Herpes zoster syndrome (shingles)

Published on 02/04/2015 by admin

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158 Herpes zoster syndrome (shingles)

Instruction

Look at this patient.

Salient features

History

• Pain, particularly in the ophthalmic branch of the trigeminal nerve (Fig. 158.1), and in the lower thoracic dermatomes (postherpetic neuralgia occurs in about 50% of patients with zoster over the age of 60 years)

• Past history of chickenpox

• Presence of an underlying immunocompromised state (e.g. recurrent zoster indicates a poorer prognosis in patients with established AIDS). Zoster occurs at least seven times more frequently in homosexual men with HIV infection than in HIV-negative controls.

Fig. 158.1 Vesicular rash and pain in the ophthalmic branch of the trigeminal nerve.

Examination

• Vesicular rash along a dermatome (usually affects thoracic and lumbar dermatomes)

• Enlargement of a draining lymph node.

Remember: The virus affects both the posterior horn of the spinal cord and the skin supplied by sensory fibres that pass through the diseased root ganglion (Fig. 158.2).

Fig. 158.2 Rash in skin supplied by sensory fibres of the nerve.

Diagnosis

This patient has a vesicular rash along the sixth thoracic dermatome (lesion) caused by herpes zoster (aetiology), and has severe local pain (functional status).

Advanced-level questions

In which layer of the skin are the vesicles formed?

They are formed in the prickle-cell layer of the epidermis as a result of the ‘balloon degeneration’ of cells and serous exudation from the corium.

How does this condition present?

Pain in the distribution of the dermatome; malaise; fever, followed a few days later by a rash in the same distribution as the pain. Starts as macules then forms vesicles and then pustules.

Which nerve is affected when the lesions are present on the tip of the nose?

The ophthalmic division of the trigeminal nerve.

How would you confirm the diagnosis?

The diagnosis is usually clinical. It is confirmed by rising viral titres and isolation of the virus from the blister. The Tzanck smear demonstrates a multinucleated giant cell and virual inclusions when material scraped from the floor of a vesicle is stained with the Wright’s stain. The Tzanck test can be positive in infections with herpes simplex, herpes zoster and varicella.

How would you manage such a patient?

• Pain relief, including gabapentin, pregabalin, lidocaine patch, topical casaicin and amitriptyline in severe cases

• Antiviral therapy (aciclovir, valaciclovir or famciclovir) results in faster healing, lessening of acute pain and reduced incidence and intensity of post-herpetic neuralgia

• Interferon appears to be effective in limiting zoster in patients with cancer.

What is the role of vaccination?

There is waning cell-mediated immunity to the virus in the elderly. Therefore, vaccination in patients >60 years reduces the incidence of herpes zoster by 50% and lessens the severity and chance of complications (N Engl J Med 2005;352:2271–84).

Is varicella-zoster immunoglobulin useful in preventing zoster eruptions?

There are no known means of effectively preventing zoster eruptions; however, results on the effectiveness of the recently developed live attenuated varicella vaccine are awaited. Although there is considerable controversy, with arguments for and against universal vaccination, the American Academy of Pediatrics has recently adopted a position in support of universal vaccination of healthy non-immune children and adults.

What are the complications of herpes zoster?

• Corneal ulcerations

• Gangrene of the affected area

• Phrenic nerve palsy

• Meningoencephalitis

• Ramsay Hunt syndrome

• Postherpetic neuralgia: intrathecal methyl prednisolone is an effective treatment for post-herpetic neuralgia (N Engl J Med 2000;343:1514–19)

• Disseminated zoster including pneumonia.

What are the features of herpes zoster in patients with human immunodeficiency virus infection?

It is usually unidermatomal and uneventful. However, it may be multidermatomal, disseminated recurrent, or chronically persistent as a hyperkeratotic nodular lesion.

How does the varicella zoster virus affect the central nevous system in such co-infected patients?

In AIDS, the virus may cause the following:

• Multifocal encephalitis

• Ventriculitis

• Acute haemorrhagic meningomyeloradiculitis

• Focal necrotizing myelitis

• Vasculitis of the leptomeningeal arteries.

J Ramsay Hunt (1874–1937), a US neurologist.

Shingles, from the Latin cingulum or ‘girdle.’

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