Case Report Kulit(1)(1)

8/14/2019 Case Report Kulit(1)(1)

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CASE REPORT

Identity of patient

Name : Ms. EPD

Sex : Female

Registration number : 96-85-2

!ge : "8 #ears ol$

!$$ress : %ing&e

P'one number : 856688(")"

Examination $ate : Se*tember "t'2")

HistoryThe Chief Complain :

+esi,les it' *ain on t'e let si$e o t'orax sin,e 2 $a#s beore a$mission.

History of present illness:

Patient ,ame to t'e 'os*ital ,om*laine$ /esi,les $e/elo*s u*on t'e er#t'ematous base

it' *ain0 it,'# an$ burning sensation o t'e let si$e o t'e t'orax sin,e 2 $a#s beore

a$mission. !t irst0 *atient oun$ re$$is' ras' aroun$ 'er let t'orax t'en ater " $a#

s'e oun$ t'e same /esi,les it' er#t'ematous base it' *ain0 it,'# an$ burning

sensation aroun$ 'er let in ront an$ ba,& si$e o t'orax. 1'e ras' be,ome more it,'#

an$ *ain. Patient also elt 'er bo$# be,omes ea& an$ ,on/in,e$ o e/er. Fe/er as

elt ater t'e ras' a**ear. Patient ,onesses t'at s'e 'as a lot o a,ti/it# an$ a$mitte$

atigue ) $a#s beore t'e /esi,les a**ears. Patient $enie$ s'e got an# inse,t bite or

'a$ a ras' ater ,onsume$ an# oo$ ,onsist o 'eat an$ #o$ium.

History of previous illness:

Patient ne/er ,om*laine$ li&e t'is beore. S'e e/er got /ari,ella 'en s'e as 5 #ears

ol$.

History of Family disease :

None o 'er amil# 'a$ t'is &in$ o $isease

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History of Treatment:

Patient 'a$ Caladine*o$er.

History of Social Habits:

Patient 'a$ a lot o a,ti/it# 5 $a#s beore a$mission

Physical Examination

+ital Sign :

Not ,'e,&e$

Dermatological status:

!

Figure ". First /isit at Se*tember "t'0 2"). 3rou* /esi,les on an er#t'ematous base

it' lesion in t'e let 1) $ermatomes let si$e t'orax. !. %esion on let si$e t'orax. .

%esion on ba,& si$e t'orax.

a4r 1'ora,'alis sinistra et anterior an$ *osterior oun$ grou* /esi,les on an

er#t'ematous base0 osteriorm arrangement0 some lesion are ,onluens an$ t'ere is

normal s&in among t'e lesion0 milier to lenti&uler sie0 an$ unilateral $istribution int'e let 1) $ermatomes.

Clinical Test

No ,lini,al test a/ailable

Differential Diagnosis

". er*es 7oster at regio t'ora,'alis anterior an$ *osterior sinistra in t'e let 1)

$ermatomes

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2. Dermatitis +enenata

). Dermatitis er*etiormis

Planning Diagnosis

1an& smear0 but not ,'e,&e$. t'is tan& test being ,'e,&e$ a result is a

multinu,leate$ giant ,ell ill be oun$ in mi,ros,o*i, examination.

Diagnosis

er*es 7oster at regio t'ora,'alis anterior an$ *osterior sinistra in t'e let 1)

$ermatomes

Treatment

S#stemi, Me$i,ation :

!nti/iral : !,#,lo/ir 5 x 8 mg or $a#s;

!nalgeti, : Meenami, a,i$ ) x 5 mg

1o*i,al Me$i,ation :

!**l# sali,il tal, 2< o/er t'e lesion

Education

". Do not tou,' or s,rat,' o/er t'e lesion.

2. 1a&e a rest an$ $on=t $o a lot o a,ti/it# $uring " ee&

). Don=t arai$ i t'e lesion a**ear more t'an beore0 be,ause t'e a,ti/e *'ase o

t'e ine,tion t'at ill be least in " ee&.

(. !ter " ee& lesion ill be ,ruste$ an$ 'eals normall# an$ sometimes ill get

a *ain an$ burn sensation o/er t'e lesion

5. 1a&e a me$i,ine routinel# as *res,ribe$.

