Herpes Zoster

Contents
• Introduction
• Etiology
• Risk factors
• Pathophysiology
• Clinical features
• Differentials
• Complications
• Investigations
• Treatment
• Prevention
Introduction
• a.k.a. Shingles
• It is an acute viral infection of nerve cells and their surrounding skin
• its caused by the reactivation of Varicella zoster virus, which also causes
Chicken pox
• Characterised by rash of blisters which is painful.
• The infection is contagious to those who have no prior immunity to
varicella-zoster
• Its transmitted by direct skin contact or by air droplets
• The disease is infectious 1-2 days before the rash appears until the
lesions have crusted
Etiology
• Varicella zoster virus is a human herpes virus
• Belongs to the family of herpesviridae
• Genus is varicellovirus
• It’s similar to herpes simplex virus
• These viruses envelop double stranded DNA genomes that encode
more than 70 proteins
• Proteins are targets of cellular and humoral immunity
Risk factors
• Ageing
• usage of immunosuppressive drugs
• occurence of lymphoma or other malignancies
• fatigue
• emotional stress
• radiational therapy
Pathophysiology
• Virus enters body via respiratory tract
• Undergoes replication in regional lymph nodes.
• Primary viremia in blood
• Further replication in liver and spleen
• Secondary viremia
• Enters nerve endings and then into dorsal root ganglion and remains
dormant
• Reactivation - dorsal root ganglion - inflammation
• Infection of neurons and dermatomes
 Clinical features
Burning type of pain, tenderness,
paresthesia, fever and malaise precedes
eruption by 3-4 days
patchy erythema and grouped
umblicated vesicles, only within
dermatomal area
vesicles may become pustular and then
forms crusts
heals in 2-3 weeks
mc affected areas are cervical and
thoracic dermatomes
in elderly and hiv pts ophthalmic branch
of trigenimal nerve is mc affected
Differentials
• Chicken pox – a rash of itchy blisters, spread throughout body
• Dermatitis herpetiformis – associated with celiac disease and gluten
sensitivity
• Impetigo – it has itchy blisters, but the fluid within is yellowish,
generally occurs on face and both upper and lower limbs, caused by
gram positive bacteria.
• Herpes simplex – it’s not completely dermatomal, moderate painful,
no scarring of skin and no post-herpetic neuralgia.
• Hives (urticaria) – burning and itching sensation present, have wheals
and have history of allergy
Complications
• Post-herpetic neuralgia: persistence of pain after a month of onset of herpes
zoster
• Disseminated herpes zoster: More than twenty skin lesions developing outside
the primarily affected area or dermatomes directly adjacent to it.
• Encephalitis
• myelitis
• cranial and peripheral nerve palsies
• syndrome of delayed contralateral hemipareisis and acute retinal necrosis
• during pregnancy, varicella may lead to infection in the fetus and complications in
the newbon
• Ramsay hunt syndrome: facial palsy with painful ear lesions
Herpes zoster in HIV patients
• The reactivation of varicella zoster virus may occur in the course of
HIV infection as an indicator of the disease.
• Post-herpetic neuralgia and multiple vesiculobullous lesions occur in
HIV-infected patients with herpes zoster.
Lesions seen are:
• Multidermatomal herpes
zoster commonly seen in
immunocompromised
patients
• Hemorrhagic vesicles
• Purpuric spots
 Investigations
• Tzanck smear is obtained by scraping from
the base of a fresh vesicular lesion after its
roof has been removed and pushed back
on one side, spreading and drying the
collected material on a glass slide, staining
the result with Giemsa, and examining the
material with a microscope which shows
multinucleated giant cells.
• Varicella-zoster virus-specific IgM antibody
in blood is detected during active infection
• Direct fluorescent antibody testing of
vesicular fluid or corneal fluid can be done
when there is eye involvement – directly
detect vzv antigen in specimen using
fluorescein-tagged antibodies
• PCR testing of vesicular fluid, a corneal
lesion, or blood
Treatment
Anti pruritic lotion like calamine
1% phenol
antihistamines
• topical antibiotics
• Anti-viral drugs:
• acyclovir 800 mg five times a day for 7-10 days in case of high risk of perisistent pain,
dissemination, ophthalmic zoster
• foscarnet in acyclovir-resistent cases.
• famiciclovir 500mg 3 times a day
• valacyclovir 1g 3 times a day
• preferred because of better pharmacokinetics and simpler dosing regimes
Prevention
Thank you