Presented By

Shalina Shaik

PGY 3 Emory Family Medicine

Date: August 5, 2010

57 yo Hispanic male w/ DM, HTN, HLD presented w/rash x 2 days.

Rash extending to back

Herpes Zoster - Shingles

What is Shingles ( Herpes Zoster )

• Endogenous reactivation of latent VZV infection within the sensory ganglia

• Painful, unilateral vesicular eruption restricted to dermatomal pattern

Pathogenesis

Clinical Manifestations

• Rash : starts as erythematous papules, quickly evolve into grouped vesicles or bullae. Within 3 – 4 days

• Crust by 7 – 10 days • Occ 2 or 3 neighbouring dermatomes• Thoracic and lumbar dermatomes most

common• 20% have systemic symptoms: HA/

malaise/fever/fatigue

Rash pattern: thoracic dermatomes

Rash pattern : Cervical dermatomes

Shingles rash

Clinical Manifestations cont

• Acute neuritis : 75% have prodromal pain in the dermatome where the rash appears

• Can precede the rash days to week• Pain: burning, stabbing, pruritus, allodynia• Confused with angina/ cholecystitis/ renal

colic depending upon dermatome• Clinical dx. May need viral cx,

immunoflurescence or PCR

HZV tx

• Acyclovir (least expensive) 800 mg five times a day x 7 or 14 days

• Valcyclovir 1000mg PO TID • Famciclovir 500 mg TID • Initiated within 48 to 72 hrs of onset of symptoms• Promote more rapid healing of lesions• Decrease viral shedding• Lessen the severity and duration of pain associated with

acute neuritis and reduces PHN• Recom: > 50 yrs , younger than 50 benefit not clear• HIV pts tx regardless of age

Reference pt after Tx

2 wk f/u visit

Reference pt – healed lesions

Is shingles contagious?

• Can spread to children or adults who have not had chickenpox.

• Spreads through direct contact or airborne route

• They develop chickenpox, not shingles• Once all of blisters are crusted over, no longer

contagious

Complications in immunocompetent hosts at 60 days

• Post herpetic neuralgia – 7.9%• Bacterial infection – 2.3%• Uveitis and Keratitis – 1.6%• Motor neuropathy – 0.9%• Meningitis – 0.5%• Herpes zoster oticus – 0.2%

Clinical recurrences

• Rare in immunocompetent hosts• Do occur in immunocompromised hosts

Dictionary meaning of word shingles

• 1. A thin oblong piece of material, such as wood or slate, that is laid in overlapping rows to cover the roof or sides of a house or other building.

• 2. Informal A small signboard, as one indicating a professional office.

• 3. A woman's close-cropped haircut.

Post herpetic neuralgia

• Acute herpetic neuralgia: prodromal pain w/ rash persists upto 30 days from onset

• Subacute herpetic neuralgia: resolves within 4 months of onset

• PHN persists beyond 4 months from the initial onset of rash

• Incidence increases with age, older than 60yrs• Burning, areas of anesthesia, deficits of

thermal, tactile,pinprick and vibration

Pathogenesis of PHN

• As cellular immunity wanes with age, the virus that lies dormant in the dorsal root ganglia travels up the peripheral nerve and causes neuritis

• Hemorrhagic inflammation of peripheral nerve, movement of viral particles from sensory nerves to skin and sub cut tissues

Tx of PHN

• Antidepressants: amitryptiline, nortryptiline• Anticonvulsants: gabapentin, lyrica• Opioids• Capsaicin• Topical lidocaine• Steroids: role not proven

Prevention of PHN

• Tx of acute zoster or vaccine• Incidence reduced by 67% with vaccine• Low dose amitryptiline or nortryptiline

initiated within 2 days of rash onset , continued for 90 days

• Intolerance to TCA -> gabapentin, lyrica

Vaccine – Zostavax for prevention

• Approved for use in adults ages 60 and over regardless of prior HZ or not. SQ single dose

• Reduces incidence of HZ by 51% and PHN by 67%

• Booster dose of chickenpox vaccine thats given to children

• Not for acute outbreak. May use w/ pts w/ hx HZ

Shingles vaccine not recommended for

• If allergic reaction to gelatin or the antibiotic neomycin

• Prior allergy to any component of the shingles vaccine

• Weakened immune system due to conditions such as leukemia, human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS)

• Receiving treatment for cancer• Being treated with drugs that suppress their

immune system, including high-dose steroids• Pregnant or might become pregnant within 4 weeks

of getting the vaccine

Other forms of Herpes zoster

HZ in pregnancy

• Congenital varicella not asso w/ maternal HZ infection

• Tx same as non pregnant• Acyclovir is safe

Herpes zoster ophthalmicus: nasociliary br of ophthalmic division of trigeminal nerve

HZ ophthalmicus

• Complication: permanent vision loss if not treated.

• Causes corneal ulcers and acute retinal necrosis

• Hutchinson sign: prognostic value: involvement of tip of nose precedes the development of severe eye inflammation

Start oral antivirals and give Ophtho referral

Herpes zoster oticus

• Lesions in inner /middle ear, external canal and pinna

• Affects geniculate ganglion• Ipsilateral LMN facial paralysis : Ramsay Hunt

syndrome

Summary

• Identify HZ . Start tx within 72 hrs• Zostavax for 60 yrs or older• Vaccine reduces incidence of HZ by 51% &

PHN by 67%• HZ over nose -> refer to Ophtho