Herpes Zoster (Shingles)


Article Author:
Pragya Nair


Article Editor:
Bhupendra Patel


Editors In Chief:
Sherri Murrell


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
5/6/2019 8:27:16 PM

Introduction

Herpes zoster is commonly known as shingles. It is a viral disease caused by reactivation of varicella-zoster virus which remains dormant in the sensory ganglia of the cranial nerve or the dorsal root ganglia after a previous varicella infection. Varicella is commonly called as chicken pox occurs in children while herpes zoster occurs in adults or the elderly.[1][2][3]

Etiology

Upon reactivation, the virus replicates in neuronal cell bodies, and virions shed from the cells which are carried down the nerve to the area of skin innervated by that ganglion. In the skin, the virus causes local inflammation and blistering. The pain caused by zoster is due to inflammation of affected nerves with the virus.[4][5][6]

Epidemiology

The incidence of herpes zoster ranges from 1.2 to 3.4 per 1000 persons per year among younger healthy individuals while incidence is 3.9 to 11.8 per 1000 persons per year among patients older than 65 years. There is no seasonal variation seen with herpes zoster.

Pathophysiology

Cutaneous lesions of herpes zoster produce Varicella-zoster virus-specific T-cell proliferation, while production of interferonra leads to resolution of herpes zoster. In immunocompetent patients, specific antibodies (IgG, IgM, and IgA) appear more rapidly and reach higher titers during reactivation (herpes zoster) than during the primary infection causing long-lasting, enhanced, cell-mediated immunity to the varicella-zoster virus.

History and Physical

Zoster characteristically presents with a prodrome of fever, malaise, and excruciating burning pain followed by the outbreak of vesicles which appear in one to three crops over three to five days. Lesions are distributed unilaterally within a single dermatome.

Clinically, lesions start as closely grouped erythematous papules which, rapidly become vesicles on an erythematous and edematous base and may occur in continuous or interrupted bands in one, two, or more contiguous dermatomes unilaterally. Dermatomes commonly involved are thoracic (53%), cervical (20%), and trigeminal (15%) including ophthalmic and lumbosacral (11%).

Shingles oticus is also known as Ramsay Hunt syndrome type II. It is due to spreading of the virus from the facial nerve to the vestibulocochlear nerve which involves the ear and causes hearing loss and vertigo (rotational dizziness).

Zoster may occur in the mouth if the maxillary or mandibular division of the trigeminal nerve is affected. Clinically, it presents with vesicles or erosions occurring over mucous membrane of the upper jaw (palate, gums of the upper teeth) or the lower jaw (tongue or gums of the lower teeth). Oral involvement may occur alone or in combination with the lesions on the skin over the cutaneous distribution of the same trigeminal branch.

Due to the close relationship of blood vessels to nerves, the virus can spread to involve the blood vessels compromising the blood supply, and causing ischemic necrosis. Complications such as osteonecrosis, tooth loss, periodontitis, pulp calcification, pulp necrosis, periapical lesions, and tooth developmental anomalies can occur due to it.

The ophthalmic division of the trigeminal nerve is the most commonly involved branch which causes ophthalmic zoster. The skin of the forehead, upper eyelid, and orbit of the eye may be involved. It is seen in approximately 10% to 25% of cases presenting with features of, keratitis, uveitis, and optic nerve palsies. Complications in the form of chronic ocular inflammation, loss of vision, and debilitating pain can occur.

Complications of herpes zoster include secondary bacterial infection, post-herpetic neuralgia, scarring, nerve palsy, and encephalitis in the case with disseminated zoster.

  1. Disseminated zoster is defined as more than twenty skin lesions developing outside the primarily affected area or dermatomes directly adjacent to it. Besides the skin, other organs may also be affected, causing hepatitis or encephalitis making this condition potentially lethal.
  2. Post-herpetic neuralgia is the persistence of pain after a month of onset of herpes zoster. It is the commonest side effect seen in elderly patients with involvement of ophthalmic division of trigeminal nerve.
  3. Complications like cranial neuropathies, polyneuritis, myelitis, aseptic meningitis, or partial facial paralysis occur due to the involvement of the nervous system.

During pregnancy, varicella may lead to infection in the fetus and complications in the newborn, but chronic infection or reactivation, in other words, herpes zoster, is not associated with fetal infection.

