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  1. 1. DiscussionDiscussion Herpes zosterHerpes zoster Synonym: ShinglesShingles Causes: Re-activation of varicella zoster virus (VZV), related to aging, stress, impaired immune system Signs & symptoms:  Headache, fever, general malaise, burning sensation, pain (stinging, tingling, aching, numbing or throbbing)  Vesicular or bullous lesions typically appear along a single dermatome and unilateral.  Thoracic (>50%), trigeminal (10 to 20%), lumbosacral & cervical (10 to 20%)  Lymphadenopathy, sensory or motor nerve changes
  2. 2. DiscussionDiscussion Herpes zosterHerpes zoster
  3. 3. DicussionDicussion Herpes zosterHerpes zoster Signs & symptoms:  The typical rash appears in 2 to 3 days, consists of red patches of skin with small blisters filled with a serous exudate. The rash often increases over the next 3 to 5 days.  The painful vesicles eventually become cloudy or darkened as they fill with blood, crust over within 7 to 10 days.  The blisters break, forming small ulcers that begin to dry and form crusts. The crusts fall off in 2 to 3 weeks, leaving behind pink healing skin.
  4. 4. DisscussionDisscussion Herpes zosterHerpes zoster Signs & symptoms:  Herpes zoster ophthalmicus: 10~25%, ophthalmic division of trigeminal nerve.  Herpes zoster oticus (Ramsay Hunt syndrome type II): facial nerve & vestibulocochlear nerve.  Ramsay Hunt syndrome type I (dyssynergia cerebellaris myoclonica): impairment of a regulatory mechanism between cerebellar and brainstem nuclei.  Zoster sine herpete: patient that has symptoms of nerve involvement herpes zoster without cutaneous rash.  Abdominal zoster: present with severe abdominal or chest pain that precede rash by hours to days.
  5. 5. DiscussionDiscussion Herpes zosterHerpes zoster Diagnosis:  Mainly based on the appearance of the skin lesions, and previous history of chickenpox or shingles.  Tzanck smear: multinucleated acantholytic epidermal cells(Tzanck cells)  VZV antigen detection: direct fluorescent antibody (DFA)  Viral culture  WBC ↑  PCR: for viral DNA  Electron microscope: for viral particles
  6. 6. DiscussionDiscussion Herpes zosterHerpes zoster Differential diagnosis:  Prodromal stage/localized pain:  Mimic migraine, cardiac or pleural disease, acute abdomen, vertebral disease  Bell’s palsy  Conjunctivitis  Corneal ulceration & Ulcerative keratitis  Acute angle-closure glaucoma  Acute appendicitis  Cholecystitis & Biliary colic  Renal calculi  Trigeminal neuralgia
  7. 7. DiscussionDiscussion Herpes zosterHerpes zoster Differential diagnosis:  Dermatomal eruption:  Herpes simplex  Phytoallergic contact dermatitis(ivy & oak posison)  Erysipelas  Bullous impetigo  Necrotizing fasciitis
  8. 8. DiscussionDiscussion Herpes zosterHerpes zoster Epidemiology:  Age of onset: >55 y/o (>66%), <15 y/o (5%)  Incidence:  >30 y/o: at risk for reactivation of latent VZV  > 500000 cases/year  Cumulative life-time incidence: 10~20%  Individuals with HZ: 5% were HIV-infected; 5% were cancer p’t  HIV-infected individuals: 25% (eightfold)  Renal & cardiac transplant recipients: 7~9%  Postherpetic neuralgia: 20%  Risk factors:  Diminishing immunity: malignancy, immunosuppression
  9. 9. DiscussionDiscussion Herpes zosterHerpes zoster Treatment:  Goals of therapy:  Shorten the clinical course  Provide analgesia  Prevent complications  Decrease incidence of postherpetic neuralgia
  10. 10. DiscussionDiscussion Herpes zosterHerpes zoster Prognosis:  The rash and pain usually subside within 3 to 5 weeks  Postherpetic neuralgia: 20% (>60 y/o: 40%)  1 month: 60%, 3 months: 24%, 6 months: 13%  Motor paralysis: 5%  Complications:  Local: hemorrhage, gangrene  General: cranial nerve syndromes, peripheral motor weakness, cutaneous dissemination, superinfection of skin lesions, meningoencephalitis, cerebral vascular syndromes

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