive and include both etiological and pathogenetic agents. Antiviral and immunomodulatory drugs are shown: alpizarin, acyclovir, isoprinazine, interferon, deoxyribonuclease, etc. The effectiveness of these drugs largely depends on the timing of the start of treatment: the earlier it is started, the more effective. Local treatment: spot treatment with aniline dyes, lotions with interferon, antiviral ointments (in particular alpizarin), which in complex treatment contribute to a faster recovery. Along with antiviral drugs, B vitamins are prescribed: B1, B6, B12, ascorbic acid, rutin, antihistamines, with a pain symptom - NSAIDs, analgesics. In the hospital, treatment is carried out for gangrenous and common forms of herpes zoster, as well as for damage to the eyes and ear. Also shown are angioprotectors, ganglionic blockers. In severe forms of herpes zoster complicated by a secondary infection or aggravated by concomitant diseases, broad-spectrum antibiotics are used. From physiotherapeutic agents, microwave irradiation of lesions, paravertebral ultrasound, UHF, UV irradiation, electrophoresis with novocaine, adrenaline, etc. are used.

In recent years

high affinity for virus thymidine kinase (100 times higher) and more pronounced blocking of virus replication between doses of the drug;
famciclovir has the highest bioavailability (77% versus 10-20% for acyclovir) and the longest residence time in a virus-infected cell (up to 20 hours); [!!!] famciclovir has the ability to penetrate the Schwann cells surrounding the nerve fibers;
a constant concentration of the drug in infected cells provides a long-term antiviral effect and makes it possible to take the drug less often (for herpes zoster - 500 mg every 8 hours - 3 times a day - for 7 days ... compare - acyclovir for shingles is taken at 0.8 g 5 times a day for 7 days);
famciclovir is the only antiviral drug that reduces the duration of postherpetic neuralgia in herpes zoster (by 100 days compared with placebo).

For citation: Korsunskaya I.M. Shingles // BC. 1998. No. 6. S. 10

Key words: Herpes - virus - nervous system - ganglia - sensitivity - antiviral agents - methysazon - acyclic nucleotides - analgesics.

Herpes zoster is a viral disease that often occurs, especially against the background of immunosuppression. Diagnosis is based on clinical manifestations. Treatment should be comprehensive and include antiviral drugs, ganglion blockers, analgesics.

Key words: Herpes - virus - nervous system - ganglia - antiviral agents - methisazone - acyclic nucleosides - analgetics.

Herpes zoster is a viral disease that is most common especially in immunodeficiency. The diagnosis is based on its clinical manifestations. Treatment should be combined and include antiviral, ganglion-blocking, and analgetic agents.

THEM. Korsunskaya - Ph.D. honey. Sci., Assistant Professor, Department of Dermatovenereology, Russian Medical Academy of Postgraduate Education

I.M.Korsunskaya, Candidate of Medical Sciences, Assistant, Department of Dermatovenereology, Russian Medical Academy of Postgraduate Training

O shingles (Herpes zoster) is a common viral disease that attracts the attention of not only dermatologists, neurologists and virologists, but also doctors of other specialties.

Etiology

The history of this disease is very old, but only at the end of the last century, neuropathologists Erb (1893) and Landori (1885) first suggested the infectious genesis of Herpes zoster, which was confirmed by the following clinical data: fever, cyclic course, disease of two members of the same family and more. The virus (Varicella zoster - VZ) belongs to the group of DNA-containing viruses. The size of the virus is from 120 to 250 microns. The virion core consists of DNA covered with protein. The composition of the virion includes more than 30 proteins with a molecular weight of up to 2.9. 10 daltons. Viruses of this group begin to reproduce in the nucleus. In cross-neutralization experiments performed by Taylor-Robinson (1959), the varicella-zoster virus and the Herpes zoster virus were equally neutralized by the sera of convalescents. At the same time, sera taken from patients with Herpes zoster in the acute period had a greater neutralizing activity than sera taken at the same time from patients with chickenpox. A. K. Shubladze and T. M. Maevskaya believe that this is apparently due to the fact that Herpes zoster is a secondary manifestation of an infection caused by the varicella-zoster virus. Most modern researchers consider the VZ virus to be the cause of this disease.

