eMedicine Specialties > Infectious Diseases > Viral Infections

Varicella-Zoster Virus: 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

  • Patients with ocular involvement may be treated in the hospital.
  • Inpatient treatment may be appropriate for people who develop complications.
  • The main patient complaint is pain.
  • Inpatient treatment is appropriate for immunocompromised people 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

  • In May 1995, the American Academy of Pediatrics reviewed the literature on the safety and effectiveness of varicella vaccine and recommended that all susceptible children and adolescents without a contraindication receive routine varicella vaccination. They reaffirmed this recommendation in January 2000. However, many logistic and financial barriers have prevented the widespread adoption of this recommendation.
  • Both clinical varicella and zoster may occur despite vaccination. However, in 3 large studies, vaccination was 100% effective in preventing severe disease.

Complications

  • In cases of typical zoster, both streptococcal and staphylococcal superinfections are common potential complications.
    • With ocular, spinal cord, or other involvement, permanent injury is a risk. With ocular involvement, the patient may require long-term antiviral treatment.
    • One study suggests that trigeminal distribution and advanced age increase risk of complications.4
  • Other complications include the following:
    • Necrotizing fasciitis
    • Gastrointestinal complications
    • Fatal hemorrhagic encephalitis
    • Motor weakness
    • Postherpetic neuralgia (most common) (The underlying pathophysiology of the condition may involve peripheral nerve injury or continued viral activation without rash, similar to zoster sin herpete.)
    • Vasculopathy

Prognosis

  • Postherpetic neuralgia remains the most common complication of varicella-zoster virus (VZV) infection reactivation, affecting up to 50% of the patients older than 60 years. Most cases are temporary, but many cases persist chronically, impairing productivity and quality of life.
  • A landmark study by Rowbotham and Fields (1996) shows no clear relationship between loss of peripheral nerve function and postherpetic neuralgia pain.5 Although many mechanisms may cause the pain, this study helps explain the efficacy of topical agents such as capsaicin or lidocaine patches.
  • As evidence of the complexity of the issue, Oaklander and colleagues (1998) examined patients with postherpetic neuralgia and found bilateral damage in patients with unilateral shingles. Neurite loss was noted in the contralateral homologous region in test subjects who experienced no pain and had no history of shingles.6
  • Many treatment options are available for postherpetic neuralgia.
    • Oral medications
    • Topical preparations
    • Gamma knife procedures
    • Jaipur blocks

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose zoster may lead to a delay in treatment, which may increase the likelihood of postherpetic neuralgia.
  • Alleviation of pain is important. Emerging evidence suggests that adequate pain control may reduce the incidence of postherpetic neuralgia.
  • Failure to treat zoster with antiviral medication may increase the likelihood of postherpetic neuralgia. However, one study suggests this is not the case in young, otherwise healthy individuals.
  • Failure to recognize keratitis, myelitis, and encephalitis may lead to morbidity and, rarely, mortality.
  • Immunocompromised patients often take acyclovir prophylactically. Because of this, zoster may have an atypical presentation without a rash (zoster sine herpete).
  • Zoster sine herpete is a difficult diagnosis and requires high clinical suspicion.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of prior coauthor Amar Safdar, MD, to the development and writing of this article.



More on Varicella-Zoster Virus

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

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Keywords

varicella-zoster virus, VZV, VZV infection, varicella-zoster virus infection, herpes zoster, shingles, zoster, postherpetic neuralgia, PHN, disseminated VZV infection, VZV encephalitis, varicella-zoster virus encephalitis, chickenpox, disseminated varicella-zoster virus infection, keratitis, herpes ophthalmicus, myelitis, impetiginization, zoster multiplex, zoster duplex unilateralis, zoster sine herpete, Ramsay-Hunt syndrome

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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

Maria D Mileno, MD, Assistant Professor, Department of Internal Medicine, Division of Infectious Diseases, Brown University
Maria D Mileno, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, International Society of Travel Medicine, and Sigma Xi
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Gordon L Woods, MD, Consulting Staff, Department of Internal Medicine, University Medical Center
Gordon L Woods, MD is a member of the following medical societies: Society of General Internal Medicine
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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