Shingles (zoster)

Question 1

Aetiology and risk factors of shingles

Answer 1

reactivation of latent VZV in the dorsal root ganglia and cranial nerves (Shingles)

> 50 years
Female
HIV
Chronic corticosteroid use
Chemo
Malignancies
White

Question 2

Symptoms of shingles

Answer 2

Prodromal malaise or fatigue

Localised pain in a dermatome
- Burning, stinging, itching or tingling
- Pain can precede the rash by days to weeks
- Thoracic and trigeminal dermatome
Rash
- Pruritic
- Maculopapular → clear vesicles → pustulates → crust
- Dermatomal distribution, does not cross the midline
Trigeminal nerve affected → Corneal ulceration → pain and reduced vision
Fever
Headache
Prodromal malaise or fatigue

Question 3

Management for shingles

Answer 3

Consider admission

Within 72h rash onset:
1. Famciclovir 500mg orally every 8 hours for 7 days OR valaciclovir 1000mg orally every 8 hours for 7 days
2. Mild pain → Paracetamol 500-1000mg orally every 4-6 hours AND calamine lotion topical
3. Moderate-severe pain → Amitryptiline, Duloxetine, Gabapentin, Pregabalin, Oxycodone 5mg PO, PO corticosteroids
± topical lidocaine or calamine

Question 4

What would necessitate admission in shingles

Answer 4

Serious complications (meningitis, encephalitis, myelitis)
Hutchinson’s sign (rash on tip, side, or root of nose)
Visual symptoms
Unexplained red eye
Severe immunocompromise

Question 5

Management for post-herpetic pain and neuralgia

Answer 5

Pain:
Paracetamol
Capsaicin topical
Tramadol

Neuralgia:
Amitryptiline
Duloxetine
Gabapentin
Pregabalin

Question 6

Complications of shingles

Answer 6

HZ ophthalmicus → keratitis, corneal ulceration, conjunctivitis, optic neuritis, retinitis, glaucoma
Superinfection of skin lesions
CNS: Encephalitis, meningoencephalitis, myelitis, GBS
Transverse myelitis
Varicella zoster retinitis
Disseminated zoster
Post-herpetic neuralgia
Herpes zoster oticus (Ramsay Hunt syndrome)

Question 7

Prognosis for shingles

Answer 7

Typically self-limiting
Ocular complications occur in 50%-90% of cases -> temporary or permanent decreased acuity or blindness if untreated

Question 8

What is Ramsay-Hunt syndrome

Answer 8

Reactivation of the varicella zoster virus in the geniculate ganglion of CNVII

VII and VIII involvement: Vertigo, otalgia, altered taste perception, tinnitus, ipsilateral facial paralysis, ocular pain, vesicular rash around the ear