Pathogenesis

To understand the pathogenesis of Herpes zoster, the data of post-mortem studies are important, indicating the connection of the rash sites with the lesion of the corresponding ganglia. Later, Head and Campbell (1900), on the basis of histopathological studies, came to the conclusion that both neurological phenomena in Herpes zoster and the zones of skin rashes that characterize them arise as a result of the development of a pathological process in the intervertebral nodes and their homologues (Gasser's node, etc.) . But already Volville (1924), having studied the nervous system of patients who died from the generalized form of Herpes zoster, came to the conclusion that the defeat of the intervertebral ganglia in Herpes zoster is optional. The spinal cord is often involved in the inflammatory process, and not only the posterior horns are affected, but also the anterior ones. Volville and Shubak (1924) described cases when herpetic eruptions were the first manifestations of a polyneurotic process proceeding according to the type of Landry's paralysis. Volville believes that the inflammatory process first affected the sensitive neurons, and then spread to the spinal segments and peripheral nerves. In the case described by Shubak, a pathoanatomical examination revealed nests of inflammatory infiltration in the sciatic nerves, cervical sympathetic nodes and the corresponding spinal ganglia, dorsal horns of the spinal cord.
Stamler and Stark (1958) described the histological picture of fulminant ascending radiculomyelitis zoster, in which death occurred as a result of bulbar and spinal respiratory paralysis. Demyelination of the spinal cord conductors with glial and lymphocytic reaction, perivascular infiltration and proliferation, changes in the neurons of the spinal ganglia, dorsal horns, and dorsal roots were found.
In 1961, Kro, Dunivits and Dalias reported seven cases of Herpes zoster affecting the central nervous system. The disease proceeded in the form of aseptic meningitis, meningoencephalitis involving the cranial nerves, encephalomyelitis, polyradiculoneritis. Histopathological examination revealed a picture of "posterior poliomyelitis". The authors consider it sufficient for the histological diagnosis of Herpes zos t er, when the disease proceeds without clear herpetic eruptions.

Pathomorphological and virological studies indicate that the Herpes zoster virus is widely disseminated throughout the body: during illness, it can be isolated from the contents of vesicles, saliva, lacrimal fluid, etc. This gives reason to believe that herpetic eruptions can be caused not only by sedimentation virus in the sensitive ganglia and the defeat of the parasympathetic effector cells located in them, but also by its direct introduction into the skin. Penetrating into the nervous system, it is not only localized within the peripheral sensory neuron (spinal ganglia, etc.), but also spreads to other parts of the central nervous system. When it is introduced into the motor cells and roots, a picture of amyotrophic radiculoplexitis occurs, in the gray matter of the spinal cord - myelitis syndrome, in the cerebrospinal fluid system - meningoradiculoneuritis or serous meningitis, etc.

Clinic

The clinical picture of Herpes zoster consists of skin manifestations and neurological disorders. Along with this, most patients have general infectious symptoms: fever, enlargement of hormonal lymph nodes, changes (in the form of lymphocytosis and monocytosis) of the cerebrospinal fluid. Usually, erythematous spots of round or irregular shape, raised, edematous, are found on the skin, when you run a finger over them, some pebbly skin (tiny papules) is felt. Then, in these areas, groups of bubbles appear sequentially, often of different sizes. Bubbles can merge, but most often they are located in isolation, although close to one another - the vesicular form of Herpes zoster. Sometimes they look like a small bubble surrounded by a red rim around the periphery. Since the rash occurs simultaneously, the elements of the rash are at the same stage of their development. However, the rash may appear within 1 to 2 weeks in the form of separate groups. In the latter case, when examining a patient, rashes of various stages can be detected. In typical cases, the bubbles have a transparent content for the first time, quickly turning into a cloudy one, and then dry into crusts. A deviation from the type described is the milder abortive form of Herpes zoster. With this form, papules also develop in the foci of hyperemia, which, however, do not transform into vesicles, this form differs from vesicular. Another variety is the hemorrhagic form of Herpes zoster, in which the vesicles have bloody contents, the process extends deep into the dermis, the crusts become dark brown. In severe cases, the bottom of the vesicles becomes necrotic - the gangrenous form of herpes zoster, after which cicatricial changes remain. The intensity of the rashes in this disease is very variable: from confluent forms, leaving almost no healthy skin on the side of the lesion, to individual vesicles, although in the latter case the pain can be pronounced. Such cases have given rise to the assumption that Herpes zoster can exist without skin eruption.

