Acute herpes zoster: Difference between revisions

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== Background ==
==Background==
*Caused by [[varicella zoster virus]] (VZV) causing [[Varicella]] (chicken pox) and later zoster (shingles)  
*Caused by [[varicella zoster virus]] (VZV) causing [[Varicella]] (chicken pox) and later zoster (shingles)  
*Virus is dormant in dorsal root ganglion and reactivates causing characteristic rash in dermatomal distribution  
*Virus is dormant in dorsal root ganglion and reactivates causing characteristic rash in dermatomal distribution  
*Occurs once immunity to virus declines (elderly, immunosuppressed, post transplant, HIV)
*Occurs once immunity to virus declines (elderly, immunosuppressed, post transplant, HIV)


== Clinical Features  ==
===Prevention===
[[File:Zoster.jpeg|thumbnail|Herpes Zoster]]
*Pt is contagious until lesions are crusted over
*Consider varicella-zoster immunoglobulin to immunosupressed, pregnant, neonate contacts
*Zoster vaccination if >60
 
[[File:Zoster.jpeg|thumb|Herpes Zoster]]
[[File:Shingles.jpg|thumb|Herpes Zoster]]
 
==Clinical Features==
*Prodrome: Headache, malaise, photophobia  
*Prodrome: Headache, malaise, photophobia  
*Antecedent pruritis, paresthesia, pain to dermatome 2-3 days prior to rash  
*Antecedent pruritis, paresthesia, pain to dermatome 2-3 days prior to rash  
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*Typically affects chest/face
*Typically affects chest/face


== Differential Diagnosis ==
==Differential Diagnosis==
*[[Smallpox]]
*[[Smallpox]]
*[[Cellulitis]]  
*[[Cellulitis]]  
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{{VZV types}}
{{VZV types}}


== Diagnosis==
==Diagnostic Evaluation==
===Workup===
===Workup===
[[File:Shingles.jpg|thumbnail|Herpes Zoster]]
*Generally a clinical diagnosis
*Clinical diagnosis in most cases
*May consider viral Culture, antigen, PCR of vesicle fluid
*Consider viral Culture, antigen, PCR of vesicle fluid


===Evaluation===
===Evaluation===
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**[[Encephalitis]]
**[[Encephalitis]]


== Treatment  ==
==Management==
#Pain
*Analgesia
#*PO narcotics
*Antiviral
#Antiviral
**Reduces risk/duration of postherpetic neuralgia
#*Reduces risk/duration of postherpetic neuralgia
**Immunocompetent patients:  
#*Immunocompetent patients:  
***Give [[acyclovir]] if <72hr of onset of rash or >72hr if new vesicles present/developing<ref>Cohen, J. Herpes Zoster. N Engl J Med 2013; 369:255-263. DOI: 10.1056/NEJMcp1302674</ref>  
#**Give [[acyclovir]] if <72hr of onset of rash or >72hr if new vesicles present/developing<ref>Cohen, J. Herpes Zoster. N Engl J Med 2013; 369:255-263. DOI: 10.1056/NEJMcp1302674</ref>  
***[[Acyclovir]] 800mg PO 5x/day x 7d
#**[[Acyclovir]] 800mg PO 5x/day x 7d
**Immunosuppressed patients:  
#*Immunosuppressed patients:  
***Give antiviral therapy at any stage of onset of rash  
#**Give antiviral therapy at any stage of onset of rash  
***[[Acyclovir]] 10 mg/kg IV q8h OR 800mg PO 5x/day x 7d or foscarnet for acyclovir-resistant VZV, disseminated zoster, CNS involvement, ophthalmic involvement, advanced AIDS, recent transplant
#**[[Acyclovir]] 10 mg/kg IV q8h OR 800mg PO 5x/day x 7d or foscarnet for acyclovir-resistant VZV, disseminated zoster, CNS involvement, ophthalmic involvement, advanced AIDS, recent transplant


===Not Beneficial===
===Not Beneficial===
*Steroids not shown to be beneficial
*Steroids not shown to be beneficial


