Updated: 4/19/2021

Herpes Zoster (Shingles)

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Snapshot
  • A 45-year-old woman presents to the emergency room for a rash on her face. She reports that this rash started as a small flat red rash yesterday but progressed to a very painful rash. She also reports some blurry vision in her right eye. She has a past medical history of lupus and is on long-term steroids. On physical exam, she has an extensive vesicular rash on the right side of her face involving her nose and eyes. She is admitted into the hospital for antiviral therapy, and ophthalmology is consulted.
Introduction
  • Classification
    • varicella-zoster virus (VZV)
      • an enveloped, linear double-stranded DNA virus
      • also known as human herpesvirus-3 
      • transmitted via
        • respiratory secretions
        • direct contact with skin lesions
      • causes chickenpox, herpes zoster (shingles), encephalitis, meningitis, and pneumonia
  • Epidemiology
    • demographics
      • herpes zoster in elderly population
      • encephalitis and pneumonia in the immunocompromised
      • men > women
    • risk factors
      • immunosuppression
      • advanced age
      • previous infection with VZV
  • Pathogenesis
    • the virus infects T-cells
    • the virus is often latent in the dorsal root ganglia or trigeminal ganglia
    • reactivation of the latent virus causes herpes zoster
      • often precipitated by immunocompromise or stress 
  • Prevention 
    • herpes zoster
      • recombinant vaccine
        • adults > 50 years of age
      • live vaccine
        • adults > 60 years of age
  • Prognosis
    • complete healing may take more > 1 month
Presentation
  • Symptoms 
    • preceded by prodrome of itchiness or tingling
    • painful rash
  • Physical exam
    • painful unilateral vesicular/pustular skin eruption along a single dermatome
      • does not cross midline
    • may involve the eye
      • herpes zoster opthalmicus 
      • distribution of cranial nerve V
    • may involve the ear
      • Ramsay-Hunt syndrome or herpes zoster oticus
      • distribution of cranial nerve VII
Studies
  • Labs
    • Tzanck smear
      • multinucleated giant cells
    • polymerase chain reaction
    • direct fluorescent antibody staining
  • Making the diagnosis
    • most cases are clinically diagnosed
    • in atypical cases, laboratory examination may be useful
Differential
  • Herpes simplex virus
    • distinguishing factor
      • typically does not present in a dermatomal fashion
  • Contact dermatitis
    • distinguishing factor
      • typically is more itchy than painful
Treatment
  • Management approach
    • for herpes zoster, antivirals are first-line therapy
  • Medical
    • oral antivirals 
      • indications
        • all patients with shingles
      • drugs 
        • valacyclovir
        • famciclovir
        • acyclovir
    • intravenous antivirals
      • indication
        • patients with visceral or central nervous system disease
      • drugs
        • acyclovir
    • analgesics
      • indication
        • all patients
      • drugs
        • do not give aspirin for risk of Reye syndrome
Complications
  • Disseminated disease
    • in immunocompromised patients
    • often involves the viscera
  • Post-herpetic neuralgia
    • incidence
      • very common
  • Fetal complications
    • blindness
    • scarring
    • limb hypoplasia
  • Vision loss, corneal anesthesia, and keratitis from herpes zoster opthalmicus 

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(M2.ID.15.75) A 65-year-old male is evaluated in clinic approximately six months after resolution of a herpes zoster outbreak on his left flank. He states that despite the lesions having resolved, he is still experiencing constant burning and hypersensitivity to touch in the distribution of the old rash. You explain to him that this complication can occur in 20-30% of patients after having herpes zoster. You also explain that vaccination with the shingles vaccine in individuals 60-70 years of age can reduce the incidence of this complication. What is the complication?

QID: 106722
1

Ramsay-Hunt syndrome

4%

(1/28)

2

Acute herpetic neuralgia

0%

(0/28)

3

Post-herpetic neuralgia

86%

(24/28)

4

Secondary bacterial infection

0%

(0/28)

5

Recurrent zoster

4%

(1/28)

M 6 D

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(M2.ID.14.20) A 75-year-old man presents to his primary care physician with a painful rash. He notes his side began to hurt several days prior without any visible skin changes; however, over the past 2 days a rash has developed. The patient's past medical history is only notable for diabetes mellitus type II. He was recently started on an antibiotic for sinusitis as well. In his spare time, he goes hiking and recently returned from a hiking trip 2 days ago. He is currently sexually active with both men and women. His temperature is 99.0°F (37.2°C), blood pressure is 154/88 mmHg, pulse is 83/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is notable for the finding in Figure A. Which of the following is the most likely diagnosis?

QID: 104231
FIGURES:
1

Contact dermatitis

26%

(9/34)

2

Erythema multiforme

9%

(3/34)

3

Human herpes virus 1

0%

(0/34)

4

Human herpes virus 3

62%

(21/34)

5

Human herpes virus 6

0%

(0/34)

M 6 E

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Evidence (8)
EXPERT COMMENTS (4)
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