Chief's Conference: Shingles presentation

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<ul><li>1.Presented ByShalina ShaikPGY 3 Emory Family MedicineDate: August 5, 2010</li></ul> <p>2. 57 yo Hispanic male w/ DM, HTN, HLD presentedw/rash x 2 days. 3. Rash extending to back 4. Herpes Zoster - Shingles 5. What is Shingles ( Herpes Zoster ) Endogenous reactivation of latent VZVinfection within the sensory ganglia Painful, unilateral vesicular eruption restrictedto dermatomal pattern 6. Pathogenesis 7. Clinical Manifestations Rash : starts as erythematous papules, quicklyevolve into grouped vesicles or bullae. Within3 4 days Crust by 7 10 days Occ 2 or 3 neighbouring dermatomes Thoracic and lumbar dermatomes mostcommon 20% have systemic symptoms: HA/malaise/fever/fatigue 8. Rash pattern: thoracic dermatomes 9. Rash pattern : Cervical dermatomes 10. Shingles rash 11. Clinical Manifestations cont Acute neuritis : 75% have prodromal pain inthe dermatome where the rash appears Can precede the rash days to week Pain: burning, stabbing, pruritus, allodynia Confused with angina/ cholecystitis/ renalcolic depending upon dermatome Clinical dx. May need viral cx,immunoflurescence or PCR 12. HZV tx Acyclovir (least expensive) 800 mg five times a day x 7or 14 days Valcyclovir 1000mg PO TID Famciclovir 500 mg TID Initiated within 48 to 72 hrs of onset of symptoms Promote more rapid healing of lesions Decrease viral shedding Lessen the severity and duration of pain associatedwith acute neuritis and reduces PHN Recom: &gt; 50 yrs , younger than 50 benefit not clear HIV pts tx regardless of age 13. Reference pt after Tx 14. 2 wk f/u visit 15. Reference pt healed lesions 16. Is shingles contagious? Can spread to children or adults who havenot had chickenpox. Spreads through direct contact or airborneroute They develop chickenpox, not shingles Once all of blisters are crusted over, no longercontagious 17. Complications in immunocompetent hosts at 60 days Post herpetic neuralgia 7.9% Bacterial infection 2.3% Uveitis and Keratitis 1.6% Motor neuropathy 0.9% Meningitis 0.5% Herpes zoster oticus 0.2% 18. Clinical recurrences Rare in immunocompetent hosts Do occur in immunocompromised hosts 19. Dictionary meaning of word shingles 1. A thin oblong piece of material, such as wood orslate, that is laid in overlapping rows to cover theroof or sides of a house or other building. 2. Informal A small signboard, as one indicating aprofessional office. 3. A womans close-cropped haircut. 20. Post herpetic neuralgia Acute herpetic neuralgia: prodromal pain w/rash persists upto 30 days from onset Subacute herpetic neuralgia: resolves within 4months of onset PHN persists beyond 4 months from the initialonset of rash Incidence increases with age, older than 60yrs Burning, areas of anesthesia, deficits ofthermal, tactile,pinprick and vibration 21. Pathogenesis of PHN As cellular immunity wanes with age, the virusthat lies dormant in the dorsal root gangliatravels up the peripheral nerve and causesneuritis Hemorrhagic inflammation of peripheralnerve, movement of viral particles fromsensory nerves to skin and sub cut tissues 22. Tx of PHN Antidepressants: amitryptiline, nortryptiline Anticonvulsants: gabapentin, lyrica Opioids Capsaicin Topical lidocaine Steroids: role not proven 23. Prevention of PHN Tx of acute zoster or vaccine Incidence reduced by 67% with vaccine Low dose amitryptiline or nortryptilineinitiated within 2 days of rash onset ,continued for 90 days Intolerance to TCA -&gt; gabapentin, lyrica 24. Vaccine Zostavax for prevention Approved for use in adults ages 60 and overregardless of prior HZ or not. SQ single dose Reduces incidence of HZ by 51% and PHN by67% Booster dose of chickenpox vaccine thatsgiven to children Not for acute outbreak. May use w/ pts w/ hxHZ 25. Shingles vaccine not recommended for If allergic reaction to gelatin or the antibiotic neomycin Prior allergy to any component of the shingles vaccine Weakened immune system due to conditions such as leukemia, human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) Receiving treatment for cancer Being treated with drugs that suppress their immune system, including high-dose steroids Pregnant or might become pregnant within 4 weeks of getting the vaccine 26. Other forms of Herpes zoster 27. HZ in pregnancy Congenital varicella not asso w/ maternal HZinfection Tx same as non pregnant Acyclovir is safe 28. Herpes zoster ophthalmicus: nasociliary br of ophthalmic division of trigeminal nerve 29. HZ ophthalmicus Complication: permanent visionloss if not treated. Causes corneal ulcers and acuteretinal necrosis Hutchinson sign: prognosticvalue: involvement of tip of noseprecedes the development ofsevere eye inflammation Start oral antivirals and giveOphtho referral 30. Herpes zoster oticus Lesions in inner /middle ear, external canaland pinna Affects geniculate ganglion Ipsilateral LMN facial paralysis : Ramsay Huntsyndrome 31. Summary Identify HZ . Start tx within 72 hrs Zostavax for 60 yrs or older Vaccine reduces incidence of HZ by 51% &amp;PHN by 67% HZ over nose -&gt; refer to Ophtho </p>