One of the leading symptoms of the disease are neurological disorders usually in the form of pain. Most often it occurs 1-2 days before the rash appears. The pains, as a rule, are of an intense burning character, the zone of their distribution corresponds to the roots of the affected ganglion. It should be noted that the pain syndrome intensifies at night and under the influence of a variety of stimuli (cold, tactile, kinesthetic, barometric) and is often accompanied by vegetative-vascular dystonia of the hypertonic type. In addition, patients have objective sensitivity disorders: hyperesthesia (the patient can hardly tolerate the touch of linen), hypoesthesia and anesthesia, and hyperalgesia may exist simultaneously with tactile anesthesia.
Objective sensory disturbances are variable in form and intensity, usually limited to temporary sensory disturbances in the area of the rash or scarring. Anesthesias concern all kinds of sensitivity, but in some cases a dissociated type of disorder is observed; sometimes within the same kind of sensitivity, such as hot and cold. Occasionally, hyperesthesia takes on the character of irritation in the form of causalgia.
Not in all cases, the intensity of the pain syndrome corresponds to the severity of skin manifestations. In some patients, despite the severe gangrenous form of the disease, the pain is minor and short-lived. In contrast, a number of patients have a prolonged intense pain syndrome with minimal skin manifestations.
Some patients in the acute phase have diffuse cephalgia, aggravated by a change in head position, which may be associated with a shell reaction to Herpes zoster infection. In the literature there are indications of damage to the brain and its membranes.
According to a number of authors (A.A. Kalamkaryan and V.D. Kochetkov 1973; M.K. Zucker 1976, etc.), herpetic ganglionitis of the gasser node are more common than ganglionitis of the intervertebral nodes. In most patients with this localization of the process, there is an increase in temperature and swelling of the face on the affected side, as well as pain at the exit points of the trigeminal nerve.
The cornea is often affected in the form of keratitis of a different nature. In addition, other parts of the eyeball are affected (episcleritis, iridocyclitis, iris zoster). The retina is very rarely involved (hemorrhages, embolisms), more often the changes concern the optic nerve - optic neuritis with an outcome in atrophy, possibly due to the transition of the meningeal process to the optic nerve. With ophthalmic herpes (iritis), glaucoma may develop; usually, with zoster, gynotension of the eyeball is observed, which is apparently caused by damage to the ciliary nerves. Complications of zoster from the motor nerves are quite common, they are arranged in the following order: III, IV, VI nerves. Of the branches of the oculomotor nerve, both external and internal branches are affected. Ptosis is often observed. Skin rashes in ophthalmic zoster pe, as a rule, proceed more severely than on other parts of the body, perhaps depending on the structure of the skin in the eye area. Quite often, necrosis of the vesicles, severe neuralgia, accompanied by lacrimation, are observed. Bubbles pour out not only on the skin,but also on the mucous membranes of the eye.
As a result of the process in the cornea with ophthalmic zoster, atrophy of the optic nerve and complete blindness may develop. In addition, some patients note the loss of eyebrows and eyelashes on the side of the lesion.
The maxillary branches of the trigeminal nerve are affected both in the area of the skin and in the area of the mucous membranes (half of the hard and soft palate, the palatine curtain, the upper gum, the inner surface of the buccal mucosa, while the nasal mucosa may remain unaffected). Branches supplying mucous membranes may be more affected than cutaneous branches, and vice versa. Damage to the nerves of the upper and lower jaws does not always remain strictly localized, since pain sometimes radiates to the region of the ophthalmic and other branches.
Herpes zoster usually affects the autonomic nervous system. However, clinical observations have shown that the animal nervous system can also be involved in the pathological process. Evidence of this is that in some patients, at the same time as with a lesion of the Gasser node, there was a peripheral paresis of the facial nerve on the side of herpetic eruptions. With ophthalmic zoster, both the external and internal muscles of the eye are paralyzed. IV pair paralysis is rare. Oculomotor paralysis is usually partial rather than complete; more often than other muscles, m. levator palpebrae. There are cases of ophthalmic zoster with an isolated change in the shape and size of the pupil; unilateral Argil-Robertson symptom (Guillen). These paralysis sometimes partially or completely disappear spontaneously, without special treatment.