Zoster sine herpete is an entity with a pain in the involved dermatome without any skin lesions.

Evaluation

Herpes zoster is clinically diagnosed with burning pain, characteristic morphology, and typical distribution. Herpes simplex virus can occasionally produce a rash in a pattern called as zosteriform herpes simplex.[7][8][9]

Tests for varicella-zoster virus include the following:

  • The Tzanck smear of vesicular fluid shows multinucleated giant cells. It has lower sensitivity and specificity than direct fluorescent antibody (DFA) or Polymerase chain reaction (PCR).
  • Varicella-zoster virus-specific IgM antibody in blood is detected during the active infection of chickenpox or shingles but not  when the virus is dormant
  • Direct fluorescent antibody testing of vesicular fluid or corneal fluid can be done when there is eye involvement.
  • PCR testing of vesicular fluid, a corneal lesion, or blood in a case with eye involvement or disseminated infection.

Molecular biology tests based on in vitro nucleic acid amplification (PCR tests) are currently considered the most reliable. Nested PCR test has high sensitivity, but is susceptible to contamination leading to false-positive results. The latest real-time PCR tests are rapid, easy to perform, as sensitive as nested PCR, have a lower risk of contamination, and also have more sensitivity than viral cultures.

Differential Diagnosis

Cutaneous lesions of herpes zoster need to be differentiated from herpes simplex, dermatitis herpetiformis, impetigo, contact dermatitis, candidiasis, drug reactions, and insect bites. Preceding pain without the development of skin lesions in herpes zoster is different from cholecystitis and biliary colic, renal colic, trigeminal neuralgia, or any dental infection.

Herpes zoster tends to involve only one side of the oral cavity, which distinguishes it from other oral blistering conditions. In the mouth, it presents initially as vesicles which break down quickly to leave ulcers that heal within 10 to 14 days. The prodromal pain before the rash may be confused with a toothache which leads to unnecessary dental treatment.

Treatment / Management

Antiviral therapy hastens the resolution of lesions, decreases acute pain and helps to prevent post-herpetic neuralgia especially in elderly patients. Acyclovir 800 mg, five times daily for five days, valacyclovir 1 gm three times daily for five days, and famciclovir 500 mg three times daily for seven days are the antiviral drugs used to treat herpes zoster. Topical antibiotic creams like mupirocin or soframycin help to prevent secondary bacterial infection. Analgesics help to relieve the pain. Occasionally, severe pain may require an opioid medication. Topical lidocaine and nerve blocks may also reduce pain.[7][10][11]

Post-herpetic neuralgia commonly occurs in elderly patients, and once the lesions have crusted, they can use topical capsaicin and Emla cream.

Enhancing Healthcare Team Outcomes

Shingles is a common infectious disorder in the elderly with significant morbidity. The condition has no cure but can be prevented in most patients via vaccination. When there is eye involvement, patients must be referred ASAP to an ophthalmologist.  Healthcare workers including the primary care provider, nurse practitioner, internist and pharmacist should educate the patient on the benefits of the vaccine. [12][13]


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Herpes Zoster (Shingles) - Questions

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A female presents with a group of vesicles just below her left breast. She says the lesions are extremely painful and itchy. Which of the following diagnoses is most likely?



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A patient with a heart transplant develops a maculopapular rash along the inferior border of the scapula extending to the right nipple and has significant pain. What is the appropriate treatment?



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What is the probable diagnosis in a female who presents with a painful, vesicular rash that covers her right cheek, the right side of her nose, right lower lid, and involves the roof of her mouth?



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Where is the most common site for the acute Herpes zoster rash?



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A 68 year old male complains of slightly painful, pruritic, dermatomal vesicular rash on his trunk for 24 hours. Which of the following would not be an appropriate treatment?



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Which of the following is important information to teach the patient with herpes zoster (shingles)?



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Which of the following describes a linear cutaneous lesion that forms along a single dermatome?



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Which of the following latent infections is most likely to be activated during immunosuppression?



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Which of the following viruses is responsible for shingles?



