Unknown

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Unknown 123
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• A 77-year-old man reports a five-day history of
  burning and aching pain on his right side of his
  face.
• He also reports a two-day history of erythema and
  clusters of clear vesicles, accompanied by
  headache and malaise.

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Gnann J and Whitley R. N Engl J Med
2002347340-346
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• What is the diagnosis?
• How should he be treated?

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Herpes Zoster Ophthalmicus

• A sight-threatening condition
• VZV reactivation within the trigeminal ganglion
• W/o antiviral therapy, approximately 50 percent
  of these patients will have ocular complications
• (e.g., keratopathy, episcleritis, iritis, or
  stromal keratitis)

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Treatment

• Start antivirals w/in 72 hours
• Steroid drops
• Optho consult

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Recommended Oral Antiviral Therapy for Herpes
Zoster in Immunocompetent Adults with Normal
Renal Function
Gnann J and Whitley R. N Engl J Med
2002347340-346
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Two distinct syndromes

• Primary infection
• varicella/ chickenpox
• Reactivation
• "herpes zoster" (or "shingles").

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Risk factors

• Increasing age
• the incidence of shingles 75 years of age
  exceeds 10/1000 person-years.
• The lifetime risk 10 to 20 percent
• Altered cell-mediated immunity
• Neoplastic diseases
• Immunosuppressive drugs
• Organ-transplant recipients
• HIV

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Diagnosis of Herpes Zoster
Gnann J and Whitley R. N Engl J Med
2002347340-346
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Complications

• PHN
• correlated with age
• Myelitis
• cranial- and peripheral-nerve palsies
• Acute retinal necrosis
• Ramsey Hunt

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Treatment

• Antivirals
• Decreased duration of viral shedding, halts the
  formation of new lesions more quickly,
  accelerates the rate of healing, and reduces the
  severity of acute pain
• Steroids
• Acc healing of lesions
• Rate of resolution of pain
• No effect on PHN
• Use in severe cases and in pt w/o CI to steroids

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Zostavax

• Shingles Prevention Study Group
• 38,546 subjects 60 years of age or older were
  followed for 3 years
• incidence of herpes zoster was 51 lower in the
  group of subjects who received the vaccine than
  in the group of subjects who received placebo
• The incidence of postherpetic neuralgia was 67
  lower among subjects who received the vaccine
  than among those who received placebo
• median duration of pain among subjects in whom
  herpes zoster developed was shorter in the
  vaccine group

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• Zoster prevention in patients 60 yo
• CI
• anaphylactic or anaphylactoid reactions to
  gelatin, neomycin
• history of primary or acquired immunodeficiency
  conditions or those receiving immunosuppressive
  therapy
• Pregnancy
• HIV
• Vaccinate 17 to prevent one case of herpes zoster
• Vaccinate 31 to prevent one case of postherpetic
  neuralgia