Background
Herpes zoster (shingles) is an acute, cutaneous viral infection caused by the reactivation of varicella-zoster virus (VZV), a herpes virus that initially produces chickenpox. After resolution of the primary VZV (chickenpox) infection, the virus lays dormant in the dorsal root ganglion until it undergoes local dermatomal reactivation in the form of herpes zoster (shingles).[1]
Go to Herpes Zoster, Herpes Zoster Ophthalmicus, and Herpes Zoster Oticus for complete information on these topics.
An example of herpes zoster is shown in the image below.
Herpes zoster, unilateral, trunk. Lesions
Patients present with unilateral pain followed by a unilateral vesicular rash that generally involves the skin of a single dermatome. The eruption begins as grouped vesicles on an erythematous base. These clusters of erythematous, round-to-oval lesions (2-4 mm vesicles) measure several centimeters in diameter and are oriented along the track of dermatomal innervation.
Over the ensuing days, the vesicles become pustules, and, finally, with rupture, grouped, crusted erosions are left. Lesions erupt over 7 days and develop a crust by 14-21 days.
Thoracic dermatomes are the most common site. Involvement of multiple, contiguous dermatomes is common.
Complications
Potential complications of pediatric herpes zoster include the following:
- Secondary bacterial infection
- Herpetic keratitis
- Postherpetic neuralgia (rare in the pediatric population)
- Meningoencephalitis
VZV infection may produce a facial palsy in children.[3] It may also result in zoster sine herpete (symptoms of zoster with erythematous unilateral plaque lacking vesicle formation), doing so more frequently in children than adults. In one survey of children, Ramsay Hunt syndrome (herpes zoster oticus) tended to be found in school-aged children, and zoster sine herpete was often found in preschool children.
Herpes zoster oticus may produce an acute jugular foramen syndrome.[4] It is characterized by acute-onset dysphagia and dysphonia, often accompanied or preceded by cranial, cervical, or pharyngeal pain. Herpetic vesicles on the skin or mucosa may or may not occur, may be noted late after onset, or may go undetected.
Malignancy concerns
Historically, herpes zoster (shingles) was thought to be an indicator for an underlying malignancy. Studies have shown, however, no increased incidence of malignancy in children with herpes zoster. Approximately 3% of pediatric zoster cases occur in children with malignancies. Because of this evidence, a malignancy workup is not indicated in an otherwise healthy child who has herpes zoster (shingles).
Transmission and deterrence
Herpes zoster infections are contagious to persons with no previous immunity to the VZV. However, zoster is estimated to be only one third as contagious as a primary varicella infection. Zoster is transmitted by direct contact with the lesions or by the respiratory route.
Etiology
The factors that induce the VZV (chickenpox) to reactivate are uncertain. Herpes zoster (shingles) is infrequent in healthy children. However, diminished cellular immunity seems to increase the risk of reactivation, because incidence increases with age and in immunocompromised persons.[5]
Risk factors for herpes zoster
Childhood herpes zoster has several recognized risk factors, which include the following:
- Acute lymphocytic leukemia and other malignancies
- Immunocompromised state as a result of treatments or human immunodeficiency virus (HIV)[5]
- In utero varicella exposure
- Primary VZV infection that occurred in the first year of life
- Antitumor necrosis factor-alpha agents (may pose an increased risk)[6]
- Immune reconstitution inflammatory syndrome
Immune reconstitution inflammatory syndrome (IRIS) is a paradoxical deterioration in clinical status in a patient on antiretroviral treatment, despite satisfactory control of viral replication and improvement of the patient’s CD4 count. This condition may be evident in persons with herpes zoster.
These patients may have signs and symptoms of a previously subclinical and unrecognized herpes zoster infection, as a paradoxical worsening of treatment response several weeks into therapy in the context of immune recovery on antiretroviral therapy (ART). The appearance of herpes zoster within an 8- to 12-week period after initiation of ART should prompt consideration of IRIS. Early recognition and prompt treatment, along with continuation of highly active ART, are especially important in such cases.[7]
Patients with multiple myeloma and colon cancer treated with arsenic trioxide may have a propensity to develop herpes zoster (shingles). Arsenic compounds have been suggested as a possible predisposing factor for herpes viral reactivation in these patients.[8]
Epidemiology
Incidence of herpes zoster
Lifetime incidence of herpes zoster (shingles) is 10-20%. Recurrent herpes zoster (shingles) occurs almost exclusively among people who are immunosuppressed. Approximately 25% of patients with human immunodeficiency virus (HIV) and 7-9% of patients receiving renal transplantation or cardiac transplantation experience a bout of zoster.
In the United States, zoster occurs in 300,000-500,000 individuals annually. Nearly 100% of American adults are seropositive for VZV (chickenpox) antibodies.
Racial predilection
Blacks are 25% less likely than whites to develop herpes zoster (shingles).
Age predilection
Herpes zoster (shingles) is uncommon in childhood. More than 66% of patients are older than 50 years. Of all patients with zoster, fewer than 10% are younger than 20 years, and 5% are younger than 15 years.