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A 32 year-old shoe salesman presents with a two-month history of pain the abdomen. The pain is described as being a "strip on the right side from the navel to the back." One month after onset of this symptom, he noted weakness in the right leg. Neurological examination revealed a loss of pain, temperature and perception sensations on the right side, from the level of the umbilicus down. A spastic paralysis of the right lower extremity is found. Appropriate studies indicate that the patient has a tumor of the dorsal root pressing on the spinal cord. The lesion is:



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A 55 year old woman develops severe right lower chest pain and malaise. Because of increasing discomfort, 4 days later she visits her physician. The most helpful physical finding is establishing a specific diagnosis would be:



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A man with diabetes mellitus, hypertension, and gout presented with severe burning pain on the left side of his chest. The pain started about 48 hours ago, but a week ago, he noted a burning sensation and itching in the area. He denies any trauma or any change in his medications. The pain has been keeping him awake at night, and it failed to respond to Ibuprofen. He has no allergies and is on metformin, allopurinol, and enalapril. On exam, you note the rash seen below. A Tzanck smear reveals the presence of multinucleated giant cells. At present, what is the role of corticosteroids in the treatment of such a patient?

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A patient presents to the emergency department complaining of discomfort in his chest. He denies any trauma. As he removes his shirt, the skin lesions shown in the image below become visible. Which of the following is true about this condition? Select all that apply.

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Herpes Zoster (Shingles) - References

References

Heineman TC,Cunningham A,Levin M, Understanding the immunology of Shingrix, a recombinant glycoprotein E adjuvanted herpes zoster vaccine. Current opinion in immunology. 2019 Apr 16;     [PubMed]
Watanabe D, [Cutaneous Herpesvirus Infection]. Brain and nerve = Shinkei kenkyu no shinpo. 2019 Apr;     [PubMed]
Yu YH,Lin Y,Sun PJ, Segmental zoster abdominal paresis mimicking an abdominal hernia: A case report and literature review. Medicine. 2019 Apr;     [PubMed]
Senderovich H,Grewal J,Mujtaba M, Herpes zoster vaccination efficacy in the long-term care facility population: a qualitative systematic review. Current medical research and opinion. 2019 Mar 27;     [PubMed]
Warren-Gash C,Forbes HJ,Williamson E,Breuer J,Hayward AC,Mavrodaris A,Ridha BH,Rossor MN,Thomas SL,Smeeth L, Human herpesvirus infections and dementia or mild cognitive impairment: a systematic review and meta-analysis. Scientific reports. 2019 Mar 18;     [PubMed]
Davis AR,Sheppard J, Herpes Zoster Ophthalmicus Review and Prevention. Eye     [PubMed]
Baumrin E,Van Voorhees A,Garg A,Feldman SR,Merola JF, A systematic review of herpes zoster incidence and consensus recommendations on vaccination in adult patients on systemic therapy for psoriasis or psoriatic arthritis: From the Medical Board of the National Psoriasis Foundation. Journal of the American Academy of Dermatology. 2019 Mar 15;     [PubMed]
Miles LW,Williams N,Luthy KE,Eden L, Adult Vaccination Rates in the Mentally Ill Population: An Outpatient Improvement Project. Journal of the American Psychiatric Nurses Association. 2019 Mar 13;     [PubMed]
Rooney BV,Crucian BE,Pierson DL,Laudenslager ML,Mehta SK, Herpes Virus Reactivation in Astronauts During Spaceflight and Its Application on Earth. Frontiers in microbiology. 2019;     [PubMed]
Hurley LP,Allison MA,Dooling KL,O'Leary ST,Crane LA,Brtnikova M,Beaty BL,Allen JA,Guo A,Lindley MC,Kempe A, Primary care physicians' experience with zoster vaccine live (ZVL) and awareness and attitudes regarding the new recombinant zoster vaccine (RZV). Vaccine. 2018 Nov 19;     [PubMed]
Syed YY, Recombinant Zoster Vaccine (Shingrix{sup}®{/sup}): A Review in Herpes Zoster. Drugs     [PubMed]
Mospan CM,Colvin N, What are the new vaccination recommendations for herpes zoster? JAAPA : official journal of the American Academy of Physician Assistants. 2018 Oct;     [PubMed]
Hawkins KL,Gordon KS,Levin MJ,Weinberg A,Battaglia C,Rodriguez-Barradas MC,Brown ST,Rimland D,Justice A,Tate J,Erlandson KM, Herpes Zoster and Herpes Zoster Vaccine Rates Among Adults Living With and Without HIV in the Veterans Aging Cohort Study. Journal of acquired immune deficiency syndromes (1999). 2018 Dec 1;     [PubMed]

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