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Postherpetic Neuralgia

Post Herpetic Neuralgia

Varicella is a common viral childhood infection that presents as a pruritic rash with the causative agent being the varicella zoster virus (VZV). The VZV infection is also known as “chicken pox” with initial recovery and subsequent reactivation of the virus being termed herpes zoster. Herpes zoster may be present with significant neuropathic pain that may persist and which is termed postherpetic neuralgia [1].


Presentation

The most common sites associated with postherpetic neuralgia are the cranial nerve and cervical and thoracic spine most predominantly the fourth to sixth dermatomes. The pain may range from sharp, stabbing to burning. Many patients also complain of allodynia. The other sensory modalities are usually affected within the dermatome, with diminished vibration, tactile and thermal sensation. There are usually scars along the affected dermatome, making the diagnosis less complicated [6].

Abdominal Distension
  • There was an abdominal distension, the left abdominal-wall was thinner than the right side.[ncbi.nlm.nih.gov]
  • Unilateral abdominal distension following herpes zoster outbreak. Arch Dermatol 1998;134;1168--9. Thomas JE, Howard FM. Segmental zoster paresis---a disease profile. Neurology 1972;22:459--66. Dolin R, Reichman RC, Mazur MH, Whitley RJ.[web.archive.org]
Retinal Hemorrhage
  • Diffuse retinal hemorrhages and whitening with macular involvement bilaterally are characteristic findings.[ncbi.nlm.nih.gov]
Loss of Peripheral Vision
  • Patients present with periorbital pain and floaters with hazy vision and loss of peripheral vision. Treatment is typically intravenous acyclovir, steroids and aspirin followed by oral acyclovir [ 64 ].[ncbi.nlm.nih.gov]
Joint Deformity
  • There were typical joint deformity and positive rheumatoid factor. On neurological examination superficial abdominal reflexes were diminished in the left side, with hypesthesia of the overlying skin.[ncbi.nlm.nih.gov]
Vulvar Rash
  • Shingles needs to be included in the differential diagnosis of vulvar rashes because it is a modifiable risk factor for chronic vulvar pain. The possibility of postherpetic neuralgia must be considered in women with unexplained vulvar dysesthesia.[ncbi.nlm.nih.gov]
Trigeminal Neuralgia
  • ‘Touch-induced electrical pain’ sounds a lot like trigeminal neuralgia.[drhoney.org]
  • A 99-year-old woman had a 4-year history of severe postherpetic (trigeminal) neuralgia on the left side of her face.[ncbi.nlm.nih.gov]
  • Japanese claims data were used to identify patients aged 18 years or more with PHN, postherpetic trigeminal neuralgia or postherpetic polyneuropathy who were initiated on their first PHN-associated prescription through May 2010 (before approval) or from[ncbi.nlm.nih.gov]
  • Keywords Chronic Pain Herpes Zoster Trigeminal Neuralgia Postherpetic Neuralgia Acute Herpes Zoster These keywords were added by machine and not by the authors.[doi.org]
  • neuralgia can be possible alternate causes for the symptoms. 7 Therapy For targeting post-herpetic neuralgia, the different levels of perception of pain can be addressed.[flexikon.doccheck.com]
Peripheral Neuropathy
  • OBJECTIVES: The pregabalin dose-response for pain, Patient Global Impression of Change (PGIC), and sleep quality measures in painful diabetic peripheral neuropathy (pDPN), postherpetic neuralgia (PHN), and fibromyalgia (FM) is relevant for physicians[ncbi.nlm.nih.gov]
  • Management / Guidelines: The following links provide up to date, evidence based guidance and guidelines on managing pain due to peripheral neuropathy. Many of the links deal with management of neuropathic pain in general.[paincommunitycentre.org]
  • The NUCYNTA franchise includes: NUCYNTA ER (tapentadol) extended release tablets indicated for the management of pain, including neuropathic pain associated with diabetic peripheral neuropathy (DPN), severe enough to require daily, around-the-clock, long-term[news-medical.net]
  • Peripheral neuropathy, due to diabetes, B12 deficiency, hypothyroidism - more often peripheral neuropathy, less often on face or trunk. D. Physical Examination Findings.[clinicaladvisor.com]
  • The closest listed impairment to postherpetic neuralgia in the Blue Book is Listing 11.14 for Peripheral Neuropathy.[disabilitysecrets.com]
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]
  • 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]
  • Presentations of cranial nerve involvement in two patients with herpes zoster ophthalmicus. J Commun Dis. 2001; 33 :130–5. [ PubMed ] [ Google Scholar ] 15. Volvoikar P, Patil S, Dinkar A.[ncbi.nlm.nih.gov]
Gait Ataxia
  • Recent reports of VZV meningitis [ 50, 51 ], meningoradiculitis [ 52 ] and cerebellitis (gait ataxia and tremor predominated) [ 53, 54 ], all in the absence of rash and confirmed by the detection of VZV DNA and anti-VZV antibody in CSF, revealed that[ncbi.nlm.nih.gov]

