Felix Black posted an update 2 months, 1 week ago
Shingles (Saint Anthony fire; acute back Ganglionite)
Shingles is an infection that results from the reactivation of the varicella-zoster virus from its latent state in a dorsal root ganglion. The symptoms usually begin with pain along the affected dermatome, followed after 2-3 days by a vesicular eruption which is usually diagnostic. The treatment consists of antiviral drugs given within 72 h of the appearance of the skin lesions.
Chickenpox and shingles are caused by the varicella-zoster virus (human herpesvirus 3); chickenpox is the acute invasive phase of the virus, while herpes zoster (shingles) represents the reactivation of the latent phase.
Shingles inflames the sensory ganglia, the skin of the associated dermatomer, and, sometimes, the anterior and posterior horns of the gray matter, the meninges, and the dorsal and ventral roots. Shingles occur frequently in elderly and HIV-positive patients and is more severe in immunosuppressed patients, since cell-mediated immunity is decreased in these patients. There are no well-defined precipitating factors.
Lancinating, dysesthesic or other characteristics pain develops in the site concerned, followed after 2-3 days by an eruption, generally characterized by groups of vesicles on an erythematous base. The site usually corresponds to one or more adjacent dermatomers of the thoracolumbar region, although some satellite lesions may also appear. The lesions are typically unilateral. The area is often hyperesthetic, and the pain can be severe. The lesions generally continue to form for about 3-5 days.
Shingles can spread to other regions of the skin and visceral organs, particularly in immunocompromised patients.
The zoster geniculate (Ramsay Hunt syndrome, herpes zoster oticus) derives from the participation of the geniculate ganglion. Otalgia, facial paralysis, and sometimes dizziness occur. A vesicular eruption occurs in the external auditory canal and ageusia may occur at the level of the two anterior thirds of the tongue.
Ophthalmic herpes zoster is due to involvement of the Gasser ganglion, with pain and vesicular eruption around the eye and on the forehead, in the distribution area of the ophthalmic branch of the V cranial nerve.The eye disease can be serious. Vesicles on the tip of the nose (Hutchinson’s sign) indicate involvement of the nasociliary branch, with a high risk of severe eye involvement. However, eye involvement can occur in the absence of lesions on the tip of the nose.
Oral zoster is rare but may produce a precise unilateral distribution of lesions. No prodromal symptoms are observed in the oral cavity.
Less than 4% of patients with shingles have recurrences. However, many individuals, particularly the elderly, have persistent or recurrent pain in the area involved (postherpetic neuralgia), which may persist for months or years or permanently.
The pain of post-herpetic neuralgia can be punctual and intermittent or constant and can be very debilitating.
Shingles must be suspected in patients with the characteristic eruptions and sometimes even before the rash appears if the patients have the typical dermatomal distribution pains. The diagnosis is usually based on the practically pathognomonic eruption.
If the diagnosis is doubtful, detection of multinucleated giant cells with the Tzanck test may confirm herpes simplex infection. The herpes simplex virus can produce almost identical lesions, but unlike herpes zoster, it tends to recur and has no dermatomical distribution. Viruses can be identified by culture tests or PCR (polymerase chain reaction). The detection of the Ag in a bioptic sample may be useful.
Antivirals (acyclovir, famciclovir, valaciclovir) in particular for immunocompromised patients
Wet compresses soothe pain but often it is necessary to use systemic analgesics.
For the treatment of ophthalmic herpes zoster, an ophthalmologist should be consulted. For the treatment of herpes zoster otico, an otolaryngologist should be consulted.
A new recombinant zoster vaccine is recommended for immunocompetent adults ≥ 50 years old who have had shingles or who have received the oldest live attenuated vaccine; 2 doses are administered 2 to
6 months from each other and at least 2 months after the live attenuated vaccine (for more information, see Recommendations of the kamagraapotheek.nl for Use of Herpes Zoster Vaccines). The most recent recombinant vaccine seems to provide better and more lasting protection than the old vaccine with attenuated live single-dose virus. For immunocompetent adults ≥ 60 years, recombinant vaccine or live attenuated vaccine is recommended, but recombinant vaccine is preferred. There are currently no data on the efficacy of the recombinant vaccine in immunocompromised patients and no recommendation for its use in immunocompromised patients. Live attenuated vaccine is contraindicated in immunocompromised patients.