A STUDY OF THE DERMATOMERS IN HERPES ZOSTER
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Bulletin of the Transilvania University of Braşov • Vol. 2 (51) - 2009
Series VI: Medical Sciences
A STUDY OF THE DERMATOMERS IN
HERPES ZOSTER
C. COSTACHE1 D. COSTACHE1
Abstract: We have performed a clinical study on a number of 53 herpes zoster
patients who were hospitalized in the Infectious Diseases Hospital of Brasov in
2008. In the studied group we focused on the affected body areas, on the number
of dermatomes, distribution on sexes and age groups, as well as on the possible
immunodepressing factors triggered by associated chronic diseases.
Key words: dermatome, herpes zoster.
1. Introduction As a result of the accumulation of viral
particles, the cell growth and disintegrate
Herpes Zoster is a type of neurodermitis releasing new vitrions. For the replication,
caused by the reactivation of the varicella- the virus uses the proteic device of the host
zoster virus (VZV) as a result of immuno- cell, which instead of producing cell
depression, after natural immunization proteins will produce viral proteins. By
caused by chickenpox the patients suffered means of electronic microscopy it has been
from in their childhood. The virus remained noticed that immature viral cells start
latent in the nervous ganglia and was re- appearing 12 hours after the onset of the
activated by a series of factors which harm infection. We do not know yet all the
the body. This virus harms the sensitive, details concerning viral latency and
dorsal roots of the spinal or cranial nerves, reactivation, but with the aid of PCR
the disease manifesting itself through skin techniques the VZV genome has been
rash with blisters, forming a stripe on the shown to exist at the level of the neurons,
dermatomes corresponding to the affected each infected neuron having 2 or 3 copies
sensitive nerves. The varicella-zoster virus of viral DNA. Copies of the infecting DNA
belongs to the Herpes Viridae family. It is have been reported at the level of the non-
made up of a nucleocapsida that contains a neuronal satellite cells in the sensitive
double-stranded DNA and a lipid layer, ganglia. By means of in-situ hybridization
whose surface presents a large number of it has been estimated that the VZV remains
spicules glycoproteins. The varicella-zoster dormant in 0.01-0.03% of the neuronal
virus can be cultivated on continuous or population. The reactivation consists in the
discontinuous human or simian cell resumption of the viral replication, the
lines. The reproduction of the varicella- result of which is the inflammation of the
zoster virus is obtained by viral replication. ganglion, and thus an intense neuralgia
Each infected cell is capable of providing the along the affected nerve and the centrifugal
material necessary for the production of over propagation of the VZV along the nerve
100 new viral particles. ramifications towards the dermatomes.
¹Faculty of Medicine, Transilvania University of Brasov.
20 Bulletin of the Transilvania University of Braşov • Vol. 2 (51) - 2009 • Series VI
Once in the skin, the VZV will multiply 2. Aims
intensely in the deep layers of the
epidermis, triggering specific cytopahtic The present paper aims at highlighting
effects: giant cells, with multiple nuclei the possible dermatomeric areas, the
and with eozinophilic intranuclear incriminated factors in reactivating the
inclusions. These cell lesions together with varicella-zoster virus and the incidence of
the local inflammation and the immune the disease with respect to sexes and age
response of the host will bring about the groups.
formation of blisters.
3. Material and Method Employed
1.1. Clinical Presentation
The study has been performed on a
The incubation period is not known due to group of 53 patients with ages between 15
the fact that herpes zoster consists in the and 82, who were hospitalized in the
reactivation of the dormant virus. The pre- Hospital of Infectious Diseases of Brasov
eruptive period lasts a few days and in the year 2008. The 53 patients
manifests itself through intense neuralgia at diagnosed with herpes zoster and treated
the level of one or two dermatomes specific for it were divided into 3 age groups:
of the affected nerve. The burning pain may teenagers (15-19), adults (20-59) and
be accompanied by fever and skin elderly people (60-82).
hypersensitivity, which may lead to
confusions concerning the diagnosis: 3.1. Pathologic Anatomy
pleuritis, pneumonia, myocardial arrest,
appendicitis, kidney or biliary colics.The In order to understand the evolution of
eruptive period is marked by the emergence the disease, we thought it appropriate to
of vesicles and lasts 2-3 weeks. The eruption take into account the neuro-anatomy of the
in the case of herpes zoster is characterised affected areas. Thus, the tegument of each
by radicular distribution which affects only area is divided into dermatomes, specific
the dermatomes specific of the infected innerved areas with sensitive nervous
nerve; the distribution is unilateral and stops fibres that belong to one spinal nerve.