== Disposition ==
==Disposition==
*Admit for disseminated VZ, CNS involvement, severely immunosupressed
*Admit for disseminated VZ, CNS involvement, severely immunosupressed
*Healing of lesions may take 4 or more weeks<ref>Sampathkumar P, et al. Herpes zoster (shingles) and postherpetic neuralgia. Mayo Clin Proc. 2009; 84(3):274–280.</ref>
*Healing of lesions may take 4 or more weeks<ref>Sampathkumar P, et al. Herpes zoster (shingles) and postherpetic neuralgia. Mayo Clin Proc. 2009; 84(3):274–280.</ref>
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*[[Necrotizing Fasciitis]]
*[[Necrotizing Fasciitis]]


==Prevention ==
==See Also==
*Pt is contagious until lesions are crusted over
*[[Herpes zoster ophthalmicus]]
*Consider varicella-zoster immunoglobulin to immunosupressed, pregnant, neonate contacts
*[[Herpes zoster oticus]] (Ramsay Hunt syndrome)
*Zoster vaccination if >60
 
== See Also ==
*[[Herpes Zoster Ophthalmicus]]
*[[Ramsay Hunt syndrome]]
*[[Generalized rashes]]
*[[Generalized rashes]]


== References ==
==References==
<references/>
<references/>


[[Category:ID]]
[[Category:ID]]

Revision as of 02:31, 8 September 2015

Background

  • Caused by varicella zoster virus (VZV) causing Varicella (chicken pox) and later zoster (shingles)
  • Virus is dormant in dorsal root ganglion and reactivates causing characteristic rash in dermatomal distribution
  • Occurs once immunity to virus declines (elderly, immunosuppressed, post transplant, HIV)

Prevention

  • Pt is contagious until lesions are crusted over
  • Consider varicella-zoster immunoglobulin to immunosupressed, pregnant, neonate contacts
  • Zoster vaccination if >60
Herpes Zoster
Herpes Zoster

Clinical Features

  • Prodrome: Headache, malaise, photophobia
  • Antecedent pruritis, paresthesia, pain to dermatome 2-3 days prior to rash
  • Maculopapular rash (see below) progresses to vesicles, may coalesce to bullae, in dermatomal distribution lasting 10-15 days
  • Does not cross midline
  • Typically affects chest/face

Differential Diagnosis

Varicella zoster virus

Diagnostic Evaluation

Workup

  • Generally a clinical diagnosis
  • May consider viral Culture, antigen, PCR of vesicle fluid

Evaluation

  • Confirm that the patient does not have:
  • Consider further evaluation for immunocompromized state (may be initial presentation of HIV) if:
    • Disseminated
    • If more than 3 or more dermatomes affected
    • Atypical illness/severe disease
  • In immunocompromized patients consider further evaluation for:

Management

  • Analgesia
  • Antiviral
    • Reduces risk/duration of postherpetic neuralgia
    • Immunocompetent patients:
      • Give acyclovir if <72hr of onset of rash or >72hr if new vesicles present/developing[1]
      • Acyclovir 800mg PO 5x/day x 7d
    • Immunosuppressed patients:
      • Give antiviral therapy at any stage of onset of rash
      • Acyclovir 10 mg/kg IV q8h OR 800mg PO 5x/day x 7d or foscarnet for acyclovir-resistant VZV, disseminated zoster, CNS involvement, ophthalmic involvement, advanced AIDS, recent transplant

Not Beneficial

  • Steroids not shown to be beneficial

Disposition

  • Admit for disseminated VZ, CNS involvement, severely immunosupressed
  • Healing of lesions may take 4 or more weeks[2]

Complications

See Also

References

  1. ↑ Cohen, J. Herpes Zoster. N Engl J Med 2013; 369:255-263. DOI: 10.1056/NEJMcp1302674
  2. ↑ Sampathkumar P, et al. Herpes zoster (shingles) and postherpetic neuralgia. Mayo Clin Proc. 2009; 84(3):274–280.
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