Herpes zóster. Actualización y manejo / Herpes zoster. Management and treatment update

El herpes zóster es una enfermedad infecciosa producida por el virus de la varicela zóster, caracterizada por la aparición de vesículas que suelen presentarse en una disposición metamérica. Su incidencia se encuentra en aumento y es un motivo de consulta frecuente en la práctica cotidiana. En este artículo se ofrece información actualizada acerca de su diagnóstico, tratamiento y prevención, así como sobre otros aspectos controvertidos de su manejo.

Herpes zoster is an infectious disease caused by varicella zoster virus, characterized by the development of vesicles, which usually present with a metameric arrangement. Its incidence is increasing and is a frequent reason for consultation in daily practice. This article offers updated information on its diagnosis, treatment and prevention, as well as controversial aspects of the management of this pathology.

Herpes zóster diseminado: caso clínico y revisión bibliográfica / Disseminated herpes zoster: clinical case and literature review

Herpes zoster classical clinical presentation is the acute onset of multiple vesicles over an erythematous base, disposed over one or two dermatomes with up to 20 vesicles located outside the main dermatome. Disseminated herpes zoster is an atypical and rare form of presentation of herpes zoster, which manifests with lesions beyond the described territory. It occurs mainly in patients with some type of cellular immunosuppression. The diagnosis is made with the medical history and physical examination, however, it should be confirmed with laboratory tests. Treatment must be initiated early to avoid serious complications, such as bacterial infection of the lesions, post-herpetic neuralgia, or even central nervous system involvement. The drug of choice is intravenous acyclovir that must be maintained until the cessation of the appearance of new lesions, and then switch to its oral presentation for another 5-7 days. Disseminated herpes zoster mortality rounds 5-15%. There are varicella-zoster virus vaccines, that have been shown to reduce the incidence of herpes zoster relapses, however its utility to disseminated herpes zoster is uncertain and further studies are required. We present the case of a male patient with a history of rheumatoid arthritis who consults with multiple vesicles distributed throughout his body. (AU)

Herpes zóster en un niño / Herpes zoster in a child

Se presenta el caso clínico de un niño de 9 años de edad, quien asistió al centro de salud de Santa Lucia, municipio de Itamarandiba, estado brasileño de Minas Gerais, por presentar lesiones inicialmente dolorosas y pruriginosas en el abdomen, que se irradiaban a la espalda unilateralmente. En el examen dermatológico se observaron múltiples vesículas agrupadas en forma de racimo de uvas sobre un fondo eritematoso, localizadas en el lado izquierdo del abdomen y difundidas a la región lumbar, por lo cual se diagnosticó un herpes zóster. Se le indicó el tratamiento oportuno y desaparecieron tanto las lesiones como los síntomas asociados

The case report of a 9 years boy is presented. He attended the health center of Santa Lucía, in Itamarandiba, Brazilian state of Minas Gerais, due to initially painful and pruriginous lesions in the abdomen that irradiated unilaterally to the back. In the dermatologic examination multiple vesicles grouped in a bunch of grapes form on an erythematosus base were observed, located in the left side of the abdomen and diffused to the lumbar region, reason why an herpes zoster was diagnosed. The appropriate treatment was indicated and either the lesions or the associated symptoms disappeared

Herpes zoster de poco frecuente localización en un adolescente inmunocompetente / Herpes zoster of scarcely frequent localization on an immune-compromised adolescent

Se describe el caso de un paciente de 16 años, inmunocompetente, con herpes zoster localizado en la región glútea izquierda, que evolucionó satisfactoriamente. El paciente tiene antecedente de no estar vacunado con la vacuna antivaricela ni haberse contagiado de la varicela, su madre padeció esta enfermedad a las 28 semanas de su embarazo. El herpes zoster aparece cada vez más en la adolescencia e infancia. La localización glútea es una localización poco frecuente(AU)