And Nordal (1969) was the first to point out the defeat of the geniculate node in this form of Herpes zoster. Usually on the auricle or around it, and sometimes in the ear canal and even on the eardrum, herpetic eruptions appear. There is a sharp pain in the circumference of the auricle, swelling of the lymph nodes, impaired sensitivity. Disorders of the functions of the facial, cochlear, vestibular nerves occur in the first days of rashes or precede them. Pain in such cases is localized in the depth of the auditory canal and auricle with irradiation to the mastoid, auricular and temporoparietal regions. Objective sensitivity disorders are found behind the ear, in the fold between the auricle and the mastoid process. This skin area is supplied by the ear branch of the X pair, which innervates the posterior walls of the ear canal. Finally, in cases of a very common ear zoster, the latter captures not only the external auditory canal, the auricle, the mastoid process, but also the tympanic membrane, which sometimes suffers extremely severely. In such cases, the area innervated by the V, VII and X pairs is affected, and the defeat of these nerves is accompanied by damage to the ganglia of the corresponding cranial nerves or anastomoses that connect the terminal branches of all the listed nerves.
Often, simultaneously with paralysis of the VII pair, paralysis of the soft palate, anesthesia and paresthesia in the tongue are observed, often a taste disorder in the anterior two-thirds of the tongue due to damage. The defeat of the Vlll pair usually begins with tinnitus, which sometimes persists for a long time after the disappearance of other phenomena. Hyperacusia in the defeat of the VIII pair is called paresis n. stapeblii, although this symptom may also occur in isolated and previous lesions of the auditory nerve and is in such cases a symptom of irritation. Hypoacusia can occur regardless of the damage to the auditory nerve due to local lesions of the middle ear, the rash of bubbles on the eardrum, the laying of the external auditory canal, due to swelling of the mucous membrane due to the rash of zoster.
Vestibular phenomena, in contrast to cochlear ones, usually develop extremely slowly and are expressed differently: from mild subjective symptoms of dizziness to significant static disorders.
Neuralgia in ear zoster, in contrast to ophthalmic zoster, is rare.
Long-term results are not always favorable, as persistent paresis of the facial nerve and deafness may occur.
Volville emphasizes that the combination of paralysis of the VlI and VIII pairs, although it occurs especially often in zoster, nevertheless occurs with lesions of the gasser node, ll, lll, cervical ganglia, and, finally, all of these areas can be affected simultaneously.
Rashes of zoster are also described in the region of innervation of the IX pair: the back of the soft palate, arches, posterolateral parts of the tongue, part of the posterior pharyngeal wall; the same area is innervated, in addition to IX, also by the branches of the X pair: the root of the tongue, larynx, proglottis, basal and posterior part of the pharyngeal wall. Although zoster predominantly and even selectively affects the sensitive systems, however, movement disorders are sometimes observed with it, especially when rashes are localized in the head, neck, and extremities. Paralyzes in zoster are radicular in nature, and the defeat of the posterior roots in these cases is accompanied by phenomena from the corresponding anterior roots.
The defeat of the cervical sympathetic nodes is often accompanied by rashes on the skin of the neck and scalp. Pain in this case is observed not only in the places of rashes, but also in the area of paravertebral points. Sometimes there may be seizures that mimic facial sympathy.
With ganglionitis of the lower cervical and upper thoracic localization, along with the usual symptoms of this disease, Steinbrocker's syndrome can be observed. Dominant in the picture of this syndrome are pains of a sympathetic nature in the form of a burning sensation or pressure, which occur first in the hand, and then in the entire hand. Soon appears and quickly increases swelling of the hand, spreading to the entire arm. Trophic disorders are added in the form of cyanosis and thinning of the skin, hyperhidrosis, brittle nails. The movements of the fingers are limited, painful. Often, pain and other autonomic disorders persist even after the rash has disappeared. Ganglionitis of thoracic localization often simulate the clinical picture of myocardial infarction, which leads to errors in diagnosis.
With herpetic lesions of the ganglia of the lumbosacral region, rashes are most often localized on the skin of the lower back, buttocks and lower extremities; along with pain in the places of rashes, pain syndromes can occur that simulate pancreatitis, cholecystitis, renal colic, appendicitis. Herpetic lesions of the lumbosacral ganglia are sometimes accompanied by involvement in the process of the animal nervous system, which gives a picture of ganglioradiculitis (radicular syndrome of Nori, Matskevich, Wasserman).
Sometimes, along with rashes along the nerve trunk, vesicular rashes appear all over the skin - a hepatic form of herpes zoster. Usually the disease does not recur. However, it is known from the literature that there are recurrent forms of the disease against the background of somatic burden: HIV infection, cancer, diabetes mellitus, lymphogranulomatosis, etc.

