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Herpes Zoster and PHN

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Greek language; herpes means 'to chronic cutaneous diseases' , zoster means a belt. Herpes zoster describes the girdle-like vesicular eruption of the disease in the ... – PowerPoint PPT presentation

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Title: Herpes Zoster and PHN


1
Herpes Zoster and PHN
2
Herpes Zoster
  • Historic Aspect
  • Incidence
  • Pathology
  • Clinical manifestion
  • Different diagnosis
  • Therapy

3
Historic Aspect
  • Herpes Zoster(shingles) is an acute infectious
    disease caused by herpes zoster virus belonging
    to the DNA group of viruses.
  • It primarily affects the posterior spinal root
    ganglion of the spinal nerves.
  • Greek language herpes means to chronic
    cutaneous diseases , zoster means a belt.
  • Herpes zoster describes the girdle-like vesicular
    eruption of the disease in the trunk.

4
Incidence
  • Overall incidence of HZ 131 per 100,000
    person-years.
  • No gender difference.
  • Directly related to age 75 years and older
    younger than 14 years-tenfold
  • Dermatomes thoracic dermatomes and the opthalmic
    division of the trigeminal nerve.
  • More common and severe in immunosuppressed
    patients(Lymphoma, chronic lymphocytic leukemia,
    radiation therapy, chemotherapy, lupus
    erythematosus.)
  • A small percentage of patients(5) have a
    recurrence of HZ.-same dermatome.

5
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7
Pathology
  • The virus that causes varicella gains to the
    sensory nerves in skin and passes to the dorsal
    ganglion cell in which it lies dormant.
  • Latent virus becomes reactivated often immune
    mechanisms are impaired.
  • An intense necrotizing reaction is seen in the
    dorsal root ganglia, peripheral nerves, dorsal
    horn of the spinal cord.

8
Clinical Consideration
  • Symptoms and Signs
  • Differential Diagnosis
  • Immunologic response
  • Therapy
  • complication
  • Conclusion

9
Symptoms and Sign 1
  • Commences with pain,paresthesia,and dysesthesia
    in the afflicted dermatome,followed in a few
    days(4-5days) by vesicular eruption.
  • At first the pain is mild but may increase in
    intensity over the succeeding days.
  • Pain sharp, shooting,dull,aching,burning
  • Systemic symptoms(5)
  • ( fever,malaise,headache, nausea,stiff
    neck,regional or diffuse adenopathy)
  • Localized erythema and swelling,red
    papules,vesicles,blebs, pustules,crust,(2-3wk)
  • Erythema , bleb, sharp pain resolve during 3rd
    wks.
  • Scales of the encrusting blebs begin to fall off
    leaving irregular pink scar (5th wks)
  • Older patients are more severe pain in the acute
    stage than younger patients.

10
Symptoms and Sign 2
  • Ophthalmic zoster
  • Opthalmic division of the trigeminal nerve
  • Ramsay Hunt syndrome
  • Varicella Zoster of the geniculate ganglion.
  • 7th cranial nerve involve-unilateral facial
    paralysis
  • Sacral Zoster(S2, S3, S4 dermatomes)
  • Neurogenic bladder with urinary hesitancy or
    retention.

11
Opthalmic Zoster
  • First branch of the Fifth nerve(V1)

12
Dermatomes
13
Mandibular branch of the Fifth nerve(V3)
14
Third cervical nerve(C3)
15
Thoracic 4th nerve(T4)
16
Thoracic 4th nerve(T4)
17
Thoracic 6th nerve(T6)
18
Thoracic 10th nerve(T10)
19
The 3rd lumbar nerve(L3)
20
Closeup view of lesion
21
On the back thoracic nerve
22
On the back thoracic nerve
23
Fingers digital nerves
24
Disseminated Herpes
25
Differential diagnosis
  • Herpes simplex
  • Poison ivy
  • Zoster sine herpete
  • painful disease can occur without cutaneous
    vesicles
  • Cellulitis