The case is described of an immunocompetent 16-year-old female patient with herpes zoster located in the left gluteal region, which evolved satisfactorily. The patient has a history of not being vaccinated with the vaccine anicaricela nor infected with chickenpox, her mother suffered from this disease at 28 weeks of pregnancy. Herpes zoster appears more and more in adolescence and childhood. The gluteal location is a rare location(AU)

Herpes zoster en adultos mayores en un hospital privado de la ciudad de Buenos Aires, junio 2013 - mayo 2014 / Herpes zoster in elderly adults in a community hospital in Buenos Aires. June 2013-May 2014

El herpes zoster (HZ) se produce por reactivación del virus varicela zoster. Sus principales factores de riesgo son edad avanzada y presencia de comorbilidades (diabetes, inmunodepresión). Existen escasos datos de HZ en Sudamérica, y especialmente en adultos mayores. Analizamos retrospectivamente las características epidemiológicas y clínicas de 340 pacientes mayores de 60 años atendidos por HZ, entre junio 2013 y mayo 2014. La edad promedio de consulta fue de 74 años (60-100), localización torácica 210 (62%); el 75% (255) de las consultas iniciales se realizaron en guardias. El 68%, 143, presentaron dolor y vesículas, y 4% (14) solo dolor al inicio; el dolor persistió luego de finalizar el episodio en el 41% (139) de los pacientes. El diagnóstico se realizó entre 1 y 3 días de iniciado el cuadro en el 53% (180). El promedio de consultas por episodio fue de 3.6 (1-24). Tratamiento antiviral se indicó en 91% (309) de los pacientes [en 49% (167) fue inadecuado en tiempo o dosis], y tratamiento para el dolor en el 66% (224) de los casos: drogas más usadas (solas o en combinación) AINES (43%, 146), pregabalina (30%, 102), opiáceos (24%, 82), y corticoides (12%, 41). Solo el 9% (31) presentó comorbilidades y el 27% (126) dolor post episodio (duración promedio: 138.7 días). El diagnóstico fue tardío, dificultando el uso correcto de antivirales. El dolor post episodio fue más frecuente que en la literatura consultada; sin embargo, son pocos los datos en este grupo etario.

Herpes zoster (HZ) is caused by reactivation of the varicella zoster virus. Its main risk factor is increasing age and comorbidities. There are limited data on the characteristics of HZ in South America, especially in the elderly. We analyzed epidemiological and clinical characteristics of 340 patients over 60 years assisted for HZ, between June 2013 and May 2014. The average age was 74 years (60-100), 62% (210) had thoracic location; 75% (255) of the initial consultations were held in guards; 68% (143) had pain and vesicles, and 4% (14) only pain at baseline. Pain persisted after finishing the episode in 41% (139). The diagnosis was made between 1 and 3 days from the beginning of the episode in 53% (180 patients). Average number of visits per episode was 3.6 (1-24). Antiviral treatment was supplied to 91% (309); however it was inadequate in dose or time in 49.1% (167 cases). Pain treatment was indicated in 66% (224). Most frequently used drugs (alone or in combination) were non-steroidal painkillers (43%, 146), pregabalin (30%, 102), opiates (24%, 82), and steroids (12%, 41); 9% (31) presented comorbidities; 27% (126) experienced pain after the ending of the episode, with an average duration of 138.7 days. In general, diagnosis was done late, making it difficult to use antivirals correctly. The presence of pain was more frequent than reported in other publications, however there are few data in this age group.

Zóster com comprometimento do nervo trigêmeo: relato de caso / Zoster with Trigeminal Nerve Damage: Case Report

Zóster é uma doença viral pelo qual o mecanismo de reativação, ainda é pouco compreendido. Entretanto, parece estar relacionado com algum tipo de deficiência na imunidade, além do estresse também ser apontado como fator desencadeante. O diagnóstico, na maioria das vezes, é eminentemente clínico, usualmente determinado por lesões vesículobolhosas que envolvem a pele ao longo do trajeto do nervo branquial. O objetivo desse trabalho é relatar um caso clínico de uma paciente, 21 anos de idade, diagnosticada com zóster e comprometimento do nervo trigêmeo, nos ramos oftálmico, maxilar e mandibular. Verificouse aumento de volume em região de terços médio e inferior da face esquerda, edema palpebral, linfadenopatia em região submandibular, lesões cutâneas vesículo-bolhosas em região periorbital, massetérica, geniana e submandibular. As lesões não ultrapassavam a linha média da face. Após o tratamento a paciente não apresentou sequelas. Salientase a necessidade do conhecimento dessas lesões por parte do cirurgião dentista, a fim de estabelecer diagnóstico e tratamento imediato, para minimizar sintomatologia e acompanhamento da neuralgia pós-zóster... (AU)

