1. Presented By
Shalina Shaik
PGY 3 Emory Family Medicine
Date: August 5, 2010

2. 57 yo Hispanic male w/ DM, HTN, HLD presented
w/rash x 2 days.

3. Rash extending to back

4. Herpes Zoster - Shingles

5. What is Shingles ( Herpes Zoster )
• Endogenous reactivation of latent VZV
infection within the sensory ganglia
• Painful, unilateral vesicular eruption restricted
to dermatomal pattern

6. Pathogenesis

7. Clinical Manifestations
• Rash : starts as erythematous papules, quickly
evolve into grouped vesicles or bullae. Within
3 – 4 days
• Crust by 7 – 10 days
• Occ 2 or 3 neighbouring dermatomes
• Thoracic and lumbar dermatomes most
common
• 20% have systemic symptoms: HA/
malaise/fever/fatigue

8. Rash pattern: thoracic dermatomes

9. Rash pattern : Cervical dermatomes

10. Shingles rash

11. Clinical Manifestations cont
• Acute neuritis : 75% have prodromal pain in
the dermatome where the rash appears
• Can precede the rash days to week
• Pain: burning, stabbing, pruritus, allodynia
• Confused with angina/ cholecystitis/ renal
colic depending upon dermatome
• Clinical dx. May need viral cx,
immunoflurescence or PCR

12. HZV tx
• Acyclovir (least expensive) 800 mg five times a day x 7
or 14 days
• Valcyclovir 1000mg PO TID
• Famciclovir 500 mg TID
• Initiated within 48 to 72 hrs of onset of symptoms
• Promote more rapid healing of lesions
• Decrease viral shedding
• Lessen the severity and duration of pain associated
with acute neuritis and reduces PHN
• Recom: > 50 yrs , younger than 50 benefit not clear
• HIV pts tx regardless of age

13. Reference pt after Tx

14. 2 wk f/u visit

15. Reference pt – healed lesions

17. Is shingles contagious?
• Can spread to children or adults who have
not had chickenpox.
• Spreads through direct contact or airborne
route
• They develop chickenpox, not shingles
• Once all of blisters are crusted over, no longer
contagious

18. Complications in immunocompetent hosts at 60 days
• Post herpetic neuralgia – 7.9%
• Bacterial infection – 2.3%
• Uveitis and Keratitis – 1.6%
• Motor neuropathy – 0.9%
• Meningitis – 0.5%
• Herpes zoster oticus – 0.2%

19. Clinical recurrences
• Rare in immunocompetent hosts
• Do occur in immunocompromised hosts

20. Dictionary meaning of word shingles
• 1. A thin oblong piece of material, such as wood or
slate, that is laid in overlapping rows to cover the
roof or sides of a house or other building.
• 2. Informal A small signboard, as one indicating a
professional office.
• 3. A woman's close-cropped haircut.

22. Post herpetic neuralgia
• Acute herpetic neuralgia: prodromal pain w/
rash persists upto 30 days from onset
• Subacute herpetic neuralgia: resolves within 4
months of onset
• PHN persists beyond 4 months from the initial
onset of rash
• Incidence increases with age, older than 60yrs
• Burning, areas of anesthesia, deficits of
thermal, tactile,pinprick and vibration

23. Pathogenesis of PHN
• As cellular immunity wanes with age, the virus
that lies dormant in the dorsal root ganglia
travels up the peripheral nerve and causes
neuritis
• Hemorrhagic inflammation of peripheral
nerve, movement of viral particles from
sensory nerves to skin and sub cut tissues

24. Tx of PHN
• Antidepressants: amitryptiline, nortryptiline
• Anticonvulsants: gabapentin, lyrica
• Opioids
• Capsaicin
• Topical lidocaine
• Steroids: role not proven

25. Prevention of PHN
• Tx of acute zoster or vaccine
• Incidence reduced by 67% with vaccine
• Low dose amitryptiline or nortryptiline
initiated within 2 days of rash onset ,
continued for 90 days
• Intolerance to TCA -> gabapentin, lyrica

26. Vaccine – Zostavax for prevention
• Approved for use in adults ages 60 and over
regardless of prior HZ or not. SQ single dose
• Reduces incidence of HZ by 51% and PHN by
67%
• Booster dose of chickenpox vaccine thats
given to children
• Not for acute outbreak. May use w/ pts w/ hx
HZ

27. Shingles vaccine not recommended for
• If allergic reaction to gelatin or the antibiotic
neomycin
• Prior allergy to any component of the shingles
vaccine
• Weakened immune system due to conditions such as
leukemia, human immunodeficiency virus (HIV) and
acquired immunodeficiency syndrome (AIDS)
• Receiving treatment for cancer
• Being treated with drugs that suppress their
immune system, including high-dose steroids
• Pregnant or might become pregnant within 4 weeks
of getting the vaccine

29. Other forms of Herpes zoster

30. HZ in pregnancy
• Congenital varicella not asso w/ maternal HZ
infection
• Tx same as non pregnant
• Acyclovir is safe

31. Herpes zoster ophthalmicus: nasociliary br of
ophthalmic division of trigeminal nerve

32. HZ ophthalmicus
• Complication: permanent vision
loss if not treated.
• Causes corneal ulcers and acute
retinal necrosis
• Hutchinson sign: prognostic
value: involvement of tip of nose
precedes the development of
severe eye inflammation
 Start oral antivirals and give
Ophtho referral

33. Herpes zoster oticus
• Lesions in inner /middle ear, external canal
and pinna
• Affects geniculate ganglion
• Ipsilateral LMN facial paralysis : Ramsay Hunt
syndrome

34. Summary
• Identify HZ . Start tx within 72 hrs
• Zostavax for 60 yrs or older
• Vaccine reduces incidence of HZ by 51% &
PHN by 67%
• HZ over nose -> refer to Ophtho