Herpes Zoster

Herpes zoster
Herpes zoster is an infectious disease

that is caused by the varicella-zoster
virus
It is postulated that during the course
of primary infection with VZV, the
virus migrates to the dorsal root or
cranial ganglia
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist
Herpes zoster
In some individuals the virus may
reactivate and travel along peripheral
or cranial sensory pathways to the
nerve endings, producing the pain and
skin lesions characteristic of shingles
The reason for reactivation ?
decrease in cell-mediated immunity
Risk factors
Suffering from malignancies (particularly
lymphoma)
Receiving immunosuppressive therapy

(chemotherapy, steroids, radiation)
Generally debilitated by chronic

diseases
Patients older than 60 years

SIGNS AND SYMPTOMS

Herpetic pain:
5-7 day before of skin lesions
May be accompanied by flu-like symptoms
Progresses from a dull, aching sensation to
unilateral,
Segmental, band-like dysesthesias and
hyperpathia
Burning pain , hyperesthesia, allodynia
Zoster sine herpete

SIGNS AND SYMPTOMS

From a mild self-limited problem to a
debilitating, constantly burning pain
that is exacerbated by light touch,
movement, anxiety,and/or
temperature change
Can lead to suicide

TREATMENT
Relief of acute pain and symptoms
Prevention of complications, including
postherpetic neuralgia
Earlier treatment
less likely postherpetic
neuralgia
TREATMENT
Sympathetic neural blockade appears
to be the treatment of choice to
relieve the symptoms of acute
herpes zoster as well as to prevent
the occurrence of postherpetic
neuralgia
Noordenbos "fiber dissociation"

TREATMENT
Herpes zoster in trigeminal nerve & geniculate,
cervical, and high thoracic regions:
stellate ganglionblockade with
LA daily basis
Herpes zoster thoracic, lumbar, and sacral
regions:
epidural neural blockade with
LA
daily basis
TREATMENT
If the pain is not as severe, NSAIDs or
acetaminophen may be all that is
needed
In acute eruption oral narcotics may
be
administered in the short term,
especially with (NSAIDs)
TREATMENT
Narcotic analgesics may be useful in
relieving the aching pain
Antidepressants will help :
Alleviate the significant sleep disturbance
Ameliorate the neurotic component of the pain
May exert a mood-elevating
May cause urinary retention and constipation

TREATMENT
Anticonvulsants
May be of value as an adjunct to sympathetic
neural blockade
They may be particularly useful in persistent
paresthetic or dysesthetic pain

TREATMENT
Anxiety may be treated
Hydroxyzine
Behavioral interventions
(e.g., monitored relaxation training and hypnosis)

TREATMENT
Antiviral agents:
Acyclovir , valacyclovir, famcyclovir
and perhaps interferon have been
shown to shorten the course of acute
herpes zoster

Zoster sine
herpete

Classic zoster sine herpete (ZSH) is

defined clinically as dermatomal
distribution pain without rash
First defined by Lewis(1958) who
described zoster patients with
dermatomal distribution pain in areas
outside that affected by
zoster rash
Gilden and colleagues reported 2 men

aged
62 and 66 years who had had chronic
thoracic distribution radicular pain in
whom PCR-amplifiable VZV DNA was
detected in the CSF 5 and 8 months
after the onset of pain (1994)
Treatment with IV acyclovir produced
marked improvement
A third man over 60 years old with

similar chronic radicular pain was
subsequently reported in whom the
VZV etiology was proved by
detection of VZV DNA in blood
mononuclear cells (MNCs) (1996)


R. Nau, MD
M. Lantsch, MD
M. Stiefel, MD
T. Polak, MD
H. Reiber, PhD

Departments of Neurology and

Neuroradiology
University of Gttingen, Germany

42-year-old immunocompetent man

no history of herpes zoster
suddenly experienced dys- and
hypesthesia in his left hand
fluctuating paresis of the flexion and
extension of the fingers of the left hand
increased tendon reflexes on the left at
the upper and lower extremities were
noted
Within the next 10 days, the

hypesthetic region expanded to the
fingers and the left forearm, and he
noticed progressive distal weakness
of his left upper extremity

ESR was 17 mm in the first and 33 mm in

the second hour.
Serologic tests (c- and p-ANCA, rheumatoid
factor, antibodies against DNA, the
Sjogren-associated nuclear antigens SS-A
and SS-B, and antibodies against
extractable nuclear antigens Sm, RNP, Scl70, and
Jo-1) and a rectum biopsy did not reveal any
evidence for systemic vasculitis
On MRI, multiple ischemic lesions in

the territory of the right middle
cerebral artery (MCA) were detected


MR angiography revealed a proximal

stenosis of the right MCA


Lumbar CSF contained 5 leukocytes/pL

(predominantly mononuclear cells),
and a normal total protein and
lactate concentration
The CSF-to-serum concentration
quotient of total IgG, for vzv
resulting in an antibody index (AI)