Treatment

In the treatment of Herpes zoster of various localization and severity, early administration of antiviral drugs is necessary. It is known that the composition of the virus includes proteins that form its shell and carry the enzymatic function, as well as nucleic acid - the carrier of its genetic properties. Penetrating into cells, viruses are released from the proteinaceous protective shell. It has been shown that at this moment their reproduction can be inhibited with the help of nucleases. These enzymes hydrolyze the nucleic acids of viruses, but do not damage the nucleic acids of the cell itself. It was found that pancreatic deoxyribonuclease sharply inhibits the synthesis of DNA-containing viruses, such as herpes viruses, vaccinia, adenoviruses. Considering the above, it is recommended that Herpes zoster patients be prescribed deoxyribonuclease intramuscularly 1-2 times a day, 30-50 mg for 7 days. In addition, in patients with rashes on the oral mucosa, conjunctiva and cornea, the drug is used topically in the form of an aqueous solution. The appointment of deoxyribonuclease contributes to the rapid regression of skin rashes and a decrease in pain.
Good results are obtained by the use of metisazon. It is prescribed orally at the rate of 20 mg per 1 kg of the patient's body weight per day in 3 divided doses after meals for 6 to 7 days. The drug is contraindicated in severe lesions of the liver and kidneys, gastrointestinal diseases in the acute stage. It is not recommended to take alcoholic beverages during treatment. No complications were observed during the use of the drug.
Metisazon does not affect the adsorption of the virus by the cell and its penetration into the cell. It does not affect the synthesis of viral DNA and does not interfere with the synthesis of many viral proteins. The drug apparently interferes with the synthesis of late proteins involved in the construction of a viral particle. It has also been suggested that metisazon induces the formation of a new ribonucleic acid in the cell, which provides the synthesis of a protein with antiviral properties. When administered orally, metisazon can be detected after 30–40 minutes in the blood serum, and after 2–3 hours in the urine.
In recent years, antiviral chemotherapy drugs from the group of synthetic acyclic nucleosides have been used to treat Herpes zoster. The most well studied at present is acyclovir. The mechanism of action of acyclovir is based on the interaction of synthetic nucleosides with the replication enzymes of herpes viruses. Herpesvirus thymidine kinase binds to acyclovir thousands of times faster than cellular thymidine, so the drug accumulates almost exclusively in infected cells. This explains the complete absence of cytotoxic, teratogenic and mutagenic properties in acyclovir. The synthetic nucleoside is built into a chain of DNA being built for the "daughter" viral particles, and this process is interrupted, thus stopping the reproduction of the virus. The daily dose of acyclovir for herpes zoster is 4 g, which should be divided into 5 single doses of 800 mg. The course of treatment is 7 - 10 days. The best therapeutic effect is achieved with early administration of the drug; the terms of rashes are reduced, there is a rapid formation of crusts, intoxication and pain syndrome are reduced.
Acyclovir of the second generation - valacyclovir, retaining all the positive aspects of acyclovir, due to increased bioavailability, allows you to reduce the dose to 3 g per day, and the number of doses - up to 3 times. The course of treatment is 7 - 10 days.
Famciclovir has been used since 1994. The mechanism of action is the same as that of acyclovir. The high affinity of the thymidine kinase of the virus for famciclovir (100 times higher than the affinity for acyclovir) makes the drug more effective in the treatment of herpes zoster. The drug is prescribed 250 mg 3 times a day for 7 days.
Along with antiviral drugs, ganglionic blockers such as ganglerone are used to reduce pain. Gangleron is used intramuscularly in the form of a 1.5% solution of 1 ml 1 time per day for 10-15 days or 0.04 g in capsules 2 times a day for 10-15 days, depending on the severity of the pain syndrome. In addition, good results are obtained by the use of carbamazepine, especially with Herpes zoster of the gasser node, the drug is prescribed from 0.1 g 2 times a day, increasing the dose by 0.1 g per day, if necessary, up to 0.6 g of the daily dose (in 3 - 4 doses). After the reduction or disappearance of pain, the dose is gradually reduced. Usually the effect occurs 3-5 days after the start of treatment.
With a pronounced pain syndrome, analgesics are prescribed per os and in the form of injections, reflexology. In reflexology, both points of general action and points corresponding to the affected ganglion are usually used, the course is 10-12 sessions. They also recommend the appointment of multivitamins, in particular vitamins of group B. Local irrigation with interferon or ointments with interferon, aniline dyes, eridine aerosol, florenal ointments, helepin, alpizarin can be used locally. With gangrenous forms of herpes zoster, pastes and ointments containing an antibiotic, as well as solcoseryl, are used.
After resolution of skin rashes, treatment is carried out by neuropathologists until the disappearance of neurological symptoms.
Thus, the treatment of herpes zoster should be comprehensive and include both etiological and pathogenetic agents.

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Ministry of Health of the Russian Federation

State budget educational institution

higher professional education

I.M. Sechenov First Moscow State Medical University

Faculty of Dentistry

Department of Therapeutic Dentistry

Disease history

B02 - Shingles

Performed:

Student of the 5th year of the 4th group

Gerasimova A.S.

Teacher:

Turkina A.Yu.

Moscow 2015

General information

Patient Name: ______

Address, phone: Moscow, _____

Year of birth: 1982

Date of access: 27.10.2015

Patient Questioning Data

Complaints: Pain, redness and multiple rashes in the area of the left half of the tongue, lower lip, chin. Pain radiates to the left ear, eating is difficult.

Development of the present disease: He considers himself ill for about 2 days, when there was a sharp pain in the tongue, the left half of the face. More than 1 week ago I had a slight runny nose and cough. She was not treated, she looked after her son, who was sick with chicken pox. Previously, such rashes were not observed.

Patient's life history

Place of birth: Moscow, Russian Federation.

Past diseases: according to the patient, there were no injuries, no operations. Chickenpox at age 10.

Hereditary history: according to the patient, there are no hereditary diseases.

Allergological history: not burdened.

Objective Research Data

General condition: Chills, malaise, headache. Body temperature 38.9°C.

Facial examination: The configuration of the face is not changed. On the skin of the chin and the red border of the lower lip on the left, there are multiple bubbles arranged in the form of a chain. Some of the vesicles are open, covered with yellowish crusts.

Mouth opening: free

Examination of the lymph nodes: the submandibular lymph nodes on the left are enlarged up to 1 cm, painful on palpation, mobile.

Oral examination

Attachment of the frenulums of the upper and lower lips: within the physiological norm.

Condition of the oral mucosa: On the mucous membrane of the lower lip, cheek, lateral surface of the tongue on the left, there are multiple small-pointed and extensive erosions with scalloped edges on a hyperemic background, covered with fibrinous plaque, sharply painful on palpation.

Bite: orthognathic

Inspection of the dentition

Anomalies in the shape, position and size of the teeth were not found. Non-carious lesions of the teeth (hypoplasia, fluorosis, wedge-shaped defect, abrasion) are absent.

