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Herpes gestationis
Herpes gestationis A report
of 2 cases
ST.4NLEY
I’.
ROBERT JOHN New
.4. R.
Orlear~~,
WEGR\‘N.
M.D.
MARKS,
B.4CGII.
JR..
M.D.
M.D.
Loui~ia7~(~
13 E c .4 1’ 5 E of the rarity of herpes gestationis and the therapeutic problem it presents, we should like to add to the literature two recent cases treated with lipoproteinnucleic acid i Re ticulosc ‘1 Herpes gestationis is probably a variety of dermatitis herpetiformis. It most cornmanly develops after the third to fourth \vcJeli of gestation in 1 of Ii.000 to 4,000 pregnancies and may recur with successive* pregnancies. Tklivery usually coincides with tlte disappearance of the lesions. liecurrcances , remissions, and exacerbations are not uncommon. Thr lesions may be associatcd with rnild constitutional distrlrbances. ‘1’1~ etiology is ohscure: psychiatric. infectious, menstrual. puerpcral, renal. viral. and allergic factors have been implicated. ‘I‘hclrsions may be vesicular. t,rythernatousF bullous, pal171lar~ or pustular. They are usualh~
Lipoprotein-nucleic acid (Reticulose:i is a protein complex combining a protein with organic lipids and nucleic acid. It is desensitized and, therefore, free from sensitizing properties. Experience in animals and humans has shown it to be nontoxic. It k standardized at a pH of 7.5 and is extrcmel! stable. 1 ts mode of action is Pssc’ntiallv LO tlnhance and accelerate leukocyte response. increase antibody production, and stimulate phagocytosis. It has been used with success on a varietv of viral svndromes. That rcconlt’vmended dosage is 2 c.c. intramuscularly rlry 4 to 6 hours. However, dosages should be adjilsted to clinical findin,gs.“-’
and
812
Vdume Number
79 4
sulfate (Mol-Iron) and the nausea was controlled with 15 mg. of prochlorperazine spansules at bedtime. The patient was followed at monthly intervals until the eighth month of gestation. During the eighth month she was followed at twoweek intervals and during the ninth month at weekly intervals. Serial urinalyses were negative for albumin. The average blood pressure was 120/70. Hemoglobin on Feb. 25, 1959, was 11.25 Gm. per cent and on March 25, 1959, was 11.0 Gm. per cent. On April 8 the patient developed a pruritic crythrmatous papulovesicular dermatitis involving her arms and axillary folds bilaterally. At this time she was seen in the Out-Patient Clinic and presented on examination a rather typical case of herpes gestationis. She was treated with 50 mg. of diphenhydramine hydrochloride 3 times a day for one day withous improvement. On April 15 the dermatitis became characterized by clusters of small bullae, although there was no extension of the involved areas. There was intense burning and itching of the involved areas. Dermatological consultation confirmed the initial diagnosis. The patient was started on 2 C.C. of lipoprotein-nucleic acid intramuscularly daily for 3 consecutive days. Within 2 hours after the initial dose, the patient noted marked symptomatic relief of pruritus and burning. On the second day the patient was asymptomatic, and there was definite regression of the bullae. By the third day the bullae had dried and had begun to crust and disappear. On April 20, 1959, the patient was admitted to USPHS Hospital, New Orleans, with a history of cramping pain in the lower back for 6 hours’ duration, accompanied by a bloody show. Physical examination and review of systams on admission revealed a gravid woman at term and in labor with no evidence of any new lesions. After 5% hours of labor the patient was delivered of a full-term viable healthy infant weighing 7 pounds. The estimated blood loss was 50 C.C. The puerperium was uneventful except for an area of thrombophlebitis in the right forearm. This was thought to arise from an intravenous injection of 50 mg. of promazine given during labor. This cleared with warm s:lline soaks. The infant’s condition was good, and she thrived on breast feeding. Mother and infant were discharged on April 26, 1959, in good health. There has been no recurrence of the lesions post partum.