The AI against herpes simplex virus

was 3.8
The polymerase chain reaction (PCR)
for VZV DNA in CSF was negative

High-dose IV acyclovir
(750 mg IV three times
daily for 10 days)
corticosteroids
(1,000 mg IV daily for 3
days, and 100 mg daily for another 10 days)
No
immediate improvement
but stopped the progression of the

disease

During the next 6 months, the motor

and sensory functions of the left
upper extremity slowly improved


Neurology 76 February 1, 2011

D.T. Blumenthal, MD
E. Shacham-Shmueli, MD
F. Bokstein, MD
D.S. Schmid, PhD
R.J. Cohrs, PhD
M.A. Nagel, MD
R. Mahalingam, PhD
D. Gilden, MD
From the Oncology Division (D.T.B., E.S.-S., F.B.),

Tel-Aviv
In 2008, a 77-year-old man developed

right C8-distribution zoster;
he was not treated with an antiviral
agent or steroids and his rash and
pain resolved completely

One year later

he developed colon cancer and was
treated every other week for 7
months with a protocol using
leucovorin, 5-fluorouracil, oxaliplatin,
and folinic acid

In November 2009, right C78distribution pain recurred, but in the

absence of rash
In December 2009, he developed a
painless right foot drop
In February 2010, neurologic
examination revealed C78
thigmesthesia and allodynia and an
incidental right peroneal palsy.
All deep tendon reflexes were reduced or

absent
Cervical MRI :degenerative changes at C5
6 and C67 without root compression
The CSF was acellular; cytology was
negative, and CSF protein was 87 mg %
A presumptive diagnosis of ZSH was

made
he was treated with valacyclovir, 1 g 3 times
daily for 14 days, and pregabalin, 150 mg at
night
A few days after treatment, he
experienced a dramatic reduction in
,pain
and 2 months later, was pain-free
Virologic studies of the CSF and serum

obtained before antiviral treatment
revealed no amplifiable VZV DNA and
no anti-HSV IgG antibody
In contrast, anti-VZV IgG antibody was
present
The serum/CSF ratio of anti-VZV IgG
antibody was markedly reduced
It is important to identify
patients with ZSH since
their symptoms and signs
may respond to IV
acyclovir
In patients with prolonged radicular

pain without rash to verify the
diagnosis
of zoster sine herpete CSF should be
examined for both
VZV DNA
anti-VZV IgG antibody
negative PCR for VZV DNA in the CSF

does not exclude the diagnosis of
VZV vasculopathy
1-Blood MNCs for VZV DNA
2- CSF VZV DNA
3- CSF Anti-VZV IgG antibody


Herpes Zoster

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Herpes Zoster

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Herpes zoster

Herpes zoster is an infectious disease

Receiving immunosuppressive therapy

Generally debilitated by chronic

Dr Mehran Rezvani pain fellowship

SIGNS AND SYMPTOMS

Dr Mehran Rezvani pain fellowship

SIGNS AND SYMPTOMS

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Classic zoster sine herpete (ZSH) is

Gilden and colleagues reported 2 men

A third man over 60 years old with

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Departments of Neurology and

Dr Mehran Rezvani pain fellowship

42-year-old immunocompetent man

Within the next 10 days, the

Dr Mehran Rezvani pain fellowship

ESR was 17 mm in the first and 33 mm in

On MRI, multiple ischemic lesions in

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

MR angiography revealed a proximal

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Lumbar CSF contained 5 leukocytes/pL

Dr Mehran Rezvani pain fellowship

The AI against herpes simplex virus

Dr Mehran Rezvani pain fellowship

(750 mg IV three times

daily for 10 days)

(1,000 mg IV daily for 3

days, and 100 mg daily for another 10 days)

but stopped the progression of the

Dr Mehran Rezvani pain fellowship

During the next 6 months, the motor

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Neurology 76 February 1, 2011

From the Oncology Division (D.T.B., E.S.-S., F.B.),

In 2008, a 77-year-old man developed

Dr Mehran Rezvani pain fellowship

One year later

Dr Mehran Rezvani pain fellowship

In November 2009, right C78distribution pain recurred, but in the

All deep tendon reflexes were reduced or

A presumptive diagnosis of ZSH was

Virologic studies of the CSF and serum

In patients with prolonged radicular

negative PCR for VZV DNA in the CSF

Dr Mehran Rezvani pain fellowship

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