Herpes zoster: Difference between revisions

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==Background==
==Background==
*Caused by [[varicella zoster virus]] (VZV) causing [[Varicella]] (chicken pox) and later zoster (shingles)  
*Also known as shingles
*Virus is dormant in dorsal root ganglion and reactivates causing characteristic rash in dermatomal distribution  
*Caused by [[varicella zoster virus]] (VZV; also known as Human Herpes Virus 3) causing [[Varicella]] (chicken pox) and later zoster (shingles)  
*Virus is dormant in dorsal root ganglion and reactivates causing characteristic vesiculopapular rash in dermatomal distribution  
*Occurs once immunity to virus declines (elderly, immunosuppressed, post transplant, HIV)
*Occurs once immunity to virus declines (elderly, immunosuppressed, post transplant, HIV)


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*Zoster vaccination if >60
*Zoster vaccination if >60


{{Herpes viruses}}
==Clinical Features==
[[File:Zoster.jpeg|thumb|Herpes Zoster]]
[[File:Zoster.jpeg|thumb|Herpes Zoster]]
[[File:Shingles.jpg|thumb|Herpes Zoster]]
[[File:Shingles.jpg|thumb|Herpes Zoster]]
 
*Prodrome: [[Headache]], [[Weakness|malaise]], photophobia  
==Clinical Features==
*Antecedent [[pruritus]], [[paresthesia]], pain to dermatome 2-3 days prior to rash  
*Prodrome: Headache, malaise, photophobia  
*Maculopapular [[rash]] (see below) progresses to vesicles, may coalesce to bullae, in dermatomal distribution lasting 10-15 days  
*Antecedent pruritis, paresthesia, pain to dermatome 2-3 days prior to rash  
*Maculopapular rash (see below) progresses to vesicles, may coalesce to bullae, in dermatomal distribution lasting 10-15 days  
*Does not cross midline  
*Does not cross midline  
*Typically affects chest/face
*Typically affects chest/face
*Lumbar and sacral dermatomes may display skin sparing between the feet and groin
*V3 involvement can present initially as dental pain
[[File:Herpes Zoster.jpg|thumb]]


==Differential Diagnosis==
==Differential Diagnosis==
*[[Smallpox]]
{{Bullous rashes DDX}}
*[[Cellulitis]]
*Contact Dermatitis
*[[Measles]]
 
{{VZV types}}
{{VZV types}}


==Diagnostic Evaluation==
==Evaluation==
===Workup===
===Workup===
*Generally a clinical diagnosis
*Generally a clinical diagnosis
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*Consider further evaluation for immunocompromized state (may be initial presentation of [[HIV]]) if:
*Consider further evaluation for immunocompromized state (may be initial presentation of [[HIV]]) if:
**Disseminated
**Disseminated
**If more than 3 or more dermatomes affected  
***For skin disseminated is 3 or more dermatomes affected.
***Can also disseminate to other organs including liver, lung, and brain.
**Atypical illness/severe disease  
**Atypical illness/severe disease  
*In immunocompromized patients consider further evaluation for:
*In immunocompromised patients consider further evaluation for:
**Pneumonitis
**Pneumonitis
**[[Hepatitis]]
**[[Hepatitis]]
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==Management==
==Management==
===Analgesia===
===[[Analgesia]]===
*Analgesia is very important and should be prescribed along with an antiviral
*Analgesia is very important and should be prescribed along with an antiviral
*Consider NSAIDS, oral opioids, or gabapentin
*Consider [[lidocaine]] patch, [[NSAIDS]], oral [[opioids]], or [[gabapentin]]
*[[Diphenhydramine]] and [[ranitidine]] for itch/pain


===Antiviral===
===[[Antivirals]]===
*Reduces risk/duration of postherpetic neuralgia with dosing based on immune status and time course of disease
*Reduces risk/duration of postherpetic neuralgia with dosing based on immune status and time course of disease
*Not effective in treating postherpetic neuralgia once it has developed
'''Immunocompetent patients:'''
'''Immunocompetent patients:'''
*[[Acyclovir]] 800mg PO 5x/day x 7d if <72hr of onset of rash or >72hr if new vesicles present/developing<ref>Cohen, J. Herpes Zoster. N Engl J Med 2013; 369:255-263. DOI: 10.1056/NEJMcp1302674</ref>  
*[[Acyclovir]] 800mg PO 5x/day x 7d if <72hr of onset of rash or >72hr if new vesicles present/developing<ref>Cohen, J. Herpes Zoster. N Engl J Med 2013; 369:255-263. DOI: 10.1056/NEJMcp1302674</ref>  
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**1g PO q12hrs (CrCl 30-49 mL/min)
**1g PO q12hrs (CrCl 30-49 mL/min)
**1g PO q24hrs (CrCl 10-29 mL/min(
**1g PO q24hrs (CrCl 10-29 mL/min(
**500mg q24hrs PO (CrCl < 10 ml/min)
**500mg q24hrs PO (CrCl < 10ml/min)
'''Immunosuppressed patients:'''
'''Immunosuppressed patients:'''
*Antiviral therapy should be given regardless of the time of onset of rash  
*Antiviral therapy should be given regardless of the time of onset of rash  
*[[Acyclovir]] 10 mg/kg IV q8h OR 800mg PO 5x/day x 7d or [[Foscarnet]] for acyclovir-resistant VZV, disseminated zoster, CNS involvement, ophthalmic involvement, advanced AIDS, or recent transplant
*[[Acyclovir]] 10mg/kg IV q8h OR 800mg PO 5x/day x 7d or [[Foscarnet]] for acyclovir-resistant VZV, disseminated zoster, CNS involvement, ophthalmic involvement, advanced AIDS, or recent transplant
*Isolation precautions
*Isolation precautions
**Disseminated zoster requires airborne precautions
**Disseminated zoster requires airborne precautions


