Herpes Zoster (Shingles)

Introduction

-Herpes zoster results from reactivation of latent varicella-zoster virus infection within the sensory ganglia 

-It is usually characterized by a painful, unilateral vesicular eruption in a dermatomal distribution 

-It is usually occurs among adults, but rarely occurs in other age groups also. 

Symptoms & Signs 

-Most commonly involved sites of herpes zoster: trigeminal, thoracic and lumbar 

-It is usually confined to a single dermatome on one side and associated with burning pain in the affected area, fever, malaise, headache

-The rash starts as grouped vesicles and later become pustular and crusty. 

Herpes zoster ophthalmicus: Lesions on tip of nose, inner corner of eye and root and side of nose (Hutchinson sign) 

Herpes zoster oticus (Ramsay Hunt syndrome): vesicles in the ear canal, hearing loss, vertigo, tinnitus, Bell palsy; due to reactivation of VZV within the geniculate ganglion. 

-The lesions are considered infectious until they dry and crust over 

Diagnosis 

-Diagnosis is based on the clinical presentation

Treatment 

Antiviral agents: Acyclovir, valacyclovir, famciclovir, beneficial if started within 72 hours after the eruption of the rash 

Anterior uveitis: topical steroids, cycloplegics 

Corticosteroids do not prevent the development of postherpetic neuralgia

Prevention 

-Two shingles vaccines (Zostavax and Shingrix) are available for adults who have had chickenpox. 

-Shingrix is preferred over Zostavax.

-Shingrix is approved and recommended for people age 50 and older, including those who’ve previously received Zostavax. 

-Zostavax isn’t recommended until age 60. 

-Shingles can spread through direct contact with herpes zoster lesions 

-Patients should avoid contact with pregnant women who have never had chickenpox or varicella vaccine, immune deficiencies, and premature infants. 

Q.What is the most common complication of zoster in elderly adults? Postherpetic neuralgia 

Q. What is the most common cause of acute retinal necrosis? Herpes zoster virus



Chickenpox by Dr.Paul Kattupalli

Introduction

-Chickenpox is an infection caused by the varicella-zoster virus. 

-VZV is a double-stranded, linear DNA virus 

-VZV infection causes two clinically distinct forms of disease: varicella (chickenpox) and herpes zoster (shingles).

-It is highly contagious, spreads readily by airborne droplets and by direct contact. 

Symptoms & Signs 

-Varicella most frequently occurs in children <10 years old but may occur at any age. 

-Varicella usually is a mild, self-limited illness in healthy children. 

-Fever, headache, malaise, papules, vesicles, crusts and scabs 

-It appears on the back of the head and ears, and then spreads centrifugally to the face, neck, trunk, and proximal extremities. 

-Vesicles are described as ‘dew drops on a rose petal’

Diagnosis 

-Diagnosis is clinically made based on history and physical examination

-Tzanck smear of the vesicle: Giant cells with inclusion bodies

-Histology: “Balloon degeneration” of cells with basophilic nuclei 

Treatment 

-For healthy children  ≤12 years, varicella is mostly self-limited; no antiviral therapy

-Immunosuppressed children and adults: antiviral therapy 

-Do not give aspirin because it is associated with the onset of Reye syndrome in the setting of a viral infection 

-Breastfeeding is encouraged in infants exposed to or