Presented ByShalina ShaikPGY 3 Emory Family MedicineDate: August 5, 2010
57 yo Hispanic male w/ DM, HTN, HLD presented                w/rash x 2 days.
Rash extending to back
Herpes Zoster - Shingles
What is Shingles ( Herpes Zoster )• Endogenous reactivation of latent VZV  infection within the sensory ganglia• Painful, ...
Pathogenesis
Clinical Manifestations• Rash : starts as erythematous papules, quickly  evolve into grouped vesicles or bullae. Within  3...
Rash pattern: thoracic dermatomes
Rash pattern : Cervical dermatomes
Shingles rash
Clinical Manifestations cont• Acute neuritis : 75% have prodromal pain in  the dermatome where the rash appears• Can prece...
HZV tx• Acyclovir (least expensive) 800 mg five times a day x 7  or 14 days• Valcyclovir 1000mg PO TID• Famciclovir 500 mg...
Reference pt after Tx
2 wk f/u visit
Reference pt – healed lesions
Is shingles contagious?• Can spread to children or adults who have  not had chickenpox.• Spreads through direct contact or...
Complications in immunocompetent hosts at 60 days  •   Post herpetic neuralgia – 7.9%  •   Bacterial infection – 2.3%  •  ...
Clinical recurrences• Rare in immunocompetent hosts• Do occur in immunocompromised hosts
Dictionary meaning of word shingles• 1. A thin oblong piece of material, such as wood or  slate, that is laid in overlappi...
Post herpetic neuralgia• Acute herpetic neuralgia: prodromal pain w/  rash persists upto 30 days from onset• Subacute herp...
Pathogenesis of PHN• As cellular immunity wanes with age, the virus  that lies dormant in the dorsal root ganglia  travels...
Tx of PHN•   Antidepressants: amitryptiline, nortryptiline•   Anticonvulsants: gabapentin, lyrica•   Opioids•   Capsaicin•...
Prevention of PHN• Tx of acute zoster or vaccine• Incidence reduced by 67% with vaccine• Low dose amitryptiline or nortryp...
Vaccine – Zostavax for prevention• Approved for use in adults ages 60 and over  regardless of prior HZ or not. SQ single d...
Shingles vaccine not recommended for • If allergic reaction to gelatin or the antibiotic   neomycin • Prior allergy to any...
Other forms of Herpes zoster
HZ in pregnancy• Congenital varicella not asso w/ maternal HZ  infection• Tx same as non pregnant• Acyclovir is safe
Herpes zoster ophthalmicus: nasociliary br of   ophthalmic division of trigeminal nerve
HZ ophthalmicus• Complication: permanent vision  loss if not treated.• Causes corneal ulcers and acute  retinal necrosis• ...
Herpes zoster oticus• Lesions in inner /middle ear, external canal  and pinna• Affects geniculate ganglion• Ipsilateral LM...
Summary• Identify HZ . Start tx within 72 hrs• Zostavax for 60 yrs or older• Vaccine reduces incidence of HZ by 51% &  PHN...
Chief's Conference: Shingles presentation
Chief's Conference: Shingles presentation
Chief's Conference: Shingles presentation
Chief's Conference: Shingles presentation
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Chief's Conference: Shingles presentation

  1. 1. Presented ByShalina ShaikPGY 3 Emory Family MedicineDate: August 5, 2010
  2. 2. 57 yo Hispanic male w/ DM, HTN, HLD presented w/rash x 2 days.
  3. 3. Rash extending to back
  4. 4. Herpes Zoster - Shingles
  5. 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. 6. Pathogenesis
  7. 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. 8. Rash pattern: thoracic dermatomes
  9. 9. Rash pattern : Cervical dermatomes
  10. 10. Shingles rash
  11. 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. 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. 13. Reference pt after Tx
  14. 14. 2 wk f/u visit
  15. 15. Reference pt – healed lesions
  16. 16. 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
  17. 17. 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%
  18. 18. Clinical recurrences• Rare in immunocompetent hosts• Do occur in immunocompromised hosts
  19. 19. 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 womans close-cropped haircut.
  20. 20. 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
  21. 21. 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
  22. 22. Tx of PHN• Antidepressants: amitryptiline, nortryptiline• Anticonvulsants: gabapentin, lyrica• Opioids• Capsaicin• Topical lidocaine• Steroids: role not proven
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. Other forms of Herpes zoster
  27. 27. HZ in pregnancy• Congenital varicella not asso w/ maternal HZ infection• Tx same as non pregnant• Acyclovir is safe
  28. 28. Herpes zoster ophthalmicus: nasociliary br of ophthalmic division of trigeminal nerve
  29. 29. 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
  30. 30. Herpes zoster oticus• Lesions in inner /middle ear, external canal and pinna• Affects geniculate ganglion• Ipsilateral LMN facial paralysis : Ramsay Hunt syndrome
  31. 31. 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

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