Neurological Manifestations of Varicella Zoster Follow-up

  • Author: Wayne E Anderson, DO; Chief Editor: Karen L Roos, MD   more...
 
Updated: May 11, 2011
 

Further Inpatient Care

A study by Morgan and King[12] 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.

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Further Outpatient Care

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

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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.[13]
  • 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.
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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.[14]
  • 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.[15]
  • 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.[16]
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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.[17]
    • 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 study[18] , lidocaine patches.
  • As evidence of the complexity of the issue, Oaklander and coworkers found bilateral damage in cases of PHN from unilateral shingles.[19] 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.[20]
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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.

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Contributor Information and Disclosures
Author

Wayne E Anderson, DO  Assistant Professor of Internal Medicine/Neurology, College of Osteopathic Medicine of the Pacific Western University of Health Sciences; Clinical Faculty in Family Medicine, Touro University College of Osteopathic Medicine; Clinical Instructor, Departments of Neurology and Pain Management, 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 & Ethics, California Medical Association, and San Francisco Medical Society

Disclosure: Cephalon Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; King Honoraria Speaking and teaching; Forest Honoraria Speaking and teaching

Specialty Editor Board

J Stephen Huff, MD  Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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; Director, Neuropathy Association Center of Excellence, Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University School of Medicine

Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Neurological Association, American Paraplegia Society, Consortium of Multiple Sclerosis Centers, and National Multiple Sclerosis Society

Disclosure: Nothing to disclose.

Chief Editor

Karen L Roos, MD  John and Nancy Nelson Professor of Neurology, Professor of Neurological Surgery, Department of Neurology, Indiana University School of Medicine

Karen L Roos, MD is a member of the following medical societies: American Academy of Neurology and American Neurological Association

Disclosure: Nothing to disclose.

References

  1. Ertunc V, Dane S, Karakuzu A, Deniz O. Higher herpes zoster infection frequency in right-handed patients and more frequent appearance in the left body side of females. Acta Derm Venereol. May 1997;77(3):245. [Medline].

  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].

  5. Svozilkova P, Rihova E, Diblik P, et al. Varicella zoster virus acute retinal necrosis following eye contusion: case report. Virol J. Aug 31 2005;2:77. [Medline].

  6. Furuta Y, Fukuda S, Suzuki S, et al. Detection of varicella-zoster virus DNA in patients with acute peripheral facial palsy by the polymerase chain reaction, and its use for early diagnosis of zoster sine herpete. J Med Virol. Jul 1997;52(3):316-9. [Medline].

  7. Fabian VA, Wood B, Crowley P, Kakulas BA. Herpes zoster brachial plexus neuritis. Clin Neuropathol. Mar-Apr 1997;16(2):61-4. [Medline].

  8. Cresswell F, Eadie J, Longley N, Macallan D. Severe Guillain-Barré syndrome following primary infection with varicella zoster virus in an adult. Int J Infect Dis. Jun 5 2009;[Medline].

  9. Stein GE. Pharmacology of new antiherpes agents: famciclovir and valacyclovir. J Am Pharm Assoc (Wash). Mar-Apr 1997;NS37(2):157-63. [Medline].

  10. Kubeyinje EP. Cost-benefit of oral acyclovir in the treatment of herpes zoster. Int J Dermatol. Jun 1997;36(6):457-9. [Medline].

  11. Schmader K, Levin M, Gnann J, McNeil S, Vesikari T, et al. Efficacy, immunogenicity, safety, and tolerability of zoster vaccine (ZV) in subjects 50 to 59 years of age (Poster/Abstract). Infectious Diseases Society of America. The 48th Annual Meeting of the Infectious Diseases Society of America. 10-21-2010;Vancouver, British Columbia, Canada:Ref Type: Abstract: 3363.

  12. Morgan R, King D. Characteristics of patients with shingles admitted to a district general hospital. Postgrad Med J. Feb 1998;74(868):101-3. [Medline].

  13. Civen R, Chaves SS, Jumaan A, Wu H, Mascola L, Gargiullo P, et al. The Incidence and Clinical Characteristics of Herpes Zoster Among Children and Adolescents After Implementation of Varicella Vaccination. Pediatr Infect Dis J. Jun 16 2009;[Medline].

  14. Galil K, Choo PW, Donahue JG, Platt R. The sequelae of herpes zoster. Arch Intern Med. Jun 9 1997;157(11):1209-13. [Medline].

  15. Hong JJ, Elgart ML. Gastrointestinal complications of dermatomal herpes zoster successfully treated with famciclovir and lactulose. J Am Acad Dermatol. Feb 1998;38(2 Pt 1):279-80. [Medline].

