Shingles Disease

DESCRIPTION
Herpes zoster usually presents as a painful unilateral dermatomal eruption. Zoster results from reactivation of varicella-zoster (chickenpox) virus that has been dormant in the cranial nerve and dorsal root ganglia.
  • Postherpetic neuralgia (PHN) is usually defined as pain persisting at least one month after rash has healed. Due to variable definitions of PHN used in research, the term zoster associated with pain (ZAP) may be more useful clinically.
  • System(s) affected: Skin/Exocrine, Nervous
  • Genetics: N/A
  • Incidence/Prevalence in USA:
    • 215/100,000/year; incidence is increasing as population ages
    • Occurs in 10-20% of the population at some time
    • Active herpes zoster – 23.9/100,000
    • Postherpetic neuralgia – 86/100,000
  • Predominant age:
    • Herpes zoster incidence increases with age. 80% of cases occur in persons over age 20 years (2–3 per 1000 age 20–50; 10 per 1000 >80 years)
    • Postherpetic neuralgia incidence increases dramatically with age (4% age 30–50; 50% over age 80 years)
  • Predominant sex: Male = Female
SIGNS AND SYMPTOMS
  • Prodromal phase (sensations over involved dermatome prior to rash)
    • Tingling
    • Itching
    • Boring or knifelike pain
  • Acute phase
    • Constitutional symptoms variable (fatigue, malaise, headache, low-grade fever)
    • Dermatomal rash
    • Weakness (1% may have weakness in distribution of rash)
    • Initially erythematous and maculopapular that evolves rapidly to grouped vesicles
    • Vesicles become pustular and/or hemorrhagic in 3 to 4 days
    • Resolution of rash with crusts separating by 14 to 21 days
  • Possible sine herpete (zoster without rash) and other chronic disorders associated with varicella-zoster virus without the typical rash
  • Chronic phase
    • Postherpetic neuralgia (15% overall; increases dramatically with age)
    • A small percentage (1–5%) may affect the motor nerves causing weakness, e.g., facial nerve (Ramsay Hunt syndrome), spinal motor radiculopathies
CAUSES
Reactivation of dormant varicella-zoster (chickenpox) virus in dorsal root ganglia or gasserian ganglia
RISK FACTORS
  • Increasing age
  • Compromised cell-mediated immunity in immunosuppressed patients or patients with malignancy (especially leukemia and lymphoma)
  • Spinal surgery
  • Spinal cord radiation
LABORATORY
  • Rarely necessary
  • Viral culture
  • Tzanck smear (does not distinguish from herpes simplex and false negatives occur)
  • PCR analysis and antibody testing of CSF may be valuable for diagnostic challenges

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS
  • Multinucleated giant cells with intralesional inclusion
  • Lymphatic infiltration of sensory ganglia with focal hemorrhage and nerve cell destruction
SPECIAL TESTS
N/A
IMAGING

N/A

DIAGNOSTIC PROCEDURES
Biopsy for direct immunofluorescence testing (rarely done)
APPROPRIATE HEALTH CARE

Outpatient unless disseminated or occurring as complication of serious underlying disease requiring hospitalization

GENERAL MEASURES
  • Wet dressings with tap water or 5% aluminum acetate (Burow's) applied 30 to 60 minutes, 4–6 times per day
  • Lotions such as calamine
SURGICAL MEASURES

N/A

ACTIVITY

No restrictions

DIET

No special diet

PATIENT EDUCATION
  • Duration of rash is 2–3 weeks
  • Potential for dissemination (worrisome signs, constitutional illness signs and/or spreading rash)
  • Potential postherpetic neuralgia
  • Potential risk of transmitting illness to susceptible persons
PREVENTION/AVOIDANCE
  • Varicella vaccines currently available will theoretically reduce zoster incidence in the future
  • Vaccines are being tested for prevention of herpes zoster in individuals previously infected with wild VZ virus
  • Zoster patients may transmit virus causing varicella (chickenpox) to susceptible persons
POSSIBLE COMPLICATIONS
  • Postherpetic neuralgia
  • Ocular involvement with facial zoster
  • Meningoencephalitis
  • Cutaneous dissemination
  • Superinfection of skin lesions
  • Hepatitis
  • Pneumonitis
  • Peripheral motor weakness
  • Segmental myelitis
  • Cranial nerve syndromes, especially ophthalmic and facial (Ramsay Hunt syndrome)
  • Corneal ulceration
  • Guillain-Barré syndrome
  • Arteritis, large vessel
  • Encephalitis, small vessel
EXPECTED COURSE AND PROGNOSIS
  • Resolution of acute rash within 14 to 21 days
  • Postherpetic neuralgia may occur
  • Many patients (particularly younger patients) resolve with no complications
ASSOCIATED CONDITIONS

Immunocompromise including HIV infection, transplant recipients, and malignancies

AGE-RELATED FACTORS

Pediatric:

  • Occurs rarely in children (primarily immunosuppressed)
  • Has been reported in infants primarily infected in utero

Geriatric:

  • Increased incidence
  • Increased incidence of postherpetic neuralgia

Others: N/A

PREGNANCY

Can occur during pregnancy

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations
  • Cardiology
  • Dermatology
  • General Destistry
  • Cardiology
  • Dermatology

ROLE OF HOMOEOPATHY

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