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Herpes Zoster

Shingles

Herpes zoster is a condition characterized by development of skin rash with blisters. It is a viral disease that promotes development of rash only on one side of the body.


Presentation

Pain is the preliminary sign of herpes zoster. Few days later, skin rashes develop only on one side of the body affecting one or more skin dermatomes. In many cases, the rash develops on the left or right side of the torso. However, many individuals may develop the rash on one side of the neck or face or around the eyes. In addition to these, other signs and symptoms of herpes zoster include the following [7]:

  • Burning accompanied by tingling sensation in the affected area
  • Pruritic rashes 
  • Skin rash with blisters that break and develop crust
  • Individuals with herpes zoster also suffer from fever, fatigue and headache
Fever
  • The morphology of the lesions included erythematous papules, pseudovesicles, and plaques, with associated pain in two and pruritus in three patients; systemic symptoms ranged from none to low-grade fevers, upper respiratory symptoms, and joint pain.[ncbi.nlm.nih.gov]
  • The typical clinical manifestation is an acute segmental eruption of herpetiform umbilicated vesicles associated with malaise, pain, dysaesthesia, allodynia and probably fever.[ncbi.nlm.nih.gov]
  • Other symptoms of shingles can include Fever Headache Chills Upset stomach[web.archive.org]
  • Fever, pain, and itch are common symptoms before the onset of rash. Post-herpetic neuralgia is the most common complication associated with herpes zoster.[ncbi.nlm.nih.gov]
Chills
  • Other symptoms of shingles can include Fever Headache Chills Upset stomach[web.archive.org]
  • You begin to have symptoms of a secondary infection, such as a very high fever, chills, and severe headache.[verywell.com]
  • Other symptoms of herpes zoster include flu-like symptoms, fever, chills, a headache, and intense fatigue. How is Herpes Zoster Diagnosed? Dr. Vivian Bucay often only requires a brief physical examination for her to diagnosis herpes zoster.[drvivianbucay.com]
  • […] rash, which can appear up to five days after and first looks like small, red spots that turn into blisters Blisters which turn yellow and dry Rash which usually goes away in two to four weeks Rash is usually localized to one side of the body Fever, chills[chop.edu]
Fatigue
  • In addition, shingles may cause headache, fatigue, fever, and a general achy feeling. Individuals experiencing the aforementioned symptoms should seek medical attention.[illinoisderm.com]
  • We ask about general symptoms (anxious mood, depressed mood, fatigue, pain, and stress) regardless of condition. Last updated: May 13, 2019[patientslikeme.com]
  • This may happen due to normal aging, or the body's immune system may become weakened due to stress from illness, physical or emotional stress, fatigue, poor nutrition, certain medications, chemotherapy, radiation therapy, or other factors.[curlie.org]
  • Here are some of those things: illness or disease (such as HIV or other diseases of the immune system) fatigue or exhaustion stress or anxiety poor nutrition chemotherapy or radiation therapy certain medicines that suppress your immune system, such as[aao.org]
  • Other symptoms of herpes zoster include flu-like symptoms, fever, chills, a headache, and intense fatigue. How is Herpes Zoster Diagnosed? Dr. Vivian Bucay often only requires a brief physical examination for her to diagnosis herpes zoster.[drvivianbucay.com]
Malaise
  • The typical clinical manifestation is an acute segmental eruption of herpetiform umbilicated vesicles associated with malaise, pain, dysaesthesia, allodynia and probably fever.[ncbi.nlm.nih.gov]
  • It is frequently associated with fever, malaise, headache, and pain in the area of the rash. The vesicles typically crust and heal within 2 to 6 weeks.[nyee.edu]
  • This is a strong predictor of ocular inflammation and corneal denervation in HZO, especially if both branches of the nasociliary nerve are involved. [10] [11] Symptoms Many cases of HZO exhibit a prodromal period of fever, malaise, headache, and eye pain[eyewiki.aao.org]
  • It is a highly contagious disease characterized by a widespread papulovesicular eruption with fever and malaise. 1,2 After the primary infection, the virus remains latent within the sensory dorsal root ganglia and can reactivate as herpes zoster (HZ).[mdedge.com]
Lymphadenopathy
  • […] headache, fever Signs Skin features unilateral painful, red, vesicular rash on the forehead and upper eyelid, progressing to crusting after 2-3 weeks; resolution often involves scarring periorbital oedema (may close the eyelids and spread to opposite side) lymphadenopathy[college-optometrists.org]
  • Bowers and Ling Zhang, Reactive Lymphadenopathy with Diffuse Paracortical Pattern—Infectious Etiology, Non‐Neoplastic Hematopathology and Infections, (323-346), (2012). Nico G. Hartwig, Arnold P. Oranje, Dirk Van Gysel and Marinus C.[dx.doi.org]
  • Bowers and Ling Zhang, Reactive Lymphadenopathy with Diffuse Paracortical Pattern—Infectious Etiology, Non‐Neoplastic Hematopathology and Infections, (323-346), (2012).[dx.doi.org]
Abdominal Pain
