Introduction
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).
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 risk of reactivation because incidence increases with age and in immunocompromised states.
Herpes zoster, unilateral, trunk.
Pathophysiology
Herpes zoster (shingles) is a cutaneous viral infection; patients present with a vesicular rash that generally involves the skin of a single unilateral dermatome. Approximately 4-5 days before the eruption appears, the patient may experience preeruptive pain, itching, or burning along the affected dermatome.
Historically, herpes zoster (shingles) was thought to be an indicator for an underlying malignancy. More recent studies have shown no increased incidence of malignancy in children with herpes zoster (shingles). 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).
Frequency
United States
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, it has been noted as early as the first week of life. This occurs in infants born to mothers who had primary VZV (chickenpox) infection during pregnancy.
Incidence of the disease increases with age throughout childhood and adult life. Lifetime incidence is 10-20%. Approximately 25% of patients with human immunodeficiency virus (HIV) and 7-9% of patients receiving renal transplantation and cardiac transplantation experience a bout of zoster. Recurrent herpes zoster (shingles) occurs almost exclusively among people who are immunosuppressed.
In the United States, zoster occurs in 300,000-500,000 individuals annually. Nearly 100% of American adults are seropositive for VZV (chickenpox) antibodies. Since routine use of the live attenuated varicella vaccine began in 1994, preliminary observations have revealed that zoster frequency is significantly higher among children who had natural exposure to VZV (chickenpox), compared with those who were vaccinated.
Race
Blacks are 25% less likely than whites to develop herpes zoster (shingles).
Sex
Men and women are equally affected.
Age
Incidence increases with age. From birth to age 9 years, annual incidence is 0.74 cases per 1000 population; in persons aged 10-19 years, annual incidence is 1.38 cases per 1000 population; and in persons aged 20-29 years, annual incidence is 2.58 cases per 1000 population.
Clinical
History
- Children commonly experience systemic symptoms before cutaneous manifestations erupt. Acute phase symptoms include the following:
- Pain: This may occasionally be so severe that it may mimic appendicitis, renal calculi, or biliary colic.
- Pruritus
- Low-grade fever
- Malaise
- Headache
- Regional lymphadenopathy
- 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.1
- Herpes zoster (shingles) in childhood is unusual.2 This reactivation of varicella zoster virus (VZV) is seen with increased frequency in otherwise healthy children who acquire VZV (chickenpox) either in utero or within the first year of life.
- VZV (chickenpox) infection may produce a facial palsy in children.3 It may also result in zoster sine herpete and does so more frequently in children than adults. In one survey of children, Ramsay Hunt syndrome tended to be found in school-aged children, and zoster sine herpete was often found in preschool children.
- Ambilateral reactivation of herpes zoster V2 following cataract operation of both eyes has been described.4
Physical
- A unilateral dermatomal eruption begins as grouped vesicles on an erythematous base. These round-to-oval red lesions with surmounting clear fluid-filled blisters usually measure several centimeters in diameter and are oriented along the track of dermatomal innervation. Over the ensuing days, the fluid becomes cloudy and pustular, and, finally, with rupture of the blisters, grouped crusted erosions are left. Thoracic dermatomes are the most common site, and involvement of multiple contiguous dermatomes is common. Lesions erupt over 7 days and develop a crust by 14-21 days.
- Approximately 17-35% of patients with herpes zoster also have a few scattered vesicles in sites remote from the primary dermatome. This is likely secondary to viremia and should not be confused with generalized herpes zoster (shingles). The generalized form occurs in 2-10% of patients with herpes zoster (shingles).
- Physical examination should include a slit lamp examination for corneal findings if lesions are found in the distribution of the V1 branch of the trigeminal nerve.
- Zoster sine herpete appears as a tender erythematous unilateral patch or plaque without vesicle or bullae formation. It tends to be preceded by dysthesias, as is typical herpes zoster (shingles).
- Herpes zoster ophthalmicus can be initially evident in the eyelids.5 Careful follow-up with attention to the eyelids and eyelid eversion is recommended in patients with herpes zoster to detect early ocular involvement.
Causes
Although VZV (chickenpox) reactivates for unknown reasons, childhood herpes zoster (shingles) has several recognized risk factors. These include the following:
- Acute lymphocytic leukemia and other malignancies
- Immunocompromised state as a result of treatments or human immunodeficiency virus (HIV)
- Immune reconstitution inflammatory syndrome: This is a paradoxical deterioration in clinical status in a patient on antiretroviral treatment despite satisfactory control of viral replication and improvement of CD4 count, may be evident with herpes zoster; early recognition and prompt treatment, along with continuation of highly active antiretroviral treatment, are especially important in this case.6
- In utero varicella exposure
- Primary VZV infection (chickenpox) that occurred in the first year of life
- Antitumor necrosis factor alpha agents (may pose an increased risk)7
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References
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Further Reading
Keywords
zoster, herpes zoster, shingles, varicella-zoster virus, VZV, chickenpox, vesicular rash, human immunodeficiency virus, HIV, cardiac transplant, renal transplant, appendicitis, renal calculi, biliary colic, myeloma, colon cancer, lymphadenopathy, treatment, diagnosis