Zoster is a viral disease in which the reactivation mechanism is poorly understood. However, it seems to be related to an immunity disability, in addition to stress, which is also be appointed as a triggering factor. The diagnosis, in most cases, is eminently clinical, usually determined by vesicle-bullous lesions involving the skin over the brachial nerve pathway. The aim of this study is to report a case of a 21-year-old patient, diagnosed with zoster, with commitment of the trigeminal nerve comprehending the ophthalmic, maxillary and mandibular branches. There was tissue growth in medium-third region and the lower left cheek, eyelid edema, lymphadenopathy in the submandibular region, vesicle-bullous skin lesions in the periorbital, masseteric, genian and submandibular regions. The injury did not exceed the midline of the face. After treatment the patient had no sequelae. It is emphasized the need of understanding these lesions by the dental surgeon, in order to establish diagnosis and the due immediate treatment in order to reduce the symptoms and the follow up of post-zoster neuralgia... (AU)

Typical case: herpes zoster / Caso típico: herpes-zóster

Summary The varicella zoster virus is the causative agent of herpes zoster and varicella. In herpes zoster, the virus dormant within dorsal root ganglia is reactivated, resulting in painful vesicular lesions overlying an erythematous base.

Resumo Caso típico: herpes-zóster. O vírus varicela-zóster é o agente causador das doenças herpes-zóster e varicela. No caso do herpes-zóster, ocorre reativação do vírus que está alojado nos gânglios da raiz dorsal de gânglios simpáticos, resultando em lesões vesiculares dolorosas, agrupadas em uma base eritematosa.

Herpes zoster-associated acute urinary retention in immunocompetent patient

Herpes zoster-associated urinary retention is an uncommon event related to virus infection of the S2-S4 dermatome. The possible major reasons are ipsilateral hemicystitis, neuritis-induced or myelitis-associated virus infection. We report a case of a 65-year-old immunocompetent female patient who presented an acute urinary retention after four days under treatment with valacyclovir for gluteal herpes zoster. The patient had to use a vesical catheter, was treated with antibiotics and corticosteroids and fully recovered after eight weeks.

Herpes-zóster com manifestação bucal em paciente imunossuprimido: relato de caso / Herpes zoster with oral manifestation in na immunocompromised patient: a case report

O herpes-zóster é uma infecção viral causada pela reativação do vírus da varicela-zóster. Esta doença pode afetar pacientes imunossuprimidos e caracteriza-se por lesões papulovesiculares distribuídas na região inervada pelo nervo afetado, causando dores intensas. Este artigo relata o caso de um paciente do sexo masculino, leucoderma, 26 anos de idade, dependente químico, HIV positivo e com tuberculose ganglionar que procurou o Hospital Oswaldo Cruz (Curitiba/PR) tendo como queixa mal-estar geral, lesões na pele e mucosa oral, e linfadenopatia na região cervical. Discussão: O diagnóstico do herpes-zóster foi estabelecido por meio das características clínicas das lesões, e o tratamento estabelecido envolveu o uso de drogas antirretrovirais, analgésicos e antidepressivos. Conclusão: O cirurgião-dentista precisa estar atento às lesões papulovesiculares que acometem a pele e as mucosas de forma unilateral, acompanhadas de sintomas de prurido e dor, pois elas garantem o diagnóstico do herpes-zóster...