===Glucocorticoids===
===[[Glucocorticoids]]===
*Steroids not shown to be beneficial<ref>He L, Zhang D, Zhou M, Zhu C. Corticosteroids for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2008.</ref>
*Steroids not shown to be beneficial<ref>He L, Zhang D, Zhou M, Zhu C. Corticosteroids for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2008.</ref>


==Disposition==
==Disposition==
*Admit for disseminated VZ, CNS involvement, severely immunosupressed
*Admit for disseminated VZ, CNS involvement, severely immunosuppressed
*Healing of lesions may take 4 or more weeks<ref>Sampathkumar P, et al. Herpes zoster (shingles) and postherpetic neuralgia. Mayo Clin Proc. 2009; 84(3):274–280.</ref>
*Healing of lesions may take 4 or more weeks<ref>Sampathkumar P, et al. Herpes zoster (shingles) and postherpetic neuralgia. Mayo Clin Proc. 2009; 84(3):274–280.</ref>


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*[[Impetigo]]
*[[Impetigo]]
*[[Necrotizing Fasciitis]]
*[[Necrotizing Fasciitis]]
*[[SIADH]]


==See Also==
==See Also==

Latest revision as of 21:08, 12 July 2023

Background

  • Also known as shingles
  • Caused by varicella zoster virus (VZV; also known as Human Herpes Virus 3) causing Varicella (chicken pox) and later zoster (shingles)
  • Virus is dormant in dorsal root ganglion and reactivates causing characteristic vesiculopapular rash in dermatomal distribution
  • Occurs once immunity to virus declines (elderly, immunosuppressed, post transplant, HIV)

Prevention

  • Patient is contagious until lesions are crusted over
  • Consider varicella-zoster immunoglobulin to immunosupressed, pregnant, neonate contacts
  • Zoster vaccination if >60

Herpes Virus Types

Clinical Features

Herpes Zoster
Herpes Zoster
  • Prodrome: Headache, malaise, photophobia
  • Antecedent pruritus, paresthesia, pain to dermatome 2-3 days prior to rash
  • Maculopapular rash (see below) progresses to vesicles, may coalesce to bullae, in dermatomal distribution lasting 10-15 days
  • Does not cross midline
  • Typically affects chest/face
  • Lumbar and sacral dermatomes may display skin sparing between the feet and groin
  • V3 involvement can present initially as dental pain
Herpes Zoster.jpg

Differential Diagnosis

Vesiculobullous rashes

Febrile

Afebrile

Varicella zoster virus

Evaluation

Workup

  • Generally a clinical diagnosis
  • May consider viral Culture, antigen, PCR of vesicle fluid

Evaluation

  • Confirm that the patient does not have:
  • Consider further evaluation for immunocompromized state (may be initial presentation of HIV) if:
    • Disseminated
      • For skin disseminated is 3 or more dermatomes affected.
      • Can also disseminate to other organs including liver, lung, and brain.
    • Atypical illness/severe disease
  • In immunocompromised patients consider further evaluation for:

Management

Analgesia

Antivirals

  • Reduces risk/duration of postherpetic neuralgia with dosing based on immune status and time course of disease
  • Not effective in treating postherpetic neuralgia once it has developed

Immunocompetent patients:

  • Acyclovir 800mg PO 5x/day x 7d if <72hr of onset of rash or >72hr if new vesicles present/developing[1]
  • Valacyclovir (can also be given but is generally more expensive than acyclovir)
    • 1g PO q8hrs (CrCl normal)
    • 1g PO q12hrs (CrCl 30-49 mL/min)
    • 1g PO q24hrs (CrCl 10-29 mL/min(
    • 500mg q24hrs PO (CrCl < 10ml/min)

Immunosuppressed patients:

  • Antiviral therapy should be given regardless of the time of onset of rash
  • Acyclovir 10mg/kg IV q8h OR 800mg PO 5x/day x 7d or Foscarnet for acyclovir-resistant VZV, disseminated zoster, CNS involvement, ophthalmic involvement, advanced AIDS, or recent transplant
  • Isolation precautions
    • Disseminated zoster requires airborne precautions

Glucocorticoids

  • Steroids not shown to be beneficial[2]

Disposition

  • Admit for disseminated VZ, CNS involvement, severely immunosuppressed
  • Healing of lesions may take 4 or more weeks[3]

Complications

See Also

References

  1. ↑ Cohen, J. Herpes Zoster. N Engl J Med 2013; 369:255-263. DOI: 10.1056/NEJMcp1302674
  2. ↑ He L, Zhang D, Zhou M, Zhu C. Corticosteroids for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2008.
  3. ↑ Sampathkumar P, et al. Herpes zoster (shingles) and postherpetic neuralgia. Mayo Clin Proc. 2009; 84(3):274–280.
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