Workup

Laboratory tests

The diagnosis is usually straight forward with no need for many laboratory studies. There is usually a history of preceding herpes zoster with persistence of the pain after resolution of the rash. It may be necessary to find out the predisposing factors such as suspected human immunodeficiency virus infection, but the cause may also be obvious such as age or chemotherapy.

Imaging

Magnetic resonance imaging of the spinal level of the affect dermatome may reveal lesions, but these lesion are present even in patients whose pain does not persist [7].

Sinus Arrest
  • This report emphasizes that a sphenopalatine ganglion blockade can be employed in the treatment and prevention of sinus arrest associated with postherpetic trigeminal distribution neuralgia.[ncbi.nlm.nih.gov]
Cerebral Angiitis
  • Herpes zoster ophthalmicus and delayed contralateral hemiparesis caused by cerebral angiitis: diagnosis and management approaches. Ann Neurol. 1983; 14 :543–53. [ PubMed ] [ Google Scholar ] 48.[ncbi.nlm.nih.gov]

Treatment

A number of medications have been used to treat the pain in postherpetic neuralgia including tricyclic antidepressants such as amitriptyline. Anticonvulsants, particularly gabapentin and pregabalin have also been tried and shown to be effective in controlling the pain.

Opioids have been shown to work well but the prolonged use has the risk of addiction, physical and psychological dependence. Topical agents such as capsaicin have been used with poor results currently due to its intolerability. Other tropical agents used include topical lidocaine, but data is sparse, but the little that is there shows it may be of some benefit.

Intrathecal glucocorticoids, have been used when other modalities have failed (in non-cranial neuralgia). The last options include cryotherapy of the affected nerves and surgery with variable results [8] [9] [10].

Prognosis

Postherpetic neuralgia is a condition that is slow to resolve, but most of the patients will respond to first line treatment with tricyclic antidepressants. A few will have refractory pain requiring more radical measures.

Etiology

The virus is called human herpesvirus-3, more commonly known as varicella zoster virus or VZV. It is a double-stranded DNA virus of the herpesvirales order. After initial infection the virus remains dormant within the dorsal root ganglia until it reactivates causing herpes zoster. Most common areas of latency being the trigeminal nerve, cervical and thoracic spine [2].

Epidemiology

The incidence rates increase with age, and with increasing impairment of immunity. The incidence in people below 20 years of age is low with a rate of 1 per 1000 and the rates in the above 80 group reaching 1 per 100. It is very common in immunocompromised patients such as patients on steroids and chemotherapy. It is also has high rates in patients suffering from human immunodeficiency virus (HIV) infection. Severe emotional stress and malnutrition are also recognised risk factors [3].

Sex distribution
Age distribution

Pathophysiology

Herpes zoster (shingles) is caused by reactivation of the latent varicella zoster virus after persistence within the dorsal root ganglia. The reason for the reactivation being decreased immunity (primarily cellular immunity) due to various causes with age being the most common.