Prognosis

>uo !$ +itam : Dubia at bonam

>uo !$ Fun,tionam : Dubia at bonam

>uo !$ Sana,tionam : Dubia at bonam

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Se,on$ /isit at Se*tember "t'0 2")

The Chief Complain :

t,'# an$ burning sensation o t'e *re/ious lesion an$ arise ne lesion on t'e let arm

sin,e ( $a#s ago.

History of present illness:

Patient ,om*laine$ it,'# an$ burning sensation o t'e *re/ious lesion. Some o t'e

lesion alrea$# ,ruste$0 but anot'er lesion still *rominent. " $a# ater a$mission to

'os*ital0 *atient also oun$ a ne lesion on t'e let arm. 1'e lesion as same it' t'e

*re/ious lesion on t'e let t'orax. !t irst0 *atient oun$ re$$is' ras' aroun$ 'er let

arm t'en ater " $a# s'e oun$ t'e same /esi,les it' er#t'ematous base it' *ain0

it,'# an$ burning sensation aroun$ 'er let in ront an$ ba,& si$e arm. No t'e lesion

on arm as alrea$# ,ruste$ too. Patient also ,oness t'at s'e routinel# ta&e a me$i,ine

as *res,ribe$ an$ eel more better t'an beore.

Dermatologi, status :

!

? D

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Figure 2. Se,on$ /isit at Se*tember "t'0 2"). 3rou* /esi,les an$ bullous on an

er#t'ematous base it' lesion in t'e let 1) $ermatomes let si$e t'orax an$ ma,ula

er#t'ematous base it' ,ruste$ lesion in t'e let 12 $ermatomes. !. %esion on let

si$e t'orax. . %esion on ba,& si$e t'orax. ?0 D. Ne lesion on ront an$ ba,& arm.

Dermatologi, status :

a4r 1'ora,'alis sinistra et anterior an$ *osterior oun$ grou* /esi,les an$ bullous on

an er#t'ematous base it' some lesion alrea$# ,ruste$0 osteriorm arrangement0

some lesion are ,onluens an$ t'ere is normal s&in among t'e lesion0 milier to

lenti&uler sie0 an$ unilateral $istribution in t'e let 1) $ermatomes.

a4r umerus sinistra et anterior an$ *osterior oun$ ma,ula er#t'ematous it' ,ruste$

lesion0 osteriorm arrangement0 some lesion are ,onluens0 milier sie an$ unilateral

$istribution in t'e let 12 $ermatomes.

Treatment

S#stemi, Me$i,ation :

!nalgeti, : Meenami, a,i$ ) x 5 mg

1o*i,al Me$i,ation :

!**l# Mu*ira,in oint o/er t'e lesion ) x "

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DISCSSIO!

er*es oster s'ingles; is an a,ute0 sel-limiting0 /esi,ular eru*tion o,,urring

in a $ermatomal $istribution 'i,' is ,ause$ b# a re,ru$es,en,e o Varicella zoster

/irus. 1'e ,'ara,teristi, ras' an$ asso,iate$ *ain o,,ur 'en /ari,ella-oster/irus0

'i,' be,omes $ormant in sensor# ganglia olloing *rimar# /ari,ella-oster /irus

ine,tion is rea,ti/ate$0 oten in asso,iation it' $e,lining ,elular immunit#

asso,iate$ it' a$/an,ing age.60

1'e in,i$en,e o 'er*es oster is ".5 to ). *er " *er #ear in *erson #ears

in all ages an$ to "" *er " *er #ear in *ersons o/er 6 #ears o age in Euro*ean

an$ Nort' !meri,an stu$ies.elo t'e age o (50 t'e annual in,i$en,e is less t'an "

in " *ersons6.1'e ma@or ris& a,tor or 'er*es oster is in,reasing age0 unli&e

le/els o /irus s*e,ii, antibo$ies ,orrelates it' *rote,tion against 'er*es oster. 1'e

ris& is 'ig'er or omen t'an man0 an$ or *ersons it' a amil# 'istor# o 'er*es

oster t'an or t'ose it'out su,' ba,&groun$8. !,,or$ing to t'e ,ase0 *atient is

emale in ages "8 #ears 'i,' is $oes not it it' in,i$en,e o 'er*es oster base$ on

t'e t'eor#.

