Can't Touch This! An Approach to Shingles
A 55 year old female with no reported past medical history presents with right-sided flank pain for 2 days. She notes that when the pain began yesterday, she went to a nearby hospital where she had a CT scan that was normal. She had also received morphine with moderate improvement of her pain. The patient was told that her symptoms were likely due to a passed kidney stone and was discharged on tylenol and oxycodone. She denies any dysuria or hematuria. She denies any trauma or inciting injury.
Now the patient reports worsening pain and a painful rash due to the morphine. She states she has never had morphine before but believes this rash is secondary to the morphine that the “terrible doctor” gave her at the outside hospital. Sh continues to deny any hematuria or dysuria. She denies any fevers or chills at home.
Vital signs: BP 150/90, HR 90, T 36.7, RR 16, 99% RA
General: Patient is awake and speaking in full sentences but appears to be in moderate distress due to pain.
CV: regular rate and rhythm, no murmur or gallops
Lungs: CTA bilaterally.
Abdomen: Soft and non-tender, no rebound or guarding
Skin: Vesicular rash overlying the right flank extending to the mid axillary line, does not cross the spine. Appears erythematous with grouped vesicles, does not appear raised. No other lesions identified in the rest of the body.
The patient was treated with IV toradol and PO tylenol with mild improvement of symptoms.
CBC and Chem-9 were within normal limits. The UA was without evidence of UTI or RBCs.
She was started on 1 gm of valcyclovir, continued with oxycodone for pain control, and advised to follow up with her primary care physician.
Due to reactivation of latent VZV in neurons of the regional ganglia.
Epidemiology: 1.2 million every year. Approximately 1/3 of US population will get shingles in their life time
immunocompromised (transplant or HIV)
iatrogenic immunosuppression (steroids, disease-modifying anti-rheumatic drugs)
Antiviral: lessen severity and duration, promote healing, decrease viral shedding
Sooner the better (within 3 days)
Valacyclovir: 1g TID for 7 days
Famciclovir: 500mg TID 7 days
Acyclovir 800mg five times a day 7 days
Efficacy appears the same in all the above, but note the frequency of acyclovir (that’s too many times a day to remember)
Steroids? No real benefit for preventing post-herpetic neuralgia, also possible risk of increasing risk to superimposed bacterial infections – especially those with diabetes mellitus
NO role for antibiotics unless there is suspicion for a superimposed bacterial infection
Immunocompromised or disseminated
Admit for IV acyclovir
Transmission: Considered infectious until crusting. Usually 7-10 days Zoster → Chicken pox to those naïve
Cover up those lesions!
Herpes zoster ophthalmicus (fifth cranial nerve):
HSV keratitis (dendritic)
Lesion at tip of nose → HZO
Antivirals, steroid eye drops to decrease inflammation
Herpes zoster oticus (eighth cranial nerve)
Facial palsy + ear pain
Superimposed skin infections
Take away #1:
Pain can occur before the appearance of lesions
Take away #2:
Advise patients to cover up the lesions until they are crusted over.
Take away #3:
Uncomplicated zoster infection in an immunocompetent host can be treated outpatient with any of the above antivirals, along with adequate analgesia. Disseminated, complicated zoster, or immunocompetent patients (transplant pts, multiple comorbidities) may need to be admitted with ID consultation.
Wei Li, MD is a current second year resident at Stony Brook Emergency Medicine.
Shafran SD, Tyring SK, Ashton R, et al. Once, twice, or three times daily famciclovir compared with aciclovir for the oral treatment of herpes zoster in immunocompetent adults: a randomized, multicenter, double-blind clinical trial. J Clin Virol. 2004;29(4):248-253. doi:10.1016/S1386-6532(03)00164-1
Tyring SK, Beutner KR, Tucker BA, Anderson WC, Crooks RJ. Antiviral therapy for herpes zoster: randomized, controlled clinical trial of valacyclovir and famciclovir therapy in immunocompetent patients 50 years and older. Arch Fam Med. 2000;9(9):863-869. doi:10.1001/archfami.9.9.863
He L, Zhang D, Zhou M, Zhu C. Corticosteroids for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2008;(1):CD005582. Published 2008 Jan 23. doi:10.1002/14651858.CD005582.pub2 5. https://www.uptodate.com/contents/epidemiology-clinical-manifestations-and-diagnosis-of-herpes-zoster?search=shingles&topicRef=8293&source=see_link#H2
Edited by Bassam Zahid