Herpes generalisata associated with diabetes mellitus and pulmonary tuberculosis (A case report)

Correspondence Address:
R B Panwar
Department of Medicine, S. P. Medical College and Associated Group of Hospitals, Bikaner (Rajasthan)
India

Source of Support: None, Conflict of Interest: None

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PMID: 529170

An unusual case of Herpes Generalisata with diabetes mellitus and pulmonary tuberculosis is reported. This condition has beer, regularly reported in various immunologically suppressed states like Hodgkin's disease, other lymphomas and leukaemias, but its occur­rence with diabetes mellitus has been described for the first time in our case.

:: Introduction

:: Case report

DLC-P-79%, L-19%,

E-2%, B-0%.

Total serum proteins-5.9 gm%

Serum albumin-3.2 gm%

Serum globulins-2.7 gm%

Fasting Blood sugar-260 mg%

Serum creatinine-0.8 mg%

Serum cholesterol-218 mg%

E.S.R.-120 mm in 1st hour

(Westergren)

Urine Examination:

Albumin-Nil

Sugar-Present (++++)

Pus cells-Nil

R.B.Cs.-Nil

Ketone bodies-Negative

Skiagram chest P. A. view:

Heterogenous infiltration seen in the left infraclavicular region.

Based on these investigations and poor con­trol of his diabetes by oral hypoglycaemic agents, the patient was then controlled by Inj. Crystalline insulin after 15 days of his admis­sion. On the 16th day of his admission he start­ed complaining of severe pain in the back (right scapular and interscapular as well as in right axillary regions), On clinical examination, skin was not showing any abnormality. Chest was clear on auscultation. Skiagram chest was re­peated and showed the same lesions. He was put on analgesics but the pain persisted. On the 4th day of the onset of pain, redness ap­peared in these regions. He developed high grade continuous fever. On the 5th day papular eruptions were evident in the right interscapular, scapular, axillary and pectoral regions along the distribution of III, IV and V intercostal nerves on the right side (See [Figure 1] on page 170B). The intensity of pain also increased markedly. Three days later papules became generalised. First they spread over the abdomen followed by both upper limbs as well as over the back of the left side of the chest and then on both lower limbs (See [Figure 2],[Figure 3] and [Figure 4] on page 170B). The generalised rash of Herpes Zoster remained for 10 days and passed through the various stages i. e. vesicular, pustular and crusting. The lesions which appeared initially on the right side of the chest were the last to disappear.

Mantoux test done during the eruption stage was negative. It was negative even after 10 days of the disappearance of the lesion.

:: Discussion

Herpes Zoster skin lesions usually spread along the line of the nerve and remain localized on one side of the body. Their course depends on the host re­sponse and if there exists a condition as­sociated with depressed immune response, the lesions spread rapidly and sometimes become generalised. Such a phenomenon is commonly seen in Hodgkin's disease, other lymphomas, leukaemias, ^[4] multiple myeloma, ^[5] corticosteroid therapy and radiation exposure. ^[4]

The incidence of Herpes Zoster Gene­ralisata is maximum with Hodgkin's disease and other lymphomas. The possible explanation is thought to be a decreased immunological response, as antibodies are important in limiting the spread of viruses within the body pro­bably by quenching viraemia. ^[2] Similar conditions exist after exposure to radia­tions and corticosteroid therapy. ^[4] Im­mune suppression causes virus multipli­cation freely and hence lesions flare up.

In multiple myeloma the patient be­comes handicapped immunologically be­cause the gamma globulins in these cases do not provide immunological protection. ^[5]

Recent investigations have shown that in some cases of insulin dependent dia­betes mellitus there occurs a derange­ment of cellular immune response in the form of deranged blast cell transforma­tion and leucocyte migration inhibition i.e. cell mediated immunity. ^[1],[3] These may be the reasons of rapid spread of Herpetic lesions and to become Herpes Zoster Generalisatus.

The negative Mantoux test indicates a poor immunological status in our case. It seems that this patient developed Herpes Zoster Generalisatus probably because of existing depressed immunological re­sponse associated with diabetes mellitus.

:: Acknowledgements

Thanks are due to the Principal, S.P. Medical College and Superintendent, As­sociated Group of Hospitals, Bikaner, for their permission to report this case.

 

:: References

1.	Ahuja, M. M. S.: Autoimmunity and diabetes. J. Assoc. Phys. India, 24: 605­609, 1976.
2.	Hayword, A. H.: "Immuno-deficiency."1st Edition. Arnold Ltd., London, 1977, p. 6.
3.	MacCuish, A. C. and Irvine, W. J.: Auto-immunological aspects of diabetes mellitus. Clinics in Endocrinol. & Metab., 4: 435. 1975 as Quoted by Ahuja (1976).
4.	Merselis, J. G., Kaye, D. and Hook, E. W.: Disseminated Herpes Zoster-a report of 17 cases. Arch. Int. Med., 113: 679­686, 1964.
5.	Yaffee, H. S. and Greenberg, M. S.: Herpes Zoster resembling acute varicella associated with multiple myeloma. J. Amer. Med. Assoc., 175: 1008-1010, 1961.

Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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