Varisella zostervirus passes from lesions in the skin and mucosal surfaces into

contagious endings of sensory nerves and is transported centripetally up the sensory

fibers to the sensory ganglia. In the ganglia, the virus establishes a latent infection that

persists for life. Herpes zoster occurs most often dermatomes in which the rash of

varicella achieves the highest density division of the trigeminal nerve and by spinal

sensory ganglia from T1 to L2. Although the latent virus in the ganglia retains its

potential for full infectivity, re-activation is sporadic and infrequent, and infectious

virus doesnt appear to be present during latency. The mechanisms involved in re-

activation has been associated with immunosuppression, emotional stress, irradiation

of the spinal column, tumor involvement in the cord, local trauma, surgical of spine

and frontal sinusitis. VZV may also reactivate and would be expected to stimulate and

sustain host immunity to VZV6.

The incubating infection is partially contained by innate host defenses

(interferon, natural killer cells) and by developing VZV- specific immune responses.

In most individuals, virus replication eventually overwhelms these developing host

defenses, so that approximately 2 weeks after infection, a much larger (secondary)

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viremia and associated symptoms and lesion occur. Skin lesions appear in successive

crops, reflecting a cyclic viremia, which in the normal host is terminated after

approximately 3 days by VZV-specific humeral and cellular immune responses. VZV

may also reactivate without producing overt disease. The small quantity of viralantigens released during such contained re-activations would be expected to stimulate

and sustain host immunity to VZV6.

A'en +7+-s*esii, ,ellular immunit# alls belo some ,riti,al le/el0 re-

a,ti/ate$ /irus ,an no longer be ,ontaine$. +irus multi*lies an$ s*rea$s it'in t'e

ganglion0 ,ausing neuronal ne,rosis an$ intense inlammation0 a *ro,ess t'at is oten

a,,om*anie$ b# se/ere neuralgia. ne,tious +7+ t'en s*rea$s $on t'e sensor#

ner/es0 ,ausing intense neuritis an$ is release$ rom t'e sensor# ner/e en$ings in t'es&in0 'ere its *ro$u,e t'e ,'ara,teristi, ,luster o oster /esi,les6.

Figure ). Pat'o*'#siolog# o 'er*es oster ine,tion6

1'e ,lini,al eatures o a,ute oster is /ariable. er*es oster usuall# begins

it' a *ro$rome su,' as *ain0 it,'ing or tingling on t'e area t'at be,omes ae,te$.

1#*i,all#0 *atients ex*erien,e 'ea$a,'e0 malaise an$ sometimes *'oto*'obia or

e/er. !bnormal sensation or *ain0 oten $es,ribe$ as burning0 t'robbing or stabbing0

o,,urs in a**roximatel# 5< o *atients an$ ma# be t'e irst noti,eable eature. Bten

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*ruritus in t'e ae,te$ region is t'e most *rominent eature. ?utaneous in/ol/ement

ma# be *at,'# or ,onluent0 it' s&in ,'anges beginning it' re$ness an$

inlammation olloe$ b# t'e $e/elo*ment o ,luster o small or ,lear /esi,les. 9

!,,or$ing to t'e ,ase0 *atient e/er elt 'er bo$# be,oming atigue an$ also get

e/er or a e $a# t'at in$i,ate *ro$romal state o 'er*es oster ,lini,al eatures. S'e

also ex*erien,e$ 'ea$a,'e0 *ain an$ it,'# on t'e lesion. 1'is ,on$ition *resumabl#

be,ause o *atient 'a$ a lot o a,ti/it# an$ be,ome ea& in last t'ree $a#s.

1'e ras' o 'er*es oster oten *re,e$e$ b# tingling0 it,'ing0 or *ain or a

,ombination o t'ese; or 2 to ) $a#s0 an$ t'ese s#m*toms ,an be ,ontinuous or

e*iso$i,. 1'e ras' begins as ma,ules an$ *a*ules0 'i,' e/ol/e into /esi,les an$ t'en

*ustules. Ne lesions a**ear o/er a *erio$ o ) to 5 $a#s0 oten it' illing in o t'e

$ermatome $es*ite anti/iral treatment. 1'e ras' usuall# $ries it' ,rusting in to "

$a#s. ?'ara,teristi,s o *ain asso,iate$ it' 'er*es oster /ar#. Patients ma# 'a/e

*arest'esias e.g.0 burning an$ tingling;0 $#sest'esia altere$ or *ainul sensiti/it# to

tou,';0 allo$#nia *ain asso,iate$ it' non*ainul stimuli;0 or '#*erest'esia

exaggerate$ or *rolonge$ res*onse to *ain;. Pruritus is also ,ommonl# asso,iate$

it' 'er*es oster.5 ase$ on t'is ,onsi$eration *atient also eel *ain0 e/er0 an$

malaise o,,ur beore er#t'ematous *a*ules $e/elo* in t'e area o t'e ae,te$

$ermatome. 1'e /esi,les $e/elo* o/er se/eral $a#s0 ,rusting o/er as $a# an$ ne

lesion as a**ear at least ) $a#s ater *re/ious lesion. t be,ause t'e in,ubation

*erio$ o 'er*es oster is -"$a#s6.