  • One day after the procedure, the abdominal pain disappeared. In addition, 5 days after the intervention, the abdominal protrusion and constipation were resolved. He currently remains symptom free at a 6 month follow-up.[ncbi.nlm.nih.gov]
  • The most common side effects include headache, abdominal pain, vomiting and diarrhea. The treatment may also provide more serious symptoms such as confusion, hallucinations and affected alertness.[firstderm.com]
  • Mattila Leena, Valtonen Ville and Anttila Veli-Jukka, Visceral varicella zoster virus infection after stem cell transplantation: a possible cause of severe abdominal pain, Scandinavian Journal of Gastroenterology, 41, 2, (242), (2006).[dx.doi.org]
  • Differential diagnosis Before the rash appears the pain may be thought to originate from under that dermatome and so it must be considered as a possible cause of chest or abdominal pain.[patient.info]
Severe Abdominal Pain
  • Mattila Leena, Valtonen Ville and Anttila Veli-Jukka, Visceral varicella zoster virus infection after stem cell transplantation: a possible cause of severe abdominal pain, Scandinavian Journal of Gastroenterology, 41, 2, (242), (2006).[dx.doi.org]
Otalgia
  • Definition, prevalence and aetiology Herpes zoster oticus is a viral infection of the inner, middle and external ear characterised by herpetic blisters (small vesicles) of the skin of the external canal, pinna and/or the oral mucosa and severe otalgia[doi.org]
Eye Pain
  • This is a strong predictor of ocular inflammation and corneal denervation in HZO, especially if both branches of the nasociliary nerve are involved. [10] [11] Symptoms Many cases of HZO exhibit a prodromal period of fever, malaise, headache, and eye pain[eyewiki.aao.org]
Eye Swelling
  • ICE has three main features: Visible changes in the iris, the colored part of the eye Swelling of the cornea Glaucoma ICE is usually present in only one eye. It is caused by the movement of endothelial cells from the cornea to the iris.[nei.nih.gov]
Shoulder Pain
  • Stefano Gumina, Vittorio Candela, Daniele Passaretti and Ciro Villani, Shoulder pain due to cervical radiculopathy: an underestimated long-term complication of herpes zoster virus reactivation?, International Orthopaedics, 42, 1, (157), (2018).[dx.doi.org]
Low Back Pain
  • back pain and diabetic neuropathy. 18 Postherpetic neuralgia is of varying duration and develops in 9% to 34% of individuals with herpes zoster, depending on the definition used and population studied. 12 In a longitudinal study of 94 patients with herpes[web.archive.org]
Back Pain
  • pain and diabetic neuropathy. 18 Postherpetic neuralgia is of varying duration and develops in 9% to 34% of individuals with herpes zoster, depending on the definition used and population studied. 12 In a longitudinal study of 94 patients with herpes[web.archive.org]
Blister
  • blisters often leave no scars.[ninds.nih.gov]
  • The virus is spread through direct contact with fluid from the rash blisters caused by shingles. A person with active shingles can spread the virus when the rash is in the blister-phase. A person is not infectious before the blisters appear.[web.archive.org]
  • A hearing examination demonstrated mild-to-moderate left neurosensory hearing loss.Since then, she is having short episodes of redness on her face without pain or sweating at the exact distribution of the zoster blisters 6 years ago.[ncbi.nlm.nih.gov]
  • Red patches on the skin, followed by small blisters, form in most people: The blisters break, forming small sores that begin to dry and form crusts. The crusts fall off in 2 to 3 weeks. Scarring is rare.[nlm.nih.gov]
  • Definition Herpes zoster is a viral infection characterized by development of skin rashes with blisters specifically on one side of the body. The rash is confined to a small portion and appears as a single strap of blisters.[symptoma.com]
Eruptions
  • The time of complete resolution of pain, time of healing of skin eruption, and incidence of PHN were reported.[ncbi.nlm.nih.gov]
  • Acute inciting events for this eruption are not always known, but can include illness, stress, and mechanical injury.[ncbi.nlm.nih.gov]
  • Presentation The disease can be divided into the pre-eruptive phase, acute eruptive phase and chronic phase - postherpetic neuralgia (PHN).[patient.info]
  • Herpes zoster (Hz), which generally presents as a localized, painful cutaneous eruption, is a common clinical problem, particularly among adults 50 years of age and immunocompromised patients.[doi.org]
Vesicular Rash
  • In both cases, the orbital syndrome developed prior to the vesicular rash. These cases highlight the need to consider Herpes Zoster ophthalmicus in patients with orbital syndrome not responding to conventional treatment.[ncbi.nlm.nih.gov]
  • Most patients with herpes zoster ophthalmicus present with a periorbital vesicular rash distributed according to the affected dermatome. A minority of patients may also develop conjunctivitis, keratitis, uveitis, and ocular cranial-nerve palsies.[ncbi.nlm.nih.gov]
  • The usual presentation of herpes zoster is as a self-limiting vesicular rash, often accompanied by post-herpetic neuralgia (PHN), its most common complication.[ncbi.nlm.nih.gov]
  • Its reactivation results in herpes zoster, otherwise known as shingles, which is a painful vesicular rash in a dermatomal distribution. We present a case of foraminal disk extrusion that resulted in radicular pain in a dermatomal distribution.[ncbi.nlm.nih.gov]