Herpes zoster is a viral infection caused by the reactivation of varicella zoster virus. This disease can affect immunocompromised patients and is characterized by papulovesicular lesions distributed in the inner¬vated region by the affected nerve and may result in severe pain. This article reports the case of a male patient, leucoderm, 26 years old, user of illicit drugs, HIV positive and with lymph node tuberculosis, who came to the hospital Oswaldo Cruz (Curitiba, Paraná, Brazil), having as general complaint malaise, skin and oral lesions, and cervical lymphadenopathy. Discussion: The diagnosis of herpes zoster has been established by clinical characteristics of the lesions and established treatment involved the use of antiretroviral drugs, analgesics and antidepressants. Conclusion: The dentist needs to be aware of papulovesicular lesions affecting the skin and mucous membranes unilaterally followed by symptoms of pruritus and pain, for these ensure the diagnosis of herpes zoster...

Facial herpes zoster – case report / Herpes Zóster Facial–Relato de caso

Este artigo descreve um caso de zoster facial o qual afetou um paciente do sexo masculino de dezesseis anos de idade. Suas ulcerações comprometiam a hemiface direita não ultrapassando alinha média facial. Foram realizados a observação e o acompanhamento do paciente durante e após o tratamento. O caso foi acompanhado do aparecimento das lesões até o processo final decicatrização, onde o paciente retornou à sua condição de vida normal.A infecção por herpes zoster parece ser o resultado de um sistema imunológico enfraquecido e os pacientes portadores devem ser monitorados a fim de detectar possíveis sequelas ou doenças oportunistas não diagnosticadas.

This article describes a case of facial zoster which affected a sixteen-year-old male patient. His ulcerations involved the majority of the right hemiface not surpassing the facial midline. The observation of fallow-up of the patient during and after treatment was accomplished and the case was followed up from appearance of the lesion up the final healing process, where the patient had retumed to his normal life condition. Herpes zoster infection seems to be an outcome of a weakened immunologic system and patients must be monitored in order to detect possible sequels or undetected non-diagnosed diseases.

Penile herpes zoster: an unusual location for a common disease

Herpes zoster is a common dermatological condition which affects up to 20 percent of the population, most frequently involving the thoracic and facial dermatomes with sacral lesions occurring rarely and only a few reported cases of penile shingles. Case report: We report two cases of unusual penile clinical presentations of varicella zoster virus infection in immunocompetent men. The patients presented with grouped clusters of vesicles and erythema on the left side of penile shaft and posterior aspect of the left thigh and buttock, involving s2-s4 dermatomes. The lesions resolved quickly upon administration of oral antiviral therapy. Conclusion: Penile herpes zoster should not be overlooked in patients with unilateral vesicular rash.

Topical Glycopirrolate for the Management of Hyperhidrosis in Herpetic Neuralgia

Herpes zoster is a relapse of varicella. In certain cases, long-term pain and hyperhidrosis have been noted. Appearance of herpes zoster during pregnancy is infrequent. We described hyperhidrosis and pain treatment using glycopirrolate cream in a pregnant woman with herpetic neuralgia. A 32 year old woman, 21 weeks pregnant with second child, complained to her gynecologist of the appearance of a vesicular rash on the left half of the forehead that progressed toward her left eyelid, accompanied by lancinating pain, allodynia, hyperhidrosis and small edema, blepharitis and conjunctivitis. Following clinical and laboratory tests, she was diagnosed with herpes zoster ophtalmicus. Aciclovir therapy was administered 800 mg orally five times daily for seven days. Pain therapy was initiated with amitriptilline. We discontinued amitriptilline therapy after 10 days because of appearance of unwanted side effects. After skin changes ceased, we introduced Lidocaine patch into pain therapy which reduced the allodynia, but not the lancinating pain and hyperhidrosis. At that time we began using glycopirrolate cream which reduced pain intensity by 28.5% within 24 hours, and completely eliminated hyperhidrosis. After 48 hours of use, the pain completely disappeared. During the Glycopirrolate cream therapy, there were no side effects. This is a first report to document that a topical Glycopirrolate cream has a beneficial effect in a patient with hyperhidrosis and herpetic neuralgia.