1'e ras' o 'er*es oster is $ermatomal an$ $oes not ,ross t'e mi$line0 a

eature t'at is ,onsistent it' rea,ti/ation rom a single $orsal-root or ,ranial-ner/e

ganglion. 1'e t'ora,i, 5)


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Figure 2. Dermatomes in/ol/e$ in 'er*es oster"

# its ,lasi,,al maniestation0 t'e signs an$ s#m*toms o oster are usuall#

$istin,ti/e enoug' to ma&e an a,,urate ,lini,al $iagnosis on,e t'e ras' 'as a**eare$.5

t'us0 *atient on t'is ,ase is $iagnose$ it' 'er*es oster at region t'ora,alis sinistra

in t'e let 1) $ermatomes.

?urrentl# t'e treatment o 'er*es oster in mil$ s'ingles is s#m*tomati,0 it'

rest0 analgesia an$ blan$ $r#ing *re*arations su,' as ,alamine lotion. Se,on$ar#

ba,terial ine,tion ma# reCuire a to*i,al antise*ti, or antibioti,. More se/ere ,ases

ma# be treate$0 i seen it'in (8 'ours o onset0 it' oral a,i,lo/ir 8 mg 5 times

*er $a# or $a#s; or am,i,lo/ir5 mg on,e $ail# or $a#s; 'i,' *romote

resolution0 re$u,e t'e /iral s'e$$ing time an$ ma# re$u,e *ost-'er*eti, neuralgia.

Similarl#0 t'e *atients as in t'is ,ase is gi/en an anti/iral me$i,ation0 'i,' is oral

!,#,lo/ir i/e times $ail# it' $oses 8 mg or $a#s6.

!nti/iral t'era*# is t'e ,ornerstone in t'e management o 'er*es oster. Sin,e

anti/iral t'era*# $oes not re$u,e t'e rate o osterasso,iate$ *ain0 ,lini,ians ma#

un$era**re,iate t'e tremen$ous beneit t'ese anti/iral $rugs *ro/i$e. 1'e main

beneit o t'era*# is in re$u,tion o t'e $uration an$ se/erit# o osterasso,iate$

*ain9.

1'e *rognosis o 'er*es oster in t'is ,ase is $ubia at bonam. er*es oster ma#

be atten$e$ b# neurologi, ,om*li,ations o 'i,' PN Post er*eti, Neuralgia; is

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t'e most ,ommon an$ im*ortant. Patiens it' PN ma# suer rom ,onstant *ain

$es,ribe$ as burning0 a,'ing0 t'robbing;0 intermittent *ain stabing0 s'ooting;0 or

stimulus-e/o&e$ *ain0 in,lu$ing allo$#nia ten$er0 burning0 stabbing;. PN 'as been

/ariabl# $eine$ as an# *ain ater 'ealing or an# *ain " mont'0 ) mont's0 ( mont's or

6 mont's ater ras' onset0 it' most re,ent $einitions o,using on 9 to "2 ater

ras' onset. !ge is t'e most signii,ant ris& a,tor or PN. ?lini,all# signii,ant *ain

lasting ) mont's or more is rare in immuno,om*etent *ersons #ounger t'an 5 #ears

o age6. ase$ on t'is ,ase0 *atient also $on=t 'a/e PN 'i,' is in/ol/e$ b# ol$er

age t'an #ounger.

Most *eo*le re,o/er ,om*letel# rom an a,ute e*iso$e it' no *ain an$ s&in

,olor returns to normal. er*es oster ,omes ba,& in onl# about 2< o *eo*le0 but in

u* 2 < o *eo*le it' + !DS. %ong term ,om*li,ations su,' as *ost-'er*eti,

neuralgia0 ma# ,ontinue or mont's an$ man# #ears. 1'e $isease also ma# ,ause

/ar#ing $egrees o s&in $is,oloration0 *rimaril# $ar&ening.

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Case Report Kulit(1)(1)

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