eMedicine Specialties > Neurology > Neurological Infections

Varicella Zoster: Follow-up

Author: Wayne E Anderson, DO, Assistant Professor of Internal Medicine/Neurology, Western University of Health Sciences; Assistant Professor of Family Medicine, Touro University College of Osteopathic Medicine; Consulting Staff in Pain Management, Department of Neurology, California Pacific Medical Center; Consulting Staff in Neurology, Department of Neurology, California Pacific Medical Center
Contributor Information and Disclosures

Updated: Nov 23, 2009

Follow-up

Further Inpatient Care

A study by Morgan and King11 showed that the eye was the most common site of zoster involvement in patients requiring hospital admission. Pain was the main complaint. Inpatient treatment is appropriate for the immunocompromised or those with atypical presentations, including myelitis.

Further Outpatient Care

Typical cases of zoster may be treated in the outpatient setting. Initial evaluation should address the possibility of atypical manifestations.

Deterrence/Prevention

  • Some studies suggest that varicella immunization may protect against future episodes.
  • Varicella vaccine substantially decreases the risk of herpes zoster among vaccinated children, based on a study by Civen and colleagues.12
  • The varicella vaccine may stimulate immunity in seropositive adults, suggesting that the vaccine may constitute treatment and perhaps prevention of zoster (even with previous exposure to chickenpox).
  • However, the patient should be informed that both clinical varicella and zoster may follow the vaccine.

Complications

  • In cases of typical dermatomal zoster, superinfection with streptococci or staphylococci commonly occurs.
  • Ocular, spinal cord, or other involvement carries a risk of permanent injury, although the myelitis tends to resolve.
  • Galil et al noted that trigeminal distribution and/or advanced age increase the risk of complications.13
  • With ocular involvement, long-term antiviral treatment may be required.
  • Dermatologic superinfection may occur. Necrotizing fasciitis is another possible complication.
  • Vasculopathy is a potentially serious complication of reactivation of VZV.
  • Hong and Elgart have reported gastrointestinal complications.14
  • Westenend and Hoppenbrouwers have reported fatal hemorrhagic encephalitis in an otherwise healthy female.4
  • Motor involvement is not uncommon.
  • PHN is the most common complication, affecting as many as 50% of patients older than 60 years. The underlying pathophysiology of PHN may involve peripheral nerve damage or continued viral activity.
  • VZV is being investigated for it's possible role in least some cases of chronic fatigue syndrome.15

Prognosis

  • PHN may persist chronically, although most cases eventually resolve. Pain probably localizes to a region of peripheral nerve damage.
  • In a landmark study by Rowbotham and Fields, no clear relationship was shown between loss of peripheral nerve function and PHN pain.16
    • These authors stated that "preservation of several sensory modalities in their area of maximal pain suggests that, in some PHN patients, activity in primary afferent nociceptors that remain connected to both their peripheral and central targets contributes significantly to ongoing pain."
    • Although several mechanisms may be involved in pain generation, this study helped to explain the efficacy of topical agents such as capsaicin or, as noted by Rowbotham and colleagues in a different study17 , lidocaine patches.
  • As evidence of the complexity of the issue, Oaklander and coworkers found bilateral damage in cases of PHN from unilateral shingles.18 Neurite loss was noted in the contralateral homologous region in test subjects who had no pain and no shingles on that side.
  • Many treatment options are available for PHN, including oral and topical medications, gamma knife procedures, and Jaipur blocks.
  • Gilden and colleagues argue that PHN may result from persistent active viral activity akin to zoster sine herpete.19

Patient Education

For excellent patient education resources, visit eMedicine's Bacterial and Viral Infections Center. Also, see eMedicine's patient education articles Shingles and Chickenpox.

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose zoster may delay treatment and increase the possibility of PHN.
  • Failure to reduce pain and suffering, even if opioid therapy is required, is problematic, especially with emerging evidence that adequate pain control acutely may reduce the incidence of PHN.
  • Failure to treat zoster with antiviral medication may increase the likelihood of PHN.
    • One study by Kubeyinje concluded that acyclovir did not decrease acute pain duration in healthy young adults with typical zoster.10
    • The author also noted that, in healthy young adults, complications "were few and similar in the two groups."
  • Failure to recognize keratitis, myelitis, encephalitis, and other manifestations may lead to morbidity and, rarely, death.
  • Immunocompromised patients often take acyclovir prophylactically. In these patients, zoster may have an atypical presentation without a rash (ie, zoster sine herpete).
 


More on Varicella Zoster

Overview: Varicella Zoster
Differential Diagnoses & Workup: Varicella Zoster
Treatment & Medication: Varicella Zoster
Follow-up: Varicella Zoster
Multimedia: Varicella Zoster
References
Further Reading
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References

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  2. Goh CL, Khoo L. A retrospective study of the clinical presentation and outcome of herpes zoster in a tertiary dermatology outpatient referral clinic. Int J Dermatol. Sep 1997;36(9):667-72. [Medline].

  3. Devinsky O, Cho ES, Petito CK, Price RW. Herpes zoster myelitis. Brain. Jun 1991;114 ( Pt 3):1181-96. [Medline].

  4. Westenend PJ, Hoppenbrouwers WJ. [Fatal varicella-zoster encephalitis; a rare complication of herpes zoster]. Ned Tijdschr Geneeskd. Mar 21 1998;142(12):654-7. [Medline].

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Keywords

varicella-zoster, VSV, varicella-zoster virus, zoster treatment, zoster symptoms, VZV infection, chickenpox, chicken pox, herpes zoster, shingles, Ramsay-Hunt syndrome, zoster multiplex, zoster sine herpete, keratitis, postherpetic neuralgia, PHN, varicella zoster

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Contributor Information and Disclosures

Author

Wayne E Anderson, DO, Assistant Professor of Internal Medicine/Neurology, Western University of Health Sciences; Assistant Professor of Family Medicine, Touro University College of Osteopathic Medicine; Consulting Staff in Pain Management, Department of Neurology, California Pacific Medical Center; Consulting Staff in Neurology, Department of Neurology, California Pacific Medical Center
Wayne E Anderson, DO is a member of the following medical societies: American Academy of Neurology, American Medical Association, American Society of Law Medicine and Ethics, California Medical Association, and San Francisco Medical Society
Disclosure: Cephalon Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; King Honoraria Consulting

Medical Editor

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Paraplegia Society, and National Multiple Sclerosis Society
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

 
 
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