Gen Med 2B

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Herpes Zoster, Systemic Lupus Erythematous,
Monocular Vision Loss Connecting the Dots

• Gen Med 2B

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Herpes Zoster (Shingles)

• Vesicles and pustules on erythematous base
• Unilateral dermatome
• Varicella virus infects DRG during chickenpox,
  remains latent
• At risk population 50 immunocompromised
• Common adverse effect of Azathioprine
  immunosuppression

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Herpes Zoster

• Clinical course
• Prodrome Fever, dysesthesias, malaise, and
  headache (2-3 days before lesions)
• Pain can precede rash by days to weeks. Deep
  burning sensation
• Rash Dermatomal. Grouped vesicles/bullae evolve
  into pustular/ hemorrhagic lesions (3-4 days)
• Lesions crust by day 7-10, no longer infectious
• Complete resolution of rash by 3-4 weeks in
  Immunocompetent hosts

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Herpes ZosterComplications

• Postherpetic Neuralgia 7.9
• Bacterial skin infection 2.3
• Ocular complications 1.6
• Herpes Zoster Opthalmicus, Acute Retinal Necrosis
• Motor neuropathy .9
• Viral (aseptic) Meningitis .5
• Herpes Zoster Oticus .2
• Ramsay Hunt Syndrome
• Herpes Zoster associated Cerebral angiitis

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Herpes Zoster Opthalmicus

• VZV reactivation in Trigeminal ganglion
• Frontal branch within V1
• 50-72 with direct ocular involvement
• HA, malaise, fever unilateral pain in affected
  area hyperemic conjunctivitis, lid droop
• 2/3 develop corneal involvement (keratitis)
• Iritis in 40? chronic vasculitis, atrophy,
  poorly reactive pupils

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Anterior/Posterior Ischemic Optic Neuropathy

• Ischemic process affecting circulation of vessels
  feeding the optic nerve
• Etiology Vasculitides (e.g. Postviral
  vasculitis, Lupus Vasculitis, Polyarteritis
  Nodosa, Giant Cell Arteritis) Vasculopathies
  (HTN, DM)
• Subacute visual loss with malaise, HA, tender
  scalp and temporal arteries, jaw claudication,
  myalgia, and swelling
• Earlier manifestations malaise, fever, weight
  loss, vague GI pain, anorexia
• Poor recovery of vision

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SLE Ocular Complications

• Most common Keratoconjunctivitis Sicca
• Retinal Vasculitis Optic neuritis
• Blindness may develop over days to weeks
• Scleritis
• Anterior Uveitis

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SLE Neurologic Complications

• Cognitive defects, delirium, psychosis, seizures,
  headache, neuropathies
• Less common Cranial Neuropathies, myelitis,
  meningitis
• Thromboembolic events may lead to focal deficits

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Varicella Zoster Viral Meningitis vs.
Encephalitis

• Viral (Aseptic) Meningitis
• Clinical Presentation
• Fever, HA, malaise, myalgia, anorexia, Nausea,
  vomiting, diarrhea
• HA frontal/retroorbital photophobia
• /- Nuchal Rigidity
• Absent Kernigs Brudzinskis signs
• Etiology Enteroviruses (75-90)
• CMV, EBV, HSV, VZV

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CSF in Viral (Aseptic) Meningitis
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Varicella Zoster Viral Meningitis vs. Encephalitis

• Viral Encephalitis
• Clinical Presentation
• Brain parenchyma involved
• Acute febrile illness, confusion, behavioral
  change, altered consciousness, focal/diffuse
  neurologic deficit
• Mild lethargy ? coma
• Hallucination, psychosis, seizures
• Focal findings aphasia, ataxia, CN deficits
  (ocular palsy)
• Etiology Most important organisms include
  HSV-1, VZV, and enteroviruses

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thank you