In the area 3.1 3.2 4.1 4.2 there is supragingival tartar of light brown color. In the area of teeth 1.7 1.6 1.5 1.4 2.4 2.5 2.6 2.7 there is a large amount of soft plaque.

supragingival calculus

ICD10 diagnosis

B02 Shingles

K03.6 Deposits on teeth

K02.1 Dentinal caries - tooth 28

The diagnosis was made on the basis of the patient's complaints, the features of the development of the disease, the results of an external examination and examination of the oral cavity, and the main research methods.

Substantiation of the clinical diagnosis

1) the disease was preceded by SARS;

2) contact with a patient with chickenpox;

3) in the prodromal period, fever, malaise, headache;

4) neuralgic pain along the third branch of the trigeminal nerve on the left;

5) unilateral (asymmetric) lesions;

6) consecutive rashes: hyperemia (spot), vesicle, erosion, crust;

7) merged erosions with scalloped edges on the mucous membrane;

8) the disease appeared for the first time;

9) lack of intolerance to drugs

Main Diagnosis

Shingles with involvement of the third branch of the trigeminal nerve on the left

Under application anesthesia "Lidoxor-gel" medical treatment of erosions with 1% solution of hydrogen peroxide was carried out, soft plaque was removed. The application of Valaciclovir under the Diplen-Dent film was carried out.

General treatment prescribed:

Antiviral drugs - herpevir 200 mg 4 times a day after meals for 5 days.

Effective use of deoxyribonuclease (50 mg. 2-3 r per day intramuscularly)

Analgesics and non-steroidal anti-inflammatory drugs - ibuprofenpo 25-50 mg two to three times a day for five days.)

Vitamin preparations - vitamin B-I2 - cyanocobalamin in injections of 200-500 mcg daily or every other day, the course of treatment is up to 2 weeks;

Interferon inducers - poludan, 2 drops in each nostril 5 times a day

Antihistamines: claritin (cetrin, loratadine) 1 tab. 2-3 times a day.

Inspection data: Regression of the inflammatory process, positive dynamics in the healing of erosions.

Under application anesthesia Lidoxor-spray 15%, an antiseptic treatment of the oral cavity with a solution of hydrogen peroxide 1%, an application of "Solcoseryl" (dental adhesive paste) was carried out.

Inspection data: Residual pigmentation is observed on the skin, slight paresthesia in the area of the chin and lower lip, complete healing of the mucous membrane in the oral cavity.

10/27/2015 The patient complains of pain, hyperemia and multiple rashes in the area of the left half of the tongue, lower lip, chin. Pain radiates to the left ear, eating is difficult. When collecting an anamnesis, it was found that the development of the disease was preceded by contact with a patient with chickenpox, as well as a sharp pain in the tongue, the left side of the face. More than 1 week ago I had a slight runny nose and cough. Examination: On the skin of the chin and the red border of the lower lip on the left, there are multiple rashes arranged in the form of a chain. Erosions are covered with crusts, located on a hyperemic background. Body temperature 38.9°C. On the mucous membrane of the lower lip, cheek, lateral surface of the tongue on the left, there are multiple small-pointed and extensive erosions with scalloped edges on a hyperemic background, covered with fibrinous plaque, sharply painful on palpation. -Brown color.

Diagnosis: Shingles with lesions of the third branch of the trigeminal nerve on the left

Treatment: Assigned to the general treatment in the form of reception: herpevir 200 mg 4 times a day after meals for 5 days; ibuprofen 25 - 50 mg two - three times a day for five days, vitamin B-I2 - cyanocobalamin in injections of 200-500 mcg daily or every other day, the course of treatment is up to 2 weeks; poludan, 2 drops in each nostril 5 times a day claritin (cetrin, loratadine) 1 tab. 2-3 times a day.

Local: Under application anesthesia "Lidoxor-gel" medical treatment of erosions with 1% solution of hydrogen peroxide was carried out, soft plaque was removed. The application of Valaciclovir under the Diplen-Dent film was carried out. Recommendations: Applications "Kamistad-gel", oral hygiene with a soft toothbrush, re-examination after 3 days.

10/30/2015 On examination: Regression of the inflammatory process, positive dynamics in the healing of erosions.

Local treatment was carried out: under application anesthesia Lidoxor-spray 15%, antiseptic treatment of the oral cavity with a solution of hydrogen peroxide 1%, application of Solcoseryl (dental adhesive paste) was carried out.

11/13/2015 On examination: Residual pigmentation is observed on the skin, slight paresthesia in the area of the chin and lower lip, complete healing of the mucous membrane in the mouth. .

The prognosis of the disease is favorable. Relapse is unlikely.

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Disease history

Herpes zoster, herpetic conjunctivitis and comorbidities

Main diagnosis: Herpes zoster in the projection of the 1st branch of the 5th nerve on the right. Herpetic conjunctivitis.