Herpes zoster: Epidemiología y clínica / Clinical and epidemiological aspects of Herpes zoster

El herpes zoster (HZ) constituye una enfermedad de distribución mundial; sin embargo, existen es casos datos comunicados sobre la misma en países de Latinoamérica. Con el objetivo de evaluar aspectos clínicos y epidemiológicos de esta enfermedad en nuestra población, realizamos un análisis retrospectivo de historias clínicas de un centro privado de referencia en enfermedades infecciosas en Buenos Aires, Argentina (período: 2000-2005). Se realizó un análisis estadístico univariado para evaluar los factores asociados a neuralgia posherpética en este grupo de pacientes. Sobre un total de 302 casos evaluables, el 62% correspondieron a mujeres. La mediana de edad fue de 57 años. El 16.1% de los pacientes presentó condiciones predisponentes al desarrollo de zoster. Las localizaciones más frecuentes fueron la torácica, oftálmica y lumbosacra. El 7.75% presentó compromiso de más de dos metámeras. El 94% de los pacientes recibió medicación antiviral, siendo el aciclovir la droga más utilizada. El 94% recibió alguna medicación coadyuvante (antiinflamatorios no esteroideos, antineuríticos, corticoides). La complicación más frecuente fue la neuralgia posherpética (12%) y se encontró estadísticamente asociada a edad mayor de 50 años.

Herpes zoster (HZ) is a public health problem worldwide. Although, there is paucity of data of this disease from South American countries. The objective of this study was to evaluate clinical and epidemiological aspects of HZ in a population of patients from South America. We underwent a retrospective analysis of clinical charts of an infectious diseases reference center (period: 2000-2005). Univariate analysis was performed to assess variables related to post herpetic neuralgia (PHN). From a total of 302 cases, 62% were in women. The median age was 57 years; 16.1% of the patients had a predisposing condition for the development of HZ. Most frequent dermatomes involved were: thoracic, ophthalmic and lumbar; 93.5% of the patients received antiviral drugs and 94% complementary medications. The most frequent complication was PHN and was related with age over 50 years. Clinical and epidemiological aspects of HZ and the frequency of complications in our population were similar to data from developed countries.

Uso del Interferón Alfa en enfermedades virales por vía tópica / The usage of topic Alfa interferon in viral diseases

El Interferón es un conjunto de proteínas que se producen principalmente frente a un estímulo viral, también favorece y promueve otros mecanismos inmunológicos por lo cual es considerado una Citoquina, siendo el uso más frecuente, el terapéutico, en aquellas enfermedades donde se sospeche un origen principalmente viral. Desde su descubrimiento en el año 1957, el uso terapéutico es en afecciones las cuales se sospeche un origen viral y el cáncer, siendo más limitado su empleo como estimulador del Sistema Inmunológico. En el presente trabajo hemos tomado un grupo de estudio constituido por 362 pacientes al cual se le aplicó el Interferòn por vía tópica comparado con un Grupo control formado por 343 pacientes tratados con la terapéutica convencional durante 10 años de tratamiento. A ambos grupos se les habían diagnosticado diversas afecciones Virales de Piel y Mucosas y fueron tratados por un espacio de 10 años, tomándose una muestra inicial antes del tratamiento y posterior al mismo con intervalos de 1, 3, 6,12 meses y a los dos años de iniciado el tratamiento, comparándose algunos parámetros de la respuesta inmunológica, detectándose posteriormente en el grupo de estudio un aumento de la Inmunidad Humoral Sistémica, una remisión de los síntomas de más de 6 años y pocas reacciones colaterales.

