Presented By Shalina Shaik PGY 3 Emory Family Medicine Date: August 5, 2010

1. Chief's Conference Presented By Shalina Shaik PGY 3 EmoryFamily Medicine Date: August 5, 2010

2. 57 yo Hispanic male w/ DM, HTN, HLD presented w/rash x 2 days.

3. Rash extending to back

4. Herpes Zoster - Shingles

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. Pathogenesis

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. Rash pattern: thoracic dermatomes

9. Rash pattern : Cervical dermatomes

10. Shingles rash

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. 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. Reference pt after Tx

14. 2 wk f/u visit

15. Reference pt – healed lesions

16. Can you give shingles to others? NO

17. 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

18. 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%

19. Clinical recurrences • Rare in immunocompetent hosts • Do occur in immunocompromised hosts

20. 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 woman's close-cropped haircut.

22. 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

23. 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

24. Tx of PHN • Antidepressants: amitryptiline, nortryptiline • Anticonvulsants: gabapentin, lyrica • Opioids • Capsaicin • Topical lidocaine • Steroids: role not proven

25. 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

26. 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

27. 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

29. Other forms of Herpes zoster

30. HZ in pregnancy • Congenital varicella not asso w/ maternal HZ infection • Tx same as non pregnant • Acyclovir is safe

31. Herpes zoster ophthalmicus: nasociliary br of ophthalmic division of trigeminal nerve

32. 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

33. Herpes zoster oticus • Lesions in inner /middle ear, external canal and pinna • Affects geniculate ganglion • Ipsilateral LMN facial paralysis : Ramsay Hunt syndrome

34. 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