Concomitant diagnosis: coronary artery disease, angina pectoris. Violation of the rhythm by the type of paroxysmal extrasystole.

Patient information

1. Full name ______________

2. Age: 74 (11/27/35)

3. Place of residence: Ryazan, st. Berezovaya d.1 "B" apt. 61

4. Profession, place of work: pensioner

5. Date of illness: 09/30/10

6. Date of admission to the hospital: 2.10.10

7. Date of start and end of curation: 6.10.10-12.10.10

Complaints

At the time of curation (6.10.10.-7 day of illness) the patient had no complaints.

morbi

He considers himself ill since 09/30/10, the first day of illness, when, after an eyebrow bruise, she noticed a red formation with a diameter of 0.2 mm. There was also swelling of the right eyelid and redness of the mucous membrane of the right eye. Notes a slight rise in temperature up to 38 C and itching. On October 1, 2010, the second day of illness, erythema began to grow, and already on October 2, 2010, the third day of illness, it occupied the right half of the face. She asked for help at the emergency hospital, where she was diagnosed with facial erysipelas and the patient was referred to the infectious diseases department of the Semashko City Clinical Hospital. Hospitalized. 8.10.10 - the ninth day of illness, complaints of swelling of the right eyelid, headache. The general condition is satisfactory, locally without dynamics. 11.10.10-general condition is satisfactory, complaints of swelling of the right eyelid. Locally there is a positive trend. There are no new rashes, in place of the old ones, dried crusts.

Epidemiological history

Everyone around is healthy. 09/30/10 there was a bruise in the forehead as a result of a fall. Contact with infectious patients denies.

vitae

Born in Ryazan. She grew and developed normally. Graduated

secondary school. Upon graduation, she entered the RRTI at the Faculty of Engineering, after which she worked as an engineer at the CAM plant. Since 1964 she worked as an engineer at RKB GLOBUS. Retired from 1990 to present. Material and living conditions are good, he eats 3 times a day, takes hot meals.

Past illnesses and surgeries:

Chicken pox, rubella, SARS, acute respiratory infections. Cholecystectomy in 1998. Mastectomy in 2010.

Bad habits: smoking, drinking alcohol and drugs denies.

Family life: married, has 2 children.

Obstetric and gynecological history: menstruation since the age of 15, menopause since 1988. Pregnancies-2, childbirth-2.

Heredity: grandmother suffers from hypertension.

Allergological history: denies allergic reactions to odors, foods, drugs and chemicals.

praesens

1. General state: satisfactory

2. Patient position: active

3. Consciousness: clear

4. Build: normosthenic: epigastric angle approximately 90o. Height 162 cm, weight 59 kg.

Food: normal, skinfold thickness 0.5 cm

5. Leather: normal color, elastic, skin turgor is reduced, moderately moist. There are no hemorrhages, scratches, scars, “spider veins”, angiomas. In the region of the right half of the forehead and scalp, edema, infiltration, skin hyperemia. Against this background, small group vesicular elements.

6. Mucous membranes: the state of the nasal mucosa is satisfactory, the mucous membrane of the oral cavity and the hard palate is of normal color. The gums are not bleeding, not loosened. The tongue is of the usual shape and size, moist, lined with white coating, the severity of the papillae is within the normal range. There are no cracks, bites, sores. The mucous membrane of the throat is of normal color, moist, there are no rashes and raids. In the OD area, the conjunctiva is edematous and hyperemic.

8. Subcutaneous tissue: the development of subcutaneous adipose tissue is moderate. The thickness of the skin fold in the region of the triceps muscle of the shoulder, scapula, under the collarbone - 0.5 cm. No edema. The saphenous veins are hardly noticeable, there are no subcutaneous tumors.

9. Lymphatic system: lymph nodes: (occipital, parotid, submandibular, axillary, inguinal, popliteal) - not enlarged (in the form of peas), painless, of normal density, mobile,

10. Muscular system: moderately developed, there is no pain on palpation, no differences in diameter were detected when measuring the limbs, the muscles are in good tone. There is no involuntary muscle tremor.

12. Bone-articular apparatus: there is no pain on palpation, no percussion of the bones, the joints are of the usual form, painless, the skin over them is unchanged. Movements in the joints are preserved in full, without crunch, free. There is no pain on palpation of the joints. The skin temperature over the joints is not changed. The gait is normal. Spine. Mobility in all parts of the spine is not limited. Bending the trunk forward in a sitting position is not limited. There is no pain on palpation. The range of motion is performed.

Study of the cardiovascular system

There are no complaints.

Examination of the region of the heart.

The shape of the chest in the region of the heart is not changed. The apical impulse is visually and palpation determined in the 5th intercostal space, 1.5 cm medially from the linea medioclavicularis sinistra, reinforced, with an area of 1.5 cm. The cardiac impulse is not palpable. Cat's purring in the second intercostal space on the right side of the sternum and at the apex of the heart is not defined. "Dance of the carotid" is absent. Physiological epigastric pulsation is palpable. On palpation, the pulsation in the peripheral arteries was preserved and the same on both sides.