  16. Shapiro JS. Does varicella-zoster virus infection of the peripheral ganglia cause Chronic Fatigue Syndrome?. Med Hypotheses. Jun 9 2009;[Medline].

  17. Rowbotham MC, Fields HL. The relationship of pain, allodynia and thermal sensation in post-herpetic neuralgia. Brain. Apr 1996;119 (Pt 2):347-54. [Medline].

  18. Rowbotham MC, Davies PS, Verkempinck C, Galer BS. Lidocaine patch: double-blind controlled study of a new treatment method for post-herpetic neuralgia. Pain. Apr 1996;65(1):39-44. [Medline].

  19. Oaklander AL, Romans K, Horasek S, et al. Unilateral postherpetic neuralgia is associated with bilateral sensory neuron damage. Ann Neurol. Nov 1998;44(5):789-95. [Medline].

  20. Gilden DH, Cohrs RJ, Mahalingam R. VZV vasculopathy and postherpetic neuralgia: progress and perspective on antiviral therapy. Neurology. Jan 11 2005;64(1):21-5. [Medline].

  21. Baik JS, Kim WC, Heo JH, Zheng HY. Recurrent herpes zoster myelitis. J Korean Med Sci. Aug 1997;12(4):360-3. [Medline].

  22. Carreau JP, Gola R, Cheynet F, Guyot L. [Zona of the cranial nerves. Current aspects]. Rev Stomatol Chir Maxillofac. Oct 1998;99(3):155-64. [Medline].

  23. Cohen JI. Varicella-zoster virus. The virus. Infect Dis Clin North Am. Sep 1996;10(3):457-68. [Medline].

  24. Cohen JI, Brunell PA, Straus SE, Krause PR. Recent advances in varicella-zoster virus infection. Ann Intern Med. Jun 1 1999;130(11):922-32. [Medline].

  25. Feder HM, LaRussa P, Steinberg S, Gershon AA. Clinical varicella following varicella vaccination: don't be fooled. Pediatrics. Jun 1997;99(6):897-9. [Medline].

  26. Goldman GS. Universal varicella vaccination: efficacy trends and effect on herpes zoster. Int J Toxicol. Jul-Aug 2005;24(4):205-13. [Medline].

  27. Liang MG, Heidelberg KA, Jacobson RM, McEvoy MT. Herpes zoster after varicella immunization. J Am Acad Dermatol. May 1998;38(5 Pt 1):761-3. [Medline].

  28. Mainka C, Fuss B, Geiger H, et al. Characterization of viremia at different stages of varicella-zoster virus infection. J Med Virol. Sep 1998;56(1):91-8. [Medline].

  29. Makeham TP, Croxson GR, Coulson S. Infective causes of facial nerve paralysis. Otol Neurotol. Jan 2007;28(1):100-3. [Medline].

  30. Sawyer AR, Williams G. Misdiagnosis of burns: herpes zoster ophthalmicus. J Burn Care Res. Nov-Dec 2006;27(6):914-6. [Medline].

  31. Sjaastad O, Bakketeig LS. The rare, unilateral headaches. Vaga study of headache epidemiology. J Headache Pain. Feb 2007;8(1):19-27. [Medline].

  32. Sparks L, Russell C. The new varicella vaccine: efficacy, safety, and administration. J Pediatr Nurs. Apr 1998;13(2):85-94. [Medline].

  33. Spiegel R, Miron D, Lumelsky D, Horovitz Y. Severe Meningoencephalitis Due to Late Reactivation of Varicella-Zoster Virus in an Immunocompetent Child. J Child Neurol. Jun 3 2009;[Medline].

  34. Vu AQ, Radonich MA, Heald PW. Herpes zoster in seven disparate dermatomes (zoster multiplex): report of a case and review of the literature. J Am Acad Dermatol. May 1999;40(5 Pt 2):868-9. [Medline].

  35. Wlodaver CG, Privett T, Livengood G. The merits of varicella vaccination for varicella non-immune health care workers. J Okla State Med Assoc. Dec 1996;89(12):430-2. [Medline].

  36. Yi JY, Kim TY, Shim JH, et al. Histopathological findings, viral DNA distribution and lymphocytic immunophenotypes in vesicular and papular types of herpes zoster. Acta Derm Venereol. May 1997;77(3):194-7. [Medline].

 
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Herpes zoster in the ophthalmic (V1) distribution of the trigeminal nerve. Note the unilateral distribution of the rash and how the V1 distribution may extend to the tip of the nose. Though at risk for keratitis with zoster in this distribution, the patient had a normal ocular examination. Patient consented to picture distribution for educational use; written permission on file; contributed by JS Huff.
 
 
 
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