Although zoster is primarily a disease of adults, however, it has been noted as early as the first week of life, occurring in infants born to mothers who had primary VZV (chickenpox) infection during pregnancy.
From birth to age 9 years, the annual incidence of herpes zoster is 0.74 cases per 1000 population; in persons aged 10-19 years, the annual incidence is 1.38 cases per 1000 population; and in persons aged 20-29 years, the annual incidence is 2.58 cases per 1000 population.
Patient Education
A child can be allowed to return to school while lesions are still evident, if the lesions can be covered fully by clothing or dressings.
For more information, see the Bacterial and Viral Infections Center and Chickenpox.
[Guideline] Dworkin RH, Johnson RW, Breuer J, Gnann JW, Levin MJ, Backonja M, et al. Recommendations for the management of herpes zoster. Clin Infect Dis. Jan 1 2007;44 Suppl 1:S1-26. [Medline].
Najjar DM, Youssef OH, Flanagan JC. Palpebral subconjunctival hemorrhages in herpes zoster ophthalmicus. Ophthal Plast Reconstr Surg. Mar-Apr 2008;24(2):162-4. [Medline].
Ogita S, Terada K, Niizuma T, Kosaka Y, Kataoka N. Characteristics of facial nerve palsy during childhood in Japan: frequency of varicella-zoster virus association. Pediatr Int. Jun 2006;48(3):245-9. [Medline].
Ono N, Sakabe A, Nakajima M. [Herpes zoster oticus-associated jugular foramen syndrome]. Brain Nerve. Jan 2010;62(1):81-4. [Medline].
Wung PK, Holbrook JT, Hoffman GS, et al. Herpes zoster in immunocompromised patients: incidence, timing, and risk factors. Am J Med. Dec 2005;118(12):1416. [Medline].
Strangfeld A, Listing J, Herzer P, et al. Risk of herpes zoster in patients with rheumatoid arthritis treated with anti-TNF-alpha agents. JAMA. Feb 18 2009;301(7):737-44. [Medline].
Sharma A, Makrandi S, Modi M, Sharma A, Marfatia Y. Immune reconstitution inflammatory syndrome. Indian J Dermatol Venereol Leprol. Nov-Dec 2008;74(6):619-21. [Medline].
Nouri K, Ricotti CA Jr, Bouzari N, Chen H, Ahn E, Bach A. The incidence of recurrent herpes simplex and herpes zoster infection during treatment with arsenic trioxide. J Drugs Dermatol. Feb 2006;5(2):182-5. [Medline].
Korber A, Franckson T, Grabbe S, Dissemond J. Ambilateral reactivation of herpes zoster V2 following cataract operation of both eyes. J Eur Acad Dermatol Venereol. May 2007;21(5):712-3. [Medline].
Fernandes NF, Malliah R, Stitik TP, Rozdeba P, Lambert WC, Schwartz RA. Herpes zoster following intra-articular corticosteroid injection. Acta Dermatovenerol Alp Panonica Adriat. Mar 2009;18(1):28-30. [Medline].
Koh MJ, Seah PP, Teo RY. Zosteriform herpes simplex. Singapore Med J. Feb 2008;49(2):e59-60. [Medline].
Patel GA, Siperstein RD, Ragi G, Schwartz RA. Zosteriform lymphangioma circumscriptum. Acta Dermatovenerol Alp Panonica Adriat. Dec 2009;18(4):179-82. [Medline].
Kalpoe JS, Kroes AC, Verkerk S, et al. Clinical relevance of quantitative varicella-zoster virus (VZV) DNA detection in plasma after stem cell transplantation. Bone Marrow Transplant. Jul 2006;38(1):41-6. [Medline].
Boer A, Herder N, Blodorn-Schlicht N, Falk T. Herpes incognito most commonly is herpes zoster and its histopathologic pattern is distinctive!. Am J Dermatopathol. Apr 2006;28(2):181-6. [Medline].
Sanford M, Keating GM. Zoster vaccine (Zostavax): a review of its use in preventing herpes zoster and postherpetic neuralgia in older adults. Drugs Aging. 2010;27(2):159-76. [Medline].
Caple J. Varicella-zoster virus vaccine: a review of its use in the prevention of herpes zoster in older adults. Drugs Today (Barc). Apr 2006;42(4):249-54. [Medline].
van Hoek AJ, Gay N, Melegaro A, Opstelten W, Edmunds WJ. Estimating the cost-effectiveness of vaccination against herpes zoster in England and Wales. Vaccine. Feb 25 2009;27(9):1454-67. [Medline].
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.
Khaliq W, Alam S, Puri N. Topical lidocaine for the treatment of postherpetic neuralgia. Cochrane Database Syst Rev. 2007;(2):CD004846. [Medline].
Paster Z, Morris CM. Treatment of the localized pain of postherpetic neuralgia. Postgrad Med. Jan 2010;122(1):91-107. [Medline].
Quan D, Hammack BN, Kittelson J, Gilden DH. Improvement of postherpetic neuralgia after treatment with intravenous acyclovir followed by oral valacyclovir. Arch Neurol. Jul 2006;63(7):940-2. [Medline].
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