The Interferon is a group of proteins, produced mainly against a viral stimulus; it also favors and promotes other immunologic mechanisms and that is why it is considered a cytokine, being its most frequent use, therapeutic, mainly in diseases of suspected viral origin. Since it was discovered in 1957, it has been therapeutically used in affections of suspected viral origins and cancer, being more limitedly used as a stimulator of the Immunological System. In our work we had a study group composed by 362 patients, who received Interferon by topical way, compared to a control group of 343 patients treated with conventional therapy during 10 years. Both groups were diagnosed with various viral affections of the skin and the mucous membrane. They were treated during 10 years, taking a sample before the treatment began and at the end of the 1 st , 3 rd , 6 th , 12 th months and the 2 nd year after the beginning of the treatment. Some parameters of the immunologic answer were compared, detecting in the study group an increase of the Systemic Humoral Immunity, a remission of the more-than-6-years symptoms and few side effects.

Errores en la oportunidad y dosificación de aciclovir o valaciclovir en el tratamiento del herpes zoster / Erroneous prescriptions of aciclovir and valaciclovir in herpes zoster treatment

Medical prescription errors are frequent in community settings and information exploring its magnitude during antiviral treatment of herpes zoster is scarce. A questionnaire was applied to 31 physicians working in hospital- or community-based settings in Santiago, Chile in order to characterize their dosing and timing preferences for aciclovir or valaciclovir prescriptions. Aciclovir was more often prescribed than valaciclovir (71.9 and 28.1 percent, respectively), but less than a third of prescription (27.3 percent) fulfilled the minimal aciclovir dosing and timing criteria for clinical efficacy (4 gr per day and < 72 hours since rash initiaton). The limited size of the simple prevented exploring factors linked to a misleading prescription. Appropriate knowledge on dosing and timing of aciclovir/valaciclovir therapy for herpes zoster was infrequent in a sample of physicians working in various clinical settings in Chile.

Los errores en la prescripción de medicamentos son frecuentes en escenarios ambulatorios y no hay información disponible sobre el uso de antivirales en el tratamiento del herpes zoster. Para conocer la dosis y oportunidad en la prescripción de aciclovir o valaciclovir se aplicó un cuestionario a 31 médicos que trabajan en hospitales o sitios de atención primaria en Santiago y que declararon haber atendido este tipo de pacientes. El compuesto aciclovir fue más indicado que valaciclovir (71,9 vs 28,1 por ciento) pero menos de un tercio de las prescripciones (27,3 por ciento) cumplieron simultáneamente con una dosis mínima (4 g/día) y ventanas de tiempo apropiadas de aciclovir (hasta 72 horas del rash). El reducido tamaño de la muestra impidió efectuar un análisis de los factores ligados a este fenómeno. El conocimiento apropiado sobre dosis y oportunidad de aciclovir o valaciclovir fue infrecuente en un grupo de médicos que declararon atender pacientes con herpes zoster en Santiago.

Relato de caso: herpes-zoster após o uso de infliximabe / Case report: herpes zoster after infliximab infusion

O uso de drogas biológicas como o anti-TNF (infliximabe) no tratamento das doenças inflamatórias intestinais trouxe nova perspectiva terapêutica na busca da cura e controle dessas doenças. O TNF-alfa é um mediador inflamatório e modula a resposta imunológica celular. Portanto, existe a possibilidade de que o infliximabe possa afetar a resposta imunológica normal e predispor o paciente a infecções oportunistas com maior freqüência do que o habitual. O objetivo deste relato é descrever a ocorrência de herpes-zoster após a segunda aplicação do infliximabe em paciente com doença inflamatória intestinal. A doente com 49 anos de idade e diagnóstico de retocolite ulcerativa distal não responsiva ao tratamento com sulfassalazina, derivados e corticóide recebeu a primeira aplicação de infliximabe na dose de Smg/kg de peso, com melhora importante da sintomatologia - sangramento intestinal, diarréia e artralgia - logo nos primeiros dias. Após dois meses, foi administrada a segunda aplicação da medicação, após a qual a doente evoluiu com prurido e aparecimento de lesões pustulosas em região genital compatível com herpes-zoster. A doente foi medicada com aciclovir oral por sete dias, com regressão total do quadro. Apesar do aparecimento da infecção oportunista, o tratamento adequado e em curto intervalo de tempo não impossibilitou o tratamento continuado com infliximabe, desde que sob vigilância permanente do médico assistente.