  • Abstract Women ages 50 years and older are at risk for herpes zoster, a reactivated virus from varicella zoster virus (chickenpox) that causes a painful vesicular rash and can result in postherpetic neuralgia.[ncbi.nlm.nih.gov]
Eczema
  • The rash, especially if without pain, may be mistaken for atopic eczema, eczema herpeticum , contact dermatitis , herpes simplex or impetigo . Diagnosis of eczema/dermatitis may lead to this viral infection being treated with steroid cream.[patient.info]
  • The rash, especially if without pain, may be mistaken for atopic eczema, eczema herpeticum, contact dermatitis, herpes simplex or impetigo. Diagnosis of eczema/dermatitis may lead to this viral infection being treated with steroid cream.[patient.info]
  • […] affects around 25% of patients and is: chronic and severe in about 7% Complications can occur months or years after the acute phase Differential diagnosis Ocular lesions: herpes simplex keratitis Cutaneous lesions: cellulitis, contact dermatitis, atopic eczema[college-optometrists.org]
  • Steele, Eczema Varicella/Zoster (Varicellicum), Clinical Pediatrics, 56, 6, (579), (2017). Amrita R. John and David H.[dx.doi.org]
Facial Pain
  • The medical term for head or facial pain due to shingles is "painful trigeminal neuropathy attributed to herpes zoster."[verywell.com]
Neuralgia
  • More recently, zoster and postherpetic neuralgia have served as models for the study of the pathogenesis and treatment of neuropathic pain.[ncbi.nlm.nih.gov]
  • Although postherpetic neuralgia has been defined in different ways, recent data support the distinction between acute herpetic neuralgia (within 30 days of rash onset), subacute herpetic neuralgia (30-120 days after rash onset), and postherpetic neuralgia[web.archive.org]
Headache
  • Other symptoms of shingles can include Fever Headache Chills Upset stomach[web.archive.org]
  • KEYWORDS: headache (including migraines); pain (neurology)[ncbi.nlm.nih.gov]
  • In addition, shingles may cause headache, fatigue, fever, and a general achy feeling. Individuals experiencing the aforementioned symptoms should seek medical attention.[illinoisderm.com]
  • You begin to have symptoms of a secondary infection, such as a very high fever, chills, and severe headache.[verywell.com]
Burning Sensation
  • Some people describe the pain as an intense burning sensation. For some people, the pain can last for months or even years after the rash goes away.[cdc.gov]
  • Iris versicolor This remedy is often helpful for herpes zoster infection that is accompanied by stomach problems with burning sensations and nausea. Eruptions may appear especially on the right side of the abdomen.[uofmhealth.org]
  • Signs and Symptoms: Early signs of shingles include a burning sensation or stabbing pain and tingling or itching on the skin. After a few days, a rash or blisters appear usually on one side of the body or face.[conditions.health.qld.gov.au]
  • Post-herpetic neuralgia may be a continuous burning sensation with increased sensitivity in the affected areas or spasmodic shooting pain. The overlying skin is often numb or exquisitely sensitive to touch.[dermnetnz.org]
  • The reawakened virus generally causes a vague burning sensation or tingling over an area of skin. A painful rash usually occurs two to five days after the first symptoms appear.[permanent.access.gpo.gov]
Cranial Nerve Involvement
  • View/Print Table TABLE 1 Ocular and Cranial Nerve Involvement in Herpes Zoster Ophthalmicus Structure involved Signs Time of onset (onset of rash Day 0) Eyelid/conjunctiva Blepharoconjunctivitis Cutaneous macular rash respecting midline and involving[aafp.org]
  • nerve involvement then the patient may experience hearing or vision loss. [3] Postherpetic neuralgia, which is pain lasting longer than 90 days following the initial herpes zoster rash, was found in 24% of patients in a quality of life study by Drolet[physio-pedia.com]
  • nerve involvement) or the patient is systemically ill hospitalize and treat with acyclovir 10 mg/kg IV q8h for 5 to 10 days. systemic antivirals can be supplemented with aciclovir 3% eye ointment, 5 times daily Analgesia: Oral analgesia — IV analgeisa[lifeinthefastlane.com]
  • TABLE 1 Ocular and Cranial Nerve Involvement in Herpes Zoster Ophthalmicus Structure involved Signs Time of onset (onset of rash Day 0) Eyelid/conjunctiva Blepharoconjunctivitis Cutaneous macular rash respecting midline and involving eyelids Day 0 (preceded[web.archive.org]
Hyperesthesia
  • Patients will typically experience 1-2 days of pain, itching, and hyperesthesia before the skin lesions are noticed. [3] [1] Prevalence Shingles will affect 1 in 3 people in the United States, with approximately 1 million cases each year. [4] Half of[physio-pedia.com]
  • […] pathologic studies have demonstrated damage to the sensory nerves, the sensory dorsal root ganglia and the dorsal horns of the spinal cord in patients with this condition. 9 Clinical Presentation Herpes zoster typically presents with a prodrome consisting of hyperesthesia[web.archive.org]
  • These symptoms are commonly followed by sensations of burning pain, itching, hyperesthesia (oversensitivity), or paresthesia ("pins and needles": tingling, pricking, or numbness).[en.wikipedia.org]