On palpation of the radial arteries, the pulse is the same on both hands, synchronous, rhythmic, with a frequency of 84 beats per minute, satisfactory filling, not tense, the shape and magnitude of the pulse are not changed. There are no varicose veins.

Limits of relative cardiac dullness

The right border is determined in the 4th intercostal space - 2 cm outward from the right edge of the sternum; in the 3rd intercostal space 1.5 cm outward from the right edge of the sternum.

The upper border is defined between linea sternalis and linea parasternalis sinistra at the level of the 3rd rib.

The left border is determined in the 5th intercostal space 1.5 cm outward from the linea medioclavicularis sinistra; in the 4th intercostal space 1.5 cm outward from the linea medioclavicularis; in the 3rd intercostal space 2 cm outward from the parasternalis sinistra line.

Limits of absolute cardiac dullness

The right border is determined in the 4th intercostal space 1 cm outward from the left edge of the sternum.

The upper border is defined on the 3rd rib, between linea sternalis and parasternalis.

The left border is determined by 0.5 cm medially from the left border of relative cardiac dullness.

The vascular bundle is located - in the 1st and 2nd intercostal space, does not extend beyond the edges of the sternum.

On auscultation of the heart, clear heart sounds are heard. Rhythm disturbances by the type of paroxysmal extrasystole. There is no bifurcation, splitting of tones. Pathological rhythms, heart murmurs and pericardial rub are not detected. Blood pressure at the time of examination 125/80.

Respiratory system

There are no complaints.

The chest is of the correct form, normosthenic type, symmetrical. Both halves of it evenly and actively participate in the act of breathing. Type of breathing - chest. Breathing is rhythmic with a frequency of 17 respiratory movements per minute, of medium depth.

Palpation:

The chest is painless, rigid. The voice trembling is the same on both sides.

Topographic percussion of the lungs.

The lower borders of the lungs.

The height of the tops of the lungs: in front 5 cm above the clavicle, behind at the level of the spinous process of the 6th cervical vertebra. The width of the isthmuses of the Krenig fields is 6 cm. The active mobility of the lower edge of the lungs along the linea axilaris media is 4 cm on the right and left. With comparative percussion over the entire surface of the lungs, a clear pulmonary sound is determined. Auscultation: breathing is heard over the surface of the lungs. there are no wheezing.

Digestive system

Mucous cheeks, lips, hard palate pink. Gums of normal moisture. No caries, no loose teeth. Inspection of the tongue: the tongue is of normal size, moist, lined with a whitish coating, the papillae are preserved.

The abdomen is round, symmetrical. On superficial palpation, the abdomen is soft and painless. Deep palpation. In the left iliac region, a painless, elastic, shifting, slightly rumbling, with a smooth surface sigmoid colon with a diameter of 2 cm is determined. A cecum 2.5 cm in diameter is palpated in the right iliac region, painless, mobile, slightly rumbling.

The transverse colon is determined at the level of the navel in the form of a soft, elastic cylinder, 3 cm in diameter, not rumbling, easily displaced, painless, with a smooth surface.

The greater curvature of the stomach by balloting palpation is determined 3 cm above the navel.

The lower edge of the liver does not protrude. With percussion, the size of the liver according to Kurlov is 9-8-6 cm

The gallbladder is not palpable. There is a postoperative scar at the projection site. Symptoms of Courvoisier, Kera, Lepene, Musy, Murphy are negative.

The spleen is not palpable. Painless. Percussion upper pole along linea axillaris media at the level of the 9th rib, lower pole along linea axillaris media at the level of the 11th rib.

genitourinary system

The kidneys are not palpable. Pasternatsky's symptom on the right and left side is negative. Palpation along the ureter is painless. The bladder is not palpable, palpation in the area of its projection is painless. Urination is painless, there is no discharge from the genitals.

Neuropsychic status

Consciousness is clear, sleep is normal, mental state without features. Pupillary and tendon reflexes are preserved, the same on both sides. Skin sensitivity is preserved. Pathological reflexes are absent. Tremor of the limbs is absent. Hearing is within normal limits. There is no visible enlargement of the thyroid gland. On palpation, its isthmus is determined in the form of a soft, mobile, painless roller.

Dermographism pink, rapidly developing

Herpes zoster case history infection. Case history - herpes - infectious diseases. Clinical observation of the patient

I. Passport part

II.Complaints

III. History of the present disease (Anamnesis morbi)

IV. Life history (Anamnesis vitae)

V.Heredity

VI. Present status (Status praesens)

VII. Local Status

VIII. Data from laboratory and instrumental studies

IX. Clinical diagnosis and justification

X. Differential diagnosis

XI. Treatment

XII. Forecast

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