26
Immunologic response
27
Goals of therapy
  • Abort segmental infection
  • Prevent viral spread beyond the primary unit
  • Prevent tissue injury(cytolysis)
  • Prevent postherpetic neuralgia

28
Therapy
  • 1) Nerve Blocks
  • 2) Antiviral agents
  • 2) Antiinflammatory agents
  • 3) Systemic analgesics and ajuvant
  • agents
  • 4) Miscellaneous techniques

29
Nerve block
  • Local anesthetic infiltration-skin lesion
    healing, PHN-incidence severity-reducing
  • Peripheral sympathetic nerve block
  • restoration of intraneural bl flow,
    preservation of large fibers
  • Reducing the development ofPHN

30
Antiviral Agents
  • Acyclovir 800mg five times a day
  • Valacyclovir 1g three times a day
  • Famciclovir 500mg three times a day
  • Decrease pain
  • Hasten healing of the rash
  • Reduce the duration of PHN
  • Act to competitively inhibit DNA polymerase,
    terminating DNA synthesis and viral replication

31
corticosteroid
  • Pain relief in the acute phase
  • Shorten the time to fall crusting of lesions
  • Frequantly used prior to the development of
    antiviral agents
  • Adverse events-not recommend

32
Systemic analgesic and ajuvant agents
  • Acetaminophen,NSAID,Opioid
  • Low dose tricyclic antidepressant
    therapy(amitriptyline 10-25mg po before bedtime)

33
Complication
  • Neuralgia
  • Facial or oculomotor palsy
  • Paralysis of motor nerves
  • Myelitis
  • Meningoencephalitis
  • Postherpetic Neuralgia
  • Systemic toxicity-dissemination
  • Fever,Chills,
  • Bacterial sepsis,
  • Varicella pnumonias

34
Postherpetic neuralgia
  • Pain persisting beyond the crusting of lesions or
    beyond 4wks, 6wks, 2mons, or 6mons.
  • Similar to herpes zoster neuralgia
  • Burning, aching, itching,
  • severe paroxysm of stabbing or burning pain
  • Allodynia-87 of PHN
  • Hyperesthesia, dysesthesia, anesthesia

35
Therapy of PHN
  • Antidepressant
  • Neuroleptics
  • Anticonvulsants
  • Opioids
  • Topical agents
  • Nerve blocks
  • Tens
  • Acupuncture

36
Nerve block
  • Local infiltration
  • Somatic nerve block
  • Sympathetic nerve block
  • Epidural block
  • Neurolytic block

37
Local infiltration
  • EpsteinSQ infiltration(steroid)-64 pain relief
  • Tio,Moya,Verasan,-SQ infiltration of 0.25
    bupivacaine 0.2 triamcinolone alone 70
    improve

38
Somatic nerve block
  • Sensory nerve blocks are in early attempts to
    relieve its pain.success in managing pain in
    early stages of the disease-results are limited.
  • Nerve blocks are primarily used in postherpetic
    neuralgia for diagnosis and prognosis,esp as a
    prognostic block before neurolytic block.
  • Steroid injected around the dorsal nerve block.
    Steroids injected around the dorsal nerve have
    had unpredictable and limited success.

39
Sympathetic nerve block
  • Bonica reported good temporary-0.2pucaine(somati
    c sympathetic block)-4days interval-PHN(under
    2month)-best result.
  • Colding-concluded that sympathetic blocks for
    established PHN were no value.

40
Miscellous therapy of PHN
  • acupuncture

41
Conclusion
  • Prompt tx shortens the progressive course and
    decreases severity
  • Correlation between the age of the patient and
    the response to therapy
  • Older patients do not respond to therapy and
    specifically to sympathetic nerve blocks.
  • 40 of patients remain totally refractory or
    unsatisfactorily relieved.
  • 50(approx) of patients improve over the years
    one-half of these are receiving no tx
  • Strategies to prevent the onset of HZ in addition
    to the attempt to prevent the onset of PHN after
    the onset of HZ
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