Herpes
gestationis
813
Case 2. Mrs. C. was a 34-year-old white woman, gravida viii, para vi, who had had one abortion. The estimated date of confinement was June 29, 1959, and the last menstrual period was 8 months prior to her fisrt visit to the USPHS prenatal clinic, May 15, 1959. She gave a history of having had a normal prenatal course except for the appearance of a rash on various parts of her trunk and extremities beginning about the third month of gestation. She stated that with each of her pregnancies at about the third or fourth month this rash had appeared. It was characterized by vesicles and sometimes pustules accompanied by itching and burning. It gradually regressed following delivery. She stated they had been treated by local and systemic antibiotics, creams, and lotions without improvement. The physical examination and review of systems on the initial visit revealed an obese white woman; abdominal and pelvic findings were consistent with a 32 weeks’ gestation. The \ertex was floating; fetal heart rate was 140 in the left lower quadrant. Over the scapular regions, the anterior chest, abdomen, and extremities, more marked over the flexor surfaces, were crops of erythematous papular lesions. Some had formed vesicles and others were crusted pustular lesions. The eruption caused severe itching and burning. The remainder of the physical examination was essentially normal. The laboratory data on May 15, 1959, showed a leukocyte count of 16,900, neutrophils 32, lymphocytes 12, monocytes 2, eosinophils 3. The hemoglobin was 10.4 Gm. per cent; blood, Group A, Rh positive. Urinalysis, serological test for syphilis, and chest x-ray findings were normal. Repeat leukocyte count on May 21, 1959, was 8,000 with neutrophils 74, lymphocytes 24, eosinophils 2, and hemoglobin of 11 Cm. per cent. The patient was given routine prenatal care and instructions. She was begun on Mol-Iron, one tablet, three times daily. In addition, Reticulose, 2 C.C. intramuscularly 4 times a day, was started. This was continued for 5 days when the patient was symptomatically better with no itching or burning of the skin lesions. She was continued on Reticulose, 2 C.C. every other day, for 4 doses. At the end of 2 weeks of therapy she was asymptomatic. No new vesicles or pustules had formed and the previously present lesions appeared to he scarring and healing. Examination on June 12 showed further resolution of lesions. She is now receiving routine prenatal care.
814
Wegryn,
Marks,
and
Bough
Comment Two wntrd.
C~SCS of her~x:s gestationis Both patients were noted
are Ix”to have
REFERENCES
1. Ruswll, R., and Thorne. N. A.: Hrit. J. Dermat. 69: 339, 1957. 2. Ormsby, 0. S., and Montgomery, H.: Diseases of the Skin, ed. 8, Philadelphia, 1954, Lea and Fcbiser & 7 pp. ,+24-426.
syqtornatic and IiIJoprotein-nucleic
clinical iniprovenient acid (Reticulose‘I .
on
3. .Anderson, R. Il., and Thompson, R. M.: L’irginia M. Month. 84: 347, 1957. I. Thompson, R. M.: Mil. Surqwn 110: 51, 1952.
5, Chemic,o I.aboratories, Inc., Miami, Personal rommunic.ation.
Florida:
of 2 cases
ST.4NLEY
I’.
ROBERT JOHN New
.4. R.
Orlear~~,
WEGR\‘N.
M.D.
MARKS,
B.4CGII.
JR..
M.D.
M.D.
Loui~ia7~(~
13 E c .4 1’ 5 E of the rarity of herpes gestationis and the therapeutic problem it presents, we should like to add to the literature two recent cases treated with lipoproteinnucleic acid i Re ticulosc ‘1 Herpes gestationis is probably a variety of dermatitis herpetiformis. It most cornmanly develops after the third to fourth \vcJeli of gestation in 1 of Ii.000 to 4,000 pregnancies and may recur with successive* pregnancies. Tklivery usually coincides with tlte disappearance of the lesions. liecurrcances , remissions, and exacerbations are not uncommon. Thr lesions may be associatcd with rnild constitutional distrlrbances. ‘1’1~ etiology is ohscure: psychiatric. infectious, menstrual. puerpcral, renal. viral. and allergic factors have been implicated. ‘I‘hclrsions may be vesicular. t,rythernatousF bullous, pal171lar~ or pustular. They are usualh~
Lipoprotein-nucleic acid (Reticulose:i is a protein complex combining a protein with organic lipids and nucleic acid. It is desensitized and, therefore, free from sensitizing properties. Experience in animals and humans has shown it to be nontoxic. It k standardized at a pH of 7.5 and is extrcmel! stable. 1 ts mode of action is Pssc’ntiallv LO tlnhance and accelerate leukocyte response. increase antibody production, and stimulate phagocytosis. It has been used with success on a varietv of viral svndromes. That rcconlt’vmended dosage is 2 c.c. intramuscularly rlry 4 to 6 hours. However, dosages should be adjilsted to clinical findin,gs.“-’
and
812
Vdume Number
79 4
