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Herpes zoster

Synonym: shingles, zona

1 Definition

Herpes zoster is the secondary manifestation of an infection with Varicella zoster virus (VZV). After the primary infection with VZV, clinically presenting as "chickenpox", the virus remains inactive in ganglia cells in the spinal ganglia.

2 Epidemiology

Incidence: 400/100.000

Prevalence: 80/100.000

m:f 1:1

peak age of presentation: 50-70 years

3 Etiology

Herpes zoster occurs due to a reactivation of VZV in one ore more spinal ganglia, often associated with chronic or newly apparent immune deficiency (AIDS, immune-suppressive therapy, malign processes, stress, aging). The primary infection, chickenpox, is followed by life-long persistence of the virus in ganglia. Non-immunized children and adults can be infected via airborne transmission.

4 Clinical presentation

Unspecific symptoms, such as head ache, fever, fatigue, even meningism etc., may occur even days before the typical symptomatic presentation. Often, the patients' first consultation with a GP is due to strong neuronal pain (burning character, hyper- and paresthesias) in the affected dermatome, which may result in misdiagnosis.

Around 3 days after start of the initial phase, the characteristic skin rash develops:

  • belt-like, limited to one dermatome, not crossing the midline
  • first, hive-like grouped, then developing into a vesicular, with serous exudate

Most often, thoracic segments are affected. However, there are also presentations in the trigeminal nerve (CN. V) leading to Zoster ophthalmicus (CN. V.1) or Zoster oticus (CN. V.2,3). Zoster opthalmicus leads to pain in the forehead, upper eyelid and orbital and can be associated with conjunctivitis, keratitis, uveitis, optic nerve palsies. Zoster oticus, also known as Ramsay Hunt syndrome type 2, affects the ear region and can lead to facial nerve palsy (via the geniculate ganglion) and hearing loss and vertigo, if the vestibulocochlear nerve is affected.

Rarely, in poor immune system conditions, disseminated shingles may occur. This is defined as more than 20 skin lesions outside the originally affected dermatome or the directly adjacent dermatome. Organs, such as liver and central nervous system, might be affected, too, bearing the danger of potentially lethal complications, such as encephalitis.

The exanthema crusts over within 7-10 days, mostly healing completely, in severe blistering, however, scars and skin discoloring might remain.

5 Diagnosis

  • visual examination and clinical investigation
  • laboratory tests (IgM antibodies, PCR)
  • if central nervous infection is suspected, lumbar puncture is indicated

6 Differential Diagnoses

7 Complications

8 Therapy

Both symptomatic and systemic antiviral therapy are of paramount importance to prevent aggravation, occurrence of complications and most importantly, avoid chronic conditions, such as postherpetic neuralgia.

8.1 Antiviral therapy

Indication for anti-viral treatment

  • patient >50 years
  • patients of any age if head/neck area is affected
  • patients under immune suppression therapy
  • patients with (atopic) eczema
  • children with long-term therapy with glucocorticoids/acetylsalicylic acid

Substances:

  • Aciclovir (i.v. in serious cases, po)
  • Brivudin (po)
  • Valaciclovir
  • Famiciclovir

8.2 Symptomatic therapy

  • zinc oxide suspension for exanthema
  • analgetic therapy following WHO standard scheme as well as substances specifically for neuropathic pain, such as antikonvulsives (e.g. pregabalin, gabapentin), antidepressants

9 Prophylaxis

Vaccination of sero-negative contact persons (family).

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