He rp e s

Zo s t er
ba l A i nnun A.
Iq
Tutor 23
DEFINITION
Fitzpatrick

• Acute dermatomal infection,

characterized by unilateral,
dermatomal pain, and rash.

• Results from reactivation and

multiplication of endogenous VZV
that had persisted in latent form
within sensory ganglia following an
earlier attack of varicella.

• Herpes Zoster = Shingles

EPIDEMIO-
LOGY
• The occurrence is independent from the
prevalence of varicella

• Occurs sporadically throughout the year

without seasonal prevalence

• Cumulative lifetime incidence of HZ is 10-

20%

• Most common in older adults and

immunosuppressed individuals

• The incidence is 1.5-3 per 1000 person per

year in all ages and 7-11 per 1000 person per
year over 60 years of age in European and
North American studies

• >1 million new cases in US each year

 RISK
FACTORS
Table of Contents

Cellular immune
Older age
01 7-11 per 1000 person per year
over 60 years old 02 dysfunction
In immunosuppressed, 20-100x
greater risk of HZ (HIV, Bone
marrow transplant, leukemia,
corticosteroid, etc)

Others
03 Female sex, physical trauma in the affected dermatome, IL-10
gene polymorphisms, white race
 CLINICAL
MANIFESTATION
Prodrome of Herpes Zoster
• Pain and paresthesia in the involved dermatome often precede the eruption by several
days
• Vary from superficial itching, tingling, or burning to severe, deep, boring, or lancinating
pain
• Pain may be constant or intermittent and it is often accompanied by tenderness and
hyperesthesia of the skin in the involved dermatome
• The preeruptive pain of HZ may simulate pleurisy, myocardial infarction, duodenal ulcer,
cholecystitis, biliary or renal colic, appendicitis, prolapsed intervertebral disk, or early
glaucoma
• Uncommon in immunocompetent persons under 30 years old, but occur majority in the
patient over 60 years

• Boring pain: being pierced with a long, slender, and twisting object
• Lancinating pain: sharp, darting pain
Rash of Herpes Zoster
• The most distinctive feature of HZ is the location and distribution of the rash, which is
nearly always unilateral and is generally limited to the area of skin innervated by a single
sensory ganglion
• Most frequent: area supplied by trigeminal nerve (particularly the ophthalmic division)
and the trunk from T3 to L2
• Thoracic region alone accounts for more than half of all reported cases
• Rarely occur distal to the elbows or knees
• Evolve more slowly and usually consist of closely grouped vesicles on an erythematous
base rather than discrete, randomly distributed vesicles of varicella  intraneural spread,
not viremic spread
• Begin as erythematous macules and papules that often first appear where superficial
branches of the affected sensory nerve are given off, then the vesicles form within 12-24
hours and evolve into pustules by the third day
• Then, these vesicle dry and crust in 7-10 days and the crusts generally persist for 2-3
weeks. New lesions continue to appear for 1-7 days
Rash of Herpes Zoster—cont.
• 10-15% of all reported cases involve the ophthalmic division of trigeminal nerve  20-
70% patients report eye involvement (impaired corneal sensation, and if it is severe, it
may lead to neurotrophic keratitis and chronic ulceration)
• It also can affect mouth, ears, pharynx, or larynx
Pain of Herpes Zoster
• Although the rash is important, pain is the cardinal problem posed by herpes zoster,
especially in the elderly
• Most patients experience dermatomal pain or discomfort during the acute phase (first 30
days following rash onset) that ranges from mild to severe
• Patients describe their pain or discomfort as burning, deep aching, tingling, itching, or
stabbing
• Acute herpes zoster pain is associated with decreased physical functioning, emotional
distress, and decreased social functioning
 Stages + CM of Herpes Zoster
Prodrome
Pain, tenderness, paresthesia
in the involved dermatome
Vesicles and erosion can occur
is mucous membrane of mouth,
vagina, and bladder (depends
on dermatome involved)
Sensory defects (temp, pain,
touch) and mild motor paralysis
Active Infection
Papules (24h)  vesicles-bullae (48h) 
pustules (96h)  crusts (7-10d) + new lesions in
1w
Erythematous, edematous base with
superimposed clear vesicles, sometimes
hemorrhagic. Dermatomal crusting usually
resolves in 2-4w
Unilateral, dermatomal. Two or more contiguous
dermatomes may be involved, noncontiguous
dermatomal is rare
PHN
Constant, severe, stabbing
or burning, dysesthetic pain
that may persist for months
or years in a minority of
patients, especially in
elderly
Regional nodes draining the
area are often enlarged and
tender (lymphadenopathy)
Dermatome

Site of predilection:

Thoracic >50%

Trigeminal 10-20%

Lumbosacral and cervical 10-20%

DIFFERENTIAL
DIAGNOSIS
Based on Stages
Prodromal
Stage/Localized Pain
● Migraine
● Cardiac of pleural disease
● Acute abdomen
● Vertebral disease
Dermatomal Eruption
● HSV infection (zosteriform
herpes simplex)
● Photoallergic (poison ivy,
poison oak) contact
dermatitis
● Erysipelas
● Necrotizing fasciitis
DD
CLINICAL
DIAGNOSIS
Diagnostic Criteria
In the preeruptive stage, the prodromal pain
of HZ is often confused with other causes of
localized pain. Once the eruption appears,
the character and dermatomal location of the
rash, coupled with dermatomal pain or other
sensory abnormalities, usually makes the
diagnosis obvious
A cluster of vesicles, particularly near the
mouth or genitals, may represent HZ, but it
may also be recurrent HSV infection.
Zosteriform herpes simplex is often
impossible to distinguish from HZ. A history
of multiple recurrences at the same site is
common in herpes simplex and not in HZ
Laboratory Diagnosis
• Varicella and HZ are indistinguishable by histopathology
• Multinucleated giant cells and epithelial cells containing acidophilic intranuclear inclusion bodies
distinguishes the cutaneous lesions produced by VZV from all other vesicular eruptions, except
those produced by HSV  Tzanck smears
• The definitive diagnosis of VZV, as well as the differentiation of VZV from HSV, is accomplished
by the isolation of virus in cell cultures inoculated with vesicle fluid, blood, CSF or infected tissue,
or by the direct identification of VZV antigens or nucleic acids in these specimens
• Immunoflourescent or immunoperoxidase staining of cellular material from fresh vesicle or
prevesicular lesions has become the diagnostic method of choice in many centers
• Enzyme immunoassays provide another rapid and sensitive method for antigen detection
• Serologic tests permit the retrospective diagnosis of varicella and HZ when acute and convalescent
sera are available for comparison
 THANKS !
Do you have any questions?

CREDITS: This presentation template was created by Slidesgo, including

icons from Flaticon, and infographics & images by Freepik.

Please keep this slide as attribution.