at the anterior and dorsal midline, having a There are 31 pairs of spinal nerves: 8
‘belt’ character. The eruptive elements cervical, 12 thoracic, 5 lumbar, 5 sacral
follow the same stages as chickenpox: and 1 coccygeal. The sensory information
macula, papula, blisters and crust. The at the level of each dermatome is taken
vesicles form within 12-14 hours, grouped in over by the sensitive nervous fibres and
hives, then in confluent polycyclic blisters. directed to the nervous roots corresponding
The vesicles become cloudy in the 5th day, to the respective dermatome. In the herpes
they crust over between the 7th and the 10th zoster on the chest, the hives of blisters
days; after 2-3 weeks the crusts fall off, appear in the area where the sensitive
leaving pinkish-whitish scars. The chronic nervous fibres of the inter-costal nerves
period or the post-zoster neuralgia is emerge. Sometimes, due to the fact that the
represented by the pre-existent pain which neurons in the anterior medullary horns are
persists 4 to 12 weeks after the onset of the harmed, it may come to paralysis or
eruption or by the re-occurring pain that lasts palsies, vegetative or trophic disfunctions
for about 30 days. If not treated properly, (vasomotric, secretion).
post-zoster neuralgia may lasts for years, The herpes zoster ophtalmicus appears as
having even a higher intensity. a result of the reactivation of the dormantCostache, C. et al.: A Study of the Dermatomers in Herpes Zoster 21
VZV in the Gasser ganglion situated on the the lesions. Ocular complications are the
trajectory of the sensitive fibres of the result of the inflammations (stromal
trigeminal nerve. The ophthalmic branch keratitis, uveitis), of viral replication
of the trigeminal nerve has 3 sub-branches: (lesions of the cornea), trophic disfunctions
frontal, lachrymal and nasal. The VZV can (neuro-paralitic keratitis) and ischemia.
affect only one sub-branch. The diagnosis
depends on the topographic localisation of
Fig. 1. Dermatomers- antero-posterioara22 Bulletin of the Transilvania University of Braşov • Vol. 2 (51) - 2009 • Series VI
Fig. 2. Dermatomers- vedere laterala
4. Findings and Comments subjects). When brought to the hospital,
the patients showed the following
The distribution on age groups and sexes symptoms: fever (56%), head aches (29%),
shows a higher incidence of the disease in pain (94%), skin rash (98%), itching
the case of females (36 persons, (88%). Of the total number of subjects, 24
representing 68% of the total number of persons (45%) suffered from post-zoster
subjects) as opposed to men (17 persons neuralgia. The elderly persons also
representing 32% of the total number of showed associated secondary pathologiesCostache, C. et al.: A Study of the Dermatomers in Herpes Zoster 23
which could have caused The most frequently affected nerves
immunodepression, such as lung problems were the intercostals (42%), followed by
(9%), liver problems (13%), kidney the lumbar nerves (17%), then the brachial
microlithiasis (9%), renal insufficiency (15%), the trigeminal (9%), the sacral (9%)
(6%), liver problems (6%), diabetes (8%), and the cervical nerves. In all the 5 cases in
ischemic cardiopathy (23%), anaemia which the trigeminal nerve was affected,
(9%), HTA (25%), obesity (13%), AIDS the ophthalmic sub-branch was infected. In
(4%), leukaemia (2%). All these have 30 (57%) cases we identified the infection
diminished the immunity of the patients, of a single dermatome, whereas multiple
creating a medium favourable for the dermatomeric localisations were identified
reactivation of the varicella-zoster virus. in 23 cases (43%). The areas affected in
The topographic localisation of the the latter are presented in table 2 below.
lesions differed among the 53 patients: in At the same time, we also detected a
48 cases, the lesions appeared along the number of non-pathogenic factors which
spinal nerves, whereas in the case of 5 could have contributed to the herpes zoster
patients, the lesions followed the trajectory infection, such as old age, stress or
of the cranial nerves, as follows (see table increased emotional tension, immuno-
no. 1): suppressant medication, irradiation or
inappropriate eating habits.
Dermatomeric distribution on cranial and spinal nerves. Table 1
Trigeminal Cervical nerves Brachial Intercostal nerves Lumbar nerves Sacral
nerve C1-C4 nerves T2-T12 L1-L4 nerves
C5-T1 L5-S4
5 48 22 9 5
Multiple dermatomeric localizations Table 2
Cervico-brachial Thoracic-brachial Thoracic -lumbar Lumbar-sacral Disseminated
3 (13%) 5 (22%) 3 (13%) 3 (13%) 9 (39%)
5. Conclusions 3. Our study shows that the most frequent
localisation occurs at the level of the
1. We noticed that the elderly people and intercostal nerves (42%), followed by
the adults are equally affected by the lumbar nerves (17%), then the
shingles (45% vs. 42%), while the brachial (15%), the trigeminal (9%),
young people and the teenagers are the sacral (9%) and the cervical nerves
less affected by this disease (13%). (8%).
2. We also noticed that females (68%) 4. The affection of a single dermatome
are more affected by the disease than has been recorded in (57%) of the
men (32%). cases as opposed to multiple
dermatomeric localisations (43%).24 Bulletin of the Transilvania University of Braşov • Vol. 2 (51) - 2009 • Series VI
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