Herpes Zoster

Varicella zoster infections (VZI), also referred to as shingles or zoster, represent reactivation of the previously dormant virus, Herpesvirus varicellae, in a patient with an altered immune response. At reactivation, the virus travels down specific sensory nerves to the skin resulting in the skin manifestations of shingles. Patients with lymphoma, leukemia, or diabetes mellitus, and who are immunocompromised, are at risk for reactivated or disseminated infection.15

The rash of herpes zoster consists of clusters of vesicles and papules grouped on an erythematous base. Vesicles initially appear clear but become cloudy or purulent over several days. They eventually rupture and crust over. The lesions usually appear along an individual dermatome [ Fig 24.1-5. (Plate. . . 31)]; less often, adjacent dermatomes are involved. The lesion clusters are usually discrete and separated by normal skin; in the severe case, the cluster may become confluent along the dermatome. Approximately 60 percent of all zoster infections involve the trunk, followed by the head, extremity, and perineal regions in decreasing incidence. 16 Unilateral involvement that abruptly halts at the midline is helpful in correctly identifying the rash; occasionally, a few lesions appear immediately beyond the midline. Involvement of the nose must prompt evaluation for corneal involvement [Fig 2,4.1-6. (Plate.. ..3.2)].

FIG. 241-5 (Plate.31). A single dermatomal involvement in a patient with herpes zoster infection in a thoracic distribution.

FIG. 241-6 (Plate.32). Herpes zoster ophthalmic infection: Facial zoster involving the ophthalmic branch of the fifth cranial nerve with nasal lesions strongly suggestive of corneal infection.

Approximately one-half of cases with VZI—particularly those patients with AIDS or reticuloendothelial malignancy—experience viremia and may exhibit solitary lesions totaling less than 30 scattered across the body. Patients with AIDS, using immunosuppressive medications, or with active reticuloendothelial malignancy more often demonstrate true dissemination in which widespread vesicular lesions are distributed evenly across the trunk, extremities, and head. In fact, patients with Hodgkin's disease are particularly prone to dissemination with 15 to 50 percent of cases demonstrating involvement of the skin, lungs, and central nervous system. Patients with disseminated herpes zoster infection require admission and treatment with parenteral antiviral therapy.

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