sulfate (Mol-Iron) and the nausea was controlled with 15 mg. of prochlorperazine spansules at bedtime. The patient was followed at monthly intervals until the eighth month of gestation. During the eighth month she was followed at twoweek intervals and during the ninth month at weekly intervals. Serial urinalyses were negative for albumin. The average blood pressure was 120/70. Hemoglobin on Feb. 25, 1959, was 11.25 Gm. per cent and on March 25, 1959, was 11.0 Gm. per cent. On April 8 the patient developed a pruritic crythrmatous papulovesicular dermatitis involving her arms and axillary folds bilaterally. At this time she was seen in the Out-Patient Clinic and presented on examination a rather typical case of herpes gestationis. She was treated with 50 mg. of diphenhydramine hydrochloride 3 times a day for one day withous improvement. On April 15 the dermatitis became characterized by clusters of small bullae, although there was no extension of the involved areas. There was intense burning and itching of the involved areas. Dermatological consultation confirmed the initial diagnosis. The patient was started on 2 C.C. of lipoprotein-nucleic acid intramuscularly daily for 3 consecutive days. Within 2 hours after the initial dose, the patient noted marked symptomatic relief of pruritus and burning. On the second day the patient was asymptomatic, and there was definite regression of the bullae. By the third day the bullae had dried and had begun to crust and disappear. On April 20, 1959, the patient was admitted to USPHS Hospital, New Orleans, with a history of cramping pain in the lower back for 6 hours’ duration, accompanied by a bloody show. Physical examination and review of systams on admission revealed a gravid woman at term and in labor with no evidence of any new lesions. After 5% hours of labor the patient was delivered of a full-term viable healthy infant weighing 7 pounds. The estimated blood loss was 50 C.C. The puerperium was uneventful except for an area of thrombophlebitis in the right forearm. This was thought to arise from an intravenous injection of 50 mg. of promazine given during labor. This cleared with warm s:lline soaks. The infant’s condition was good, and she thrived on breast feeding. Mother and infant were discharged on April 26, 1959, in good health. There has been no recurrence of the lesions post partum.
Herpes
gestationis
813
Case 2. Mrs. C. was a 34-year-old white woman, gravida viii, para vi, who had had one abortion. The estimated date of confinement was June 29, 1959, and the last menstrual period was 8 months prior to her fisrt visit to the USPHS prenatal clinic, May 15, 1959. She gave a history of having had a normal prenatal course except for the appearance of a rash on various parts of her trunk and extremities beginning about the third month of gestation. She stated that with each of her pregnancies at about the third or fourth month this rash had appeared. It was characterized by vesicles and sometimes pustules accompanied by itching and burning. It gradually regressed following delivery. She stated they had been treated by local and systemic antibiotics, creams, and lotions without improvement. The physical examination and review of systems on the initial visit revealed an obese white woman; abdominal and pelvic findings were consistent with a 32 weeks’ gestation. The \ertex was floating; fetal heart rate was 140 in the left lower quadrant. Over the scapular regions, the anterior chest, abdomen, and extremities, more marked over the flexor surfaces, were crops of erythematous papular lesions. Some had formed vesicles and others were crusted pustular lesions. The eruption caused severe itching and burning. The remainder of the physical examination was essentially normal. The laboratory data on May 15, 1959, showed a leukocyte count of 16,900, neutrophils 32, lymphocytes 12, monocytes 2, eosinophils 3. The hemoglobin was 10.4 Gm. per cent; blood, Group A, Rh positive. Urinalysis, serological test for syphilis, and chest x-ray findings were normal. Repeat leukocyte count on May 21, 1959, was 8,000 with neutrophils 74, lymphocytes 24, eosinophils 2, and hemoglobin of 11 Cm. per cent. The patient was given routine prenatal care and instructions. She was begun on Mol-Iron, one tablet, three times daily. In addition, Reticulose, 2 C.C. intramuscularly 4 times a day, was started. This was continued for 5 days when the patient was symptomatically better with no itching or burning of the skin lesions. She was continued on Reticulose, 2 C.C. every other day, for 4 doses. At the end of 2 weeks of therapy she was asymptomatic. No new vesicles or pustules had formed and the previously present lesions appeared to he scarring and healing. Examination on June 12 showed further resolution of lesions. She is now receiving routine prenatal care.
814
Wegryn,
Marks,
and
Bough
Comment Two wntrd.
C~SCS of her~x:s gestationis Both patients were noted
are Ix”to have
REFERENCES
1. Ruswll, R., and Thorne. N. A.: Hrit. J. Dermat. 69: 339, 1957. 2. Ormsby, 0. S., and Montgomery, H.: Diseases of the Skin, ed. 8, Philadelphia, 1954, Lea and Fcbiser & 7 pp. ,+24-426.
syqtornatic and IiIJoprotein-nucleic
clinical iniprovenient acid (Reticulose‘I .
on
3. .Anderson, R. Il., and Thompson, R. M.: L’irginia M. Month. 84: 347, 1957. I. Thompson, R. M.: Mil. Surqwn 110: 51, 1952.
5, Chemic,o I.aboratories, Inc., Miami, Personal rommunic.ation.
Florida: