3. CASE REPORT
Name : Tn Y
Gender : Male
Age : 67 years old
Religion : Moslem
Status : Married
Address : Jl Malengkeri Komp. TVRI B7
Race : Indonesian
IDENTIFICATION
4. ANAMNESIS
Chief complaint
Patient complain of tingling and burning sensation at
the left lumbal region. 2 days after, small lesion
appear at the same site and spreading to the back.
Additional complain
None
History of disease
No family history of the same disease
History of renal stone, hypertension and diabetes
melitus
History of medication
treatment of hypertension and diabetes melitus
5. Progression of disease
The patient feel pain on his left lumbar region. He went
to medicine doctor and get the medication for his complain.
2 days later a lession appear with sensation of pain
worsening day by day.
6. PHYSICAL EXAMINATION
Generalised condition
• General condition : mild
• Consciousness : compos mentis
• Blood pressure : 150/100
• Heart rate : 88x/minute
• Respiratory rate : 20x/minute
• Body temperature : 37 ’C
• Height : 170cm
• Weight : 80 kg
Specific condition
• Head : normocephaly
• Eye (sclera / icterus) : (-)
• ENT : normal
• Neck : Normal
• Thorax : Normal
• Abdomen : Normal
• Extremity : Normal
• Localize pain : left lower abd
region
• anesthesi : (-)
14. Herper zoster is an illness caused by
infections with varicella virus.
15. Figure 1. Proposed pathogenesis of herpes zoster with establishment of
persistent but latent varicella–zoster virus in the sensory-nerve ganglia.
16. Pathogenesis
After this infection resolves, viral
particles remain in the dorsal root
or other sensory ganglia, where
they may lay dormant for years to
decades.
Once VZV is activated at
the spinal root or cranial
nerve neurons, an
inflammatory response
occurs
The inflammation in the
dorsal root ganglion can be
accompanied by
hemorrahagic necrosis of
nerve cells that result is
neuronal loss and fibrosis.
The ganglia become infected
hematogenously during the
viremia phase of varicella.
The frequency of the
dermatome involvement in
herpes zoster reflect the
ganglia exposed to
reactivating stimuli.
The primary infection,
chickenpox, is a
contagious and usually
benign febrile illness.
In this latent period, host
immunologic mechanisms
suppress replication of the virus,
but VZV reactivates when the host
mechanisms fail to contain the
virus
20. RECOMMENDED EXAMINATION
Tzank Test - searching for multinucleated
giant cells
PCR, electron microscopy, culture-
identification of virus
Serology (ELISA): most useful for
epidemiological studies.
21. Acyclovir 5 x 800 mg
Amitriptilin 2 x 12.5gr
Mefenamic acid 3 x 500mg
Fuson cream
TREATMENT
