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Herpes Zoster and PHN

Herpes Zoster and PHN. Herpes Zoster. Historic Aspect Incidence Pathology Clinical manifestion Different diagnosis Therapy. Historic Aspect. Herpes Zoster(shingles) is an acute infectious disease caused by herpes zoster virus belonging to the DNA group of viruses.

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Herpes Zoster and PHN

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  1. Herpes Zoster and PHN

  2. Herpes Zoster • Historic Aspect • Incidence • Pathology • Clinical manifestion • Different diagnosis • Therapy

  3. Historic Aspect • Herpes Zoster(shingles) is an acute infectious disease caused by herpes zoster virus belonging to the DNA group of viruses. • It primarily affects the posterior spinal root ganglion of the spinal nerves. • Greek language; herpes means “to chronic cutaneous diseases” , zoster means a belt. • Herpes zoster describes the girdle-like vesicular eruption of the disease in the trunk.

  4. Incidence • Overall incidence of HZ: 131 per 100,000 person-years. • No gender difference. • Directly related to age; 75 years and older > younger than 14 years-tenfold • Dermatomes; thoracic dermatomes and the opthalmic division of the trigeminal nerve. • More common and severe in immunosuppressed patients(Lymphoma, chronic lymphocytic leukemia, radiation therapy, chemotherapy, lupus erythematosus.) • A small percentage of patients(5%) have a recurrence of HZ.-same dermatome.

  5. Pathology • The virus that causes varicella gains to the sensory nerves in skin and passes to the dorsal ganglion cell in which it lies dormant. • Latent virus becomes reactivated often immune mechanisms are impaired. • An intense necrotizing reaction is seen in the dorsal root ganglia, peripheral nerves, dorsal horn of the spinal cord.

  6. Clinical Consideration • Symptoms and Signs • Differential Diagnosis • Immunologic response • Therapy • complication • Conclusion

  7. Symptoms and Sign 1 • Commences with pain,paresthesia,and dysesthesia in the afflicted dermatome,followed in a few days(4-5days) by vesicular eruption. • At first the pain is mild but may increase in intensity over the succeeding days. • Pain: sharp, shooting,dull,aching,burning • Systemic symptoms(5%) • ( fever,malaise,headache, nausea,stiff neck,regional or diffuse adenopathy) • Localized erythema and swelling,red papules,vesicles,blebs, pustules,crust,(2-3wk) • Erythema , bleb, sharp pain –resolve during 3rd wks. • Scales of the encrusting blebs begin to fall off –leaving irregular pink scar (5th wks) • Older patients are more severe pain in the acute stage than younger patients.

  8. Symptoms and Sign 2 • Ophthalmic zoster • Opthalmic division of the trigeminal nerve • Ramsay Hunt syndrome • Varicella Zoster of the geniculate ganglion. • 7th cranial nerve involve-unilateral facial paralysis • Sacral Zoster(S2, S3, S4 dermatomes) • Neurogenic bladder with urinary hesitancy or retention.

  9. OpthalmicZoster • First branch of the Fifth nerve(V1)

  10. Dermatomes

  11. Mandibular branch of the Fifth nerve(V3)

  12. Third cervical nerve(C3)

  13. Thoracic 4th nerve(T4)

  14. Thoracic 4th nerve(T4)

  15. Thoracic 6th nerve(T6)

  16. Thoracic 10th nerve(T10)

  17. The 3rd lumbar nerve(L3)

  18. Closeup view of lesion:

  19. On the back – thoracic nerve

  20. On the back – thoracic nerve

  21. Fingers – digital nerves

  22. Disseminated Herpes

  23. Differential diagnosis • Herpes simplex • Poison ivy • Zoster sine herpete • painful disease can occur without cutaneous vesicles • Cellulitis

  24. Immunologic response

  25. Goals of therapy • Abort segmental infection • Prevent viral spread beyond the primary unit • Prevent tissue injury(cytolysis) • Prevent postherpetic neuralgia

  26. Therapy 1) Nerve Blocks 2) Antiviral agents 2) Antiinflammatory agents 3) Systemic analgesics and ajuvant agents 4) Miscellaneous techniques

  27. Nerve block • Local anesthetic infiltration-skin lesion healing, PHN-incidence & severity-reducing • Peripheral & sympathetic nerve block restoration of intraneural bl flow, preservation of large fibers Reducing the development ofPHN

  28. Antiviral Agents • Acyclovir: 800mg five times a day • Valacyclovir: 1g three times a day • Famciclovir: 500mg three times a day • Decrease pain • Hasten healing of the rash • Reduce the duration of PHN • Act to competitively inhibit DNA polymerase, terminating DNA synthesis and viral replication

  29. corticosteroid • Pain relief in the acute phase • Shorten the time to fall crusting of lesions • Frequantly used prior to the development of antiviral agents • Adverse events-not recommend

  30. Systemic analgesic and ajuvant agents • Acetaminophen,NSAID,Opioid • Low dose tricyclic antidepressant therapy(amitriptyline 10-25mg po before bedtime)

  31. Complication • Neuralgia • Facial or oculomotor palsy • Paralysis of motor nerves • Myelitis • Meningoencephalitis • Postherpetic Neuralgia • Systemic toxicity-dissemination • Fever,Chills, • Bacterial sepsis, • Varicella pnumonias

  32. Postherpetic neuralgia • Pain persisting beyond the crusting of lesions or beyond 4wks, 6wks, 2mons, or 6mons. • Similar to herpes zoster neuralgia • Burning, aching, itching, • severe paroxysm of stabbing or burning pain • Allodynia-87% of PHN • Hyperesthesia, dysesthesia, anesthesia

  33. Therapy of PHN • Antidepressant • Neuroleptics • Anticonvulsants • Opioids • Topical agents • Nerve blocks • Tens • Acupuncture

  34. Nerve block • Local infiltration • Somatic nerve block • Sympathetic nerve block • Epidural block • Neurolytic block

  35. Local infiltration • Epstein:SQ infiltration(steroid)-64% pain relief • Tio,Moya,Verasan,-SQ infiltration of 0.25% bupivacaine & 0.2% triamcinolone alone –70% improve

  36. Somatic nerve block Sensory nerve blocks are in early attempts to relieve its pain.success in managing pain in early stages of the disease-results are limited. Nerve blocks are primarily used in postherpetic neuralgia for diagnosis and prognosis,esp as a prognostic block before neurolytic block. Steroid injected around the dorsal nerve block. Steroids injected around the dorsal nerve have had unpredictable and limited success.

  37. Sympathetic nerve block • Bonica reported good –temporary-0.2%pucaine(somatic sympathetic block)-4days interval-PHN(under 2month)-best result. • Colding-concluded that sympathetic blocks for established PHN were no value.

  38. Miscellous therapy of PHN • acupuncture

  39. Conclusion • Prompt tx shortens the progressive course and decreases severity • Correlation between the age of the patient and the response to therapy • Older patients do not respond to therapy and specifically to sympathetic nerve blocks. • 40% of patients remain totally refractory or unsatisfactorily relieved. • 50%(approx) of patients improve over the years: one-half of these are receiving no tx • Strategies to prevent the onset of HZ in addition to the attempt to prevent the onset of PHN after the onset of HZ

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