Workup

Physical examination of the skin rashes and its characteristics forms the basis of the diagnosis. In addition, history of pain and the appearance of rash on one side of the body confirm herpes zoster. In many instances, tissue scrapings can be cultured for the virus, but such a kind of method is time consuming and delays diagnosis and consequent initiation of treatment.

Laboratory tests are of no importance in diagnosing herpes zoster. Also, no type of imaging studies is indicated in diagnosis of the condition. However, MRI can be carried out in cases when there is development of encephalopathy and myelopathy.

Treatment

Herpes zoster cannot be cured; the symptoms can however be managed with antiviral drugs. These medications also reduce the risk of developing complications. Antiviral drugs such as famciclovir, valacyclovir and acyclovir are prescribed for effective management of the rash and blisters [8].

Along with antiviral drugs, numbing agents such as lidociane are also given in form of cream or gel to be applied on the affected area. In order to control the associated symptoms of herpes zoster, steroid injections can also be administered to shorten the duration of the episode [9].

Prognosis

The prognosis of the disease condition is extremely favorable with the rash that resolves within 10 to 15 days. Children and otherwise healthy individuals have a better prognosis as compared to the elderly population [5]. However, if treatment is not initiated in right time, it can cause debilitating and life threatening complications in the immunocompromised population [6].

Etiology

The virus known as varicella zoster virus (VZV) causes herpes zoster. The VZV virus belongs to the Herpesviridae family. The exact etiology that causes the reactivation of the virus years after initial exposure is not yet known. However, individuals with poor immunity status are known to fall easy prey to this disease. Certain disease conditions such as HIV and cancer can predispose the individual to develop herpes zoster [2].

Epidemiology

It has been estimated that in the US, about 99.5% adult aged 40 years and above are susceptible to reactivation of VZV. An individual of any age group who has suffered varicella early in life is susceptible to develop herpes zoster as they age. It happens probably because of lowered immunity. It has also been reported that, individuals who have suffered an attack of herpes zoster are at an increased risk of developing another attack of the disease later in the life. About 4% individuals are susceptible to develop recurrent attacks of herpes zoster [3].

