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Herpes zoster (shingles)

Classification: - localized Herpes zoster: involvement of 1 or 2 dermatomes - disseminated Herpes zoster: involvement >= 3 dermatomes Etiology: - reactivation of latent Varicella zoster - not a marker of underlying malignancy [2] - risk may be increased in patients with chronic disease [15] - risk factors among younger patients (< 50 years) [23] - systemic lupus erythematosus - rheumatoid arthritis - inflammatory bowel disease - chronic obstructive pulmonary disease - asthma (RR=1.7) [29] - chronic kidney disease - type 1 diabetes - depression - patients with contraindications to Herpes zoster vaccine (lymphoma, HIV1) at highest risk [23] - immunocompromise due to chemotherapy [2] - association of reactivation (shingles) with trauma is tentative [19] - methotrexate in combination with a biological response modifier increases risk of Herpes zoster (22 vs 9 per 1000 person-years) [24] Epidemiology: 1) primarily occurs in the elderly & immunocompromised Incidence of shingles (no shingles vaccine) [8] annual incidence age (years) 0.2% < 50 0.5% 50-60 0.7% 60-70 1.0% 70-80 1.2% >= 80 2) may occur in children & young adults [3] 3) 7 times more frequent in homosexual men with HIV than in HIV-negative controls 4) no gender or race predilection 5) unlike chickenpox, shingles has no seasonal variation 6) may occur in children infected in-utero 7) risk independent of childhood varicella vaccination [6] or varicella vaccination programs in general [19] 8) recurrence within 3 years 1.4% [8] 9) recurrence within 8 years 6.2% [10] 10) patients with shingles may spread the varicella virus via direct contact with open shingles lesions or inhalation of aerosolized respiratory droplets [36] - disseminated Herpes zoster may involve the respiratory tract [2] Pathology: 1) ballooning degeneration of epidermal cells 2) intra-epidermal vesicle 3) histology indistinguishable from Herpes simplex 4) latent in dorsal root ganglion after primary infection 5) VZV reactivates presumptively with a decline in immunity 6) disseminated Herpes zoster may involve the respiratory tract [2] Clinical manifestations: 1) often presents as group vesicles on an erythematous base within a single dermatome [2] - malaise, fever, along with pain 2) pain a) generally precedes skin manifestations by several days b) pain is generally sharp, burning, may be severe c) distribution may or may not be dermatomal d) hyperesthesia may be present e) pain may persist after resolution of lesions (post Herpetic neuralgia) f) pain may occur in the absence of rash (zoster sine herpete) 3) rash a) erythematous maculopapules appear initially b) grouped lesions become vesicular in 12-24 hours c) distribution of lesions 1] linear clustering 2] unilateral distribution 3] rash stops at the midline 4] distribution or rash is dermatomal 5] adjacent dermatomes may be involved d) lesions may become pustular or hemorrhagic e) weeping followed by crusting over 10-12 days f) resolution of crusts, frequently with scarring within 2-3 weeks g) lesions appear in various stages of development & healing [11] 4) regional lymphadenopathy may be observed [36] 5) 5% of cases with non-specific prodrome * images [27,32] Laboratory: 1) diagnosis generally clinical, no laboratory tests usually required 2) Tzanck smear, direct antigen test, viral culture of lesion [4] 3) skin biopsy 4) HIV testing a) patients under 50 years of age, especially if lesions disseminate outside of the primary dermatome b) recurrent Herpes zoster [2] 5) see ARUP consult [12] Complications: 1) disseminated Herpes zoster with visceral involvement (liver, lung, brain) in immunocompromised patients [2,26] - involvement of >= 3 dermatomes & respiratory tract 2) pneumonia 3) cranial nerve palsies, segmental zoster paresis - partial facial nerve paralysis [38] 4) transverse myelitis 5) aseptic meningitis,m encephalitis 6) cerebral vasculitis 7) superinfection of lesions 8) post herpetic neuralgia 9) ophthalmic Herpes zoster (Herpes zoster ophthalmicus) - ophthalmic branch of the trigeminal nerve is affected - forehead extending over upper eyelid - unilateral cheek with ipsilateral side of nose - nasociliary branch of the ophthalmic nerve innervates tip of nose & cornea [43] - acute retinal necrosis may occur in patients with AIDS 10) Herpes zoster oticus (Ramsay-Hunt syndrome) - involvement of cranial nerve VII & cranial nerve VIII 11) patients with HIV have a higher incidence of shingles, but not of complications 