Herpes generalisata associated with diabetes mellitus and pulmonary tuberculosis (A case report)RB Panwar, DK Kochar, BS Gupta, LK Bhatnagar, HC Saxena
Department of Medicine, S. P. Medical College and Associated Group of Hospitals, Bikaner (Rajasthan), India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 529170
Source of Support: None, Conflict of Interest: None
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.
Herpes Zoster skin lesions are usually localized but occasionally they may become disseminated, more commonly, if associated with following diseases, than it an otherwise normal individual: Hodgkin's disease and other lymphomas, corticosteroid therapy, various leukaemias radiation exposure,  and multiple myeloma. , The basis of the generalization o the lesions is thought to be alteration in host defence mechanism in the form of decrease in cell mediated immune response of the individual which is common in the patients suffering from above mentioned diseases.
We are presenting a case of Herpes Zoster Generalisata associated with diabetes mellitus, peripheral neuropathy and pulmonary tuberculosis. Such a combination has not been reported earlier in the available literature.
B.C., a 60 year old male, retired teacher was admitted on 13-12-1977 in the cottage ward of the Associated Group of Hospitals of S.P. Medical College, Bikaner as a known case of diabetes mellitus with peripheral neuropathy and pulmonary tuberculosis. He was receiving oral hypoglycaemic drug (Glibenclamide 5 mg daily) and two anti-tubercular drugs (PAS and INH). A thorough history of other medications was taken and it was found that he was not consuming anything except these drugs.
Blood: Hb-10.6 gm%,
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
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.
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,  multiple myeloma,  corticosteroid therapy and radiation exposure. 
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.  Similar conditions exist after exposure to radiations and corticosteroid therapy.  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. 
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. , 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.
Thanks are due to the Principal, S.P. Medical College and Superintendent, Associated Group of Hospitals, Bikaner, for their permission to report this case.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]