The activated virus uses the nerves transport system causing a painful neuritis, associated with a characteristic rash along the dermatome of the supplying nerve. After resolution of the rash the pain usually subsides. In those who the pain persists it is thought that there are changes to the dorsal root ganglion nerves, sensitizing them and resulting in spontaneous activity thus maintaining the continuing pain. There have been theories that persistent viral replication within the neurons causes the persistent pain [4] [5].

Prevention

Early treatment of the acute herpes zoster with antivirals has shown to be beneficial. Vaccination against the varicella zoster virus to prevent initial infection has been shown to reduce the incidence of the condition.

Summary

The neuropathic pain of postherpetic neuralgia may be severe and persistent enough to significantly decrease the quality of life, with interference of normal daily activity and sleep. The pain may persist from months to years and may recur even in successfully treated patients. Postherpetic neuralgia may be very challenging to treat.

There is variability in the definitions of postherpetic neuralgia, but the most agreed upon is persistence or recurrence of pain after the acute rash of herpes zoster subsides. Others defined it as pain persisting for four months from the initial onset of the rash.

Patient Information

Definition: Postherpetic neuralgia is a disease that occurs after a shingles attack. Shingles is a painful rash that occurs along a nerve and usually looks like a band. The pain may be persistent and last up to years. It is common in the older population.

Cause: It is caused by the chicken pox virus (varicella zoster virus). After the initial infection with chicken pox usually in childhood, the virus goes into a dormant state and hides within the nerves usually near spinal cord. When there is a drop in immunity the virus reactivates and causes shingles which may then cause postherpetic neuralgia.

Symptoms: The predominant symptom is pain which may range from burning to stabbing in nature and this pain may persist for years and affect daily activities and sleep.

Diagnosis: The diagnosis may be made by a doctor after listening to the history and usually does not require many investigations to confirm the diagnosis. The doctor may ask for a magnetic resonance imaging (MRI) of the spine to rule out other causes.

Treatment: The treatment includes medications to control the pain. Some of the medications used are the same medications used to treat depression and epilepsy. Most patients respond to these medications, but the response may be slow and more than one type of medication may have to be used to control the pain.

References

Article

  1. Dworkin RH, Portenoy RK. Pain and its persistence in herpes zoster. Pain 1996; 67:241.
  2. Burke BL, Steele RW, Beard OW, et al. Immune responses to varicella-zoster in the aged. Arch Intern Med 1982; 142:291.
  3. Helgason S, Petursson G, Gudmundsson S, Sigurdsson JA. Prevalence of postherpetic neuralgia after a first episode of herpes zoster: prospective study with long term follow up. BMJ 2000; 321:794.
  4. Woolf CJ. Recent advances in the pathophysiology of acute pain. Br J Anaesth 1989; 63:139.
  5. LaMotte RH, Shain CN, Simone DA, Tsai EF. Neurogenic hyperalgesia: psychophysical studies of underlying mechanisms. J Neurophysiol 1991; 66:190.
  6. Gilden D, Nagel MA, Mahalingam R, et al. Clinical and molecular aspects of varicella zoster virus infection. Future Neurol. Jan 1 2009;4(1):103-117
  7. Haanpaa M, Dastidar P, Weinberg A, et al. CSF and MRI findings in patients with acute herpes zoster. Neurology. Nov 1998;51(5):1405-11
  8. Argoff CE. Review of current guidelines on the care of postherpetic neuralgia. Postgrad Med 2011; 123:134.
  9. Moore RA, Wiffen PJ, Derry S, McQuay HJ. Gabapentin for chronic neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev 2011
  10. Dubinsky RM, Kabbani H, El-Chami Z, et al. Practice parameter: treatment of postherpetic neuralgia: an evidence-based report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2004; 63:959.

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Last updated: 2019-07-11 20:48