12) shingles is contagious especially in early phase [3] Varicella may be transmitted to susceptible individuals 13) risk factor for cardiovascular event in weeks after episode of shingles [20,22] a) MI (RR = 1.5), TIA (RR= 2.4), stroke (RR = 1.6-1.7) b) risk greatest in the 1st 4 weeks c) risk declines to baseline after 26 weeks [22] - risk my persist for 1 year [33] d) Herpes zoster ophthalmicus & Herpes zoster in other branches of the trigeminal nerve increase stroke risk 3-fold relative to Herpes zoster in other dermatomes [22] e) antiviral lowers risk of stroke [22] 14) not associated with increased risk of cancer [14] 15) not associated with increased risk of dementia [39] - associated with a slight decreased risk of dementia [39] - patients with CNS involvement with increased risk of dementia (RR~2) [39] Differential diagnosis: 1) before eruption of rash, differential is broad 2) rash may resemble rash of Herpes simplex* 3) post herpetic neuralgia* * may masquerade as recurrent shingles [37] Management: 1) supportive a) symptomatic relief of pain - neuropathic pain - gabapentin or pregabalin ineffective [35] - amitriptylline or duloxetine - acetaminophen - NSAIDS: ibuprofen - opiates: hydrocodone, morphine, dilaudid - radicular nerve blocks - transcutaneous electrical nerve stimulation (TENS) - pulse radiofrequency generally inferior to TENS [41] - consult pain management specialist b) prevention of secondary infection - keep lesions clean c) contact precautions & airborne precautions for disseminated Herpes zoster [2] d) contact precautions alone for localized Herpes zoster [2] 2) referral to specialist a) lesions in distribution of the ophthalmic nerve, CN-V1 (zoster ophthalmicus): consult an ophthalmologist b) ear vesicles, diminished taste on the anterior 2/3 of the tongue, ipsilateral facial paralysis = Ramsay-Hunt syndrome: refer to ENT [2] c) when >= 3 dermatomes involved consider referral to infectious disease for treatment of disseminated varicella-zoster 3) antiviral agents a) antiviral therapy if initiated within 72 hours of rash onset [2,36] can: - lessen Herpes zoster pain - expedite healing of lesions - diminish incidence & severity of postherpetic neuralgia b) mild to moderate cases - famciclovir (Famvir) 500 mg TID for 7 days (post herpetic neuralgia) - acyclovir (Zovirax) 800 mg PO 5x/day for 7-10 days - valacyclovir 1 g PO TID for 7 days - within 72 hours of onset c) severe cases (CNS involvement, immunocompromised, multiple dermatomes) - acyclovir 12.4 mg/kg IV infusion over 1 hour every 8 hours for 5-7 days - vidarabine (Vira-A) 10 mg/kg/day infusion over 12 hours for 5-7 days - antiviral therapy for zoster ophthalmicus even if > 72 hours after lesion onset - both contact precautions & airborne precautions [2] d) foscarnet for acyclovir resistant Herpes zoster (rare) e) topical antiviral agents not useful 4) oral glucocorticoids a) symptomatic relief b) do not reduce incidence of post-herpetic neuralgia c) do not use without concomitant antiviral therapy [2] d) evidence insufficient to support use (do not use) [2] 5) acupucture - reduces incidence if postherpetic neuralgia & shortens treatment [40] - no effect on pain [40] 6) quarantine until all lesions heal to minimize transmission of Varicella zoster - contact precautions for localized zoster if immunocompetent & involvement of single dermatome [2] - contact precautions & airborne precautions if immunocompromised or disseminated zoster/involvement of multiple dermatomes [2] 7) Herpes Zoster vaccine a) cuts risk of shingles in elderly in 1/2 [5] b) diminishes incidence & severity of postherpetic neuralgia c) endorsed by CDC for patients > 60 years of age 8) if lesions become superinfected, antibiotics with Staphylococcus coverage (clindamycin, Keflex + Septra) 9) for ulceration, Restore dressing may be useful 10) be aware of post-herpetic neuralgia 11) patient education a) pain usually resolves over weeks-months b) expect scarring c) notification of contact - transmission will result in chickenpox in susceptible individuals

Interactions

disease interactions

Related

cerebral granulomatous angiitis chickenpox post Herpetic neuralgia Varicella [Herpes] zoster virus (VZV); human herpesvirus 3 (HHV3)

Useful

Herpes zoster (shingles) vaccine (Zostavax, Shingrix)

Specific

Herpes zoster mandubularis Herpes zoster ophthalmicus Herpes zoster oticus; Ramsay Hunt syndrome type 2 segmental zoster paresis

General

Herpes virus infection

References

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