Sex distribution
Age distribution

Pathophysiology

The causative organism varicella zoster virus causes two discrete disease conditions, varicella and herpes zoster. Herpes zoster majorly occurs in those individuals who have suffered varicella early in their life. It is not a contagious disease, but individuals can pass on the virus to healthy individuals. As a result, the healthy individual would develop varicella and not herpes zoster.

After an episode of varicella, the virus remains in dormant state in the dorsal root ganglion. An attack of herpes zoster occurs, when the virus gets activated for reasons not clearly understood. However, certain factors such as decreased immunity or stress are known to predispose an individual to develop herpes zoster [4].

Prevention

Herpes zoster can be prevented through vaccines namely varicella vaccine and varicella–zoster vaccine. The varicella vaccine used for prevention against chicken pox is now commonly used for children. This vaccine is also recommended for adults also who have never had chicken pox.

The FDA has approved the use of varicella–zoster vaccine for individuals aged 50 years and above. This vaccine significantly decreases the likelihood that individuals would develop herpes zoster. However, this vaccine is not indicated for individuals with weakened immune system [10].

Summary

An episode of herpes zoster is short lived and manifests as skin rashes in children and adults. Individuals who have suffered from varicella (chicken pox) can develop herpes zoster later in life. Once varicella is treated, the virus stays in dormant state inside the body and is not eliminated. Years after the initial exposure, the virus often causes episodes of herpes zoster [1].

Patient Information

Definition

Herpes zoster is a viral infection characterized by development of skin rashes with blisters specifically on one side of the body. The rash is confined to a small portion and appears as a single strap of blisters.

Cause

The virus known as varicella zoster virus causes herpes zoster. Individuals who had suffered from chicken pox early in their life are more prone to develop herpes zoster. The virus stays in dormant state in the body and gets activated when it gets favorable environment to grow. Individuals with poor immunity profile are at an increased risk of developing herpes zoster.

Symptoms

Individuals with herpes zoster develop painful rash along with blisters on one side of the body. In addition, certain percentage of affected population may also experience fever along with general weakness.

Diagnosis

No laboratory studies or imaging tests are useful in diagnosis of herpes zoster. Careful physical examination of the skin rashes and its characteristics helps in establishing a definite diagnosis of the condition.

Treatment

Antiviral agents along with corticosteroids are administered for treatment of herpes zoster. For providing relief from the uncomfortable symptoms of the rashes, numbing agents such as lidocaine are also given to be applied on the affected area.

References

Article

  1. Karlin JD. Herpes zoster ophthalmicus: the virus strikes back. Ann Ophthalmol. Jun 1993;25(6):208-15.
  2. Whitley RJ, Weiss HL, Soong SJ, Gnann JW. Herpes zoster: risk categories for persistent pain. J Infect Dis 1999; 179:9.
  3. Wung PK, Holbrook JT, Hoffman GS, Tibbs AK, Specks U, et al. Herpes zoster in immunocompromised patients: incidence, timing, and risk factors. Am J Med. Dec 2005;118(12):1416.
  4. Gnann JW Jr, Whitley RJ. Clinical practice. Herpes zoster. N Engl J Med 2002; 347:340.
  5. Tseng HF, Chi M, Smith N, et al. Herpes zoster vaccine and the incidence of recurrent herpes zoster in an immunocompetent elderly population. J Infect Dis 2012; 206:190.
  6. Schmader K, George LK, Burchett BM, Pieper CF. Racial and psychosocial risk factors for herpes zoster in the elderly. J Infect Dis. Nov 1998;178 Suppl 1:S67-70.
  7. Dolin R, Reichman RC, Mazur MH, Whitley RJ. NIH conference. Herpes zoster-varicella infections in immunosuppressed patients. Ann Intern Med 1978; 89:375.
  8. Wood MJ, Shukla S, Fiddian AP, Crooks RJ. Treatment of acute herpes zoster: effect of early (< 48 h) versus late (48-72 h) therapy with acyclovir and valaciclovir on prolonged pain. J Infect Dis. Nov 1998;178 Suppl 1:S81-4.
  9. Fernandes NF, Malliah R, Stitik TP, Rozdeba P, Lambert WC, Schwartz RA. Herpes zoster following intra-articular corticosteroid injection. Acta Dermatovenerol Alp Panonica Adriat. Mar 2009;18(1):28-30.
  10. Oxman MN, Levin MJ, Johnson GR, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med 2005; 352:2271.

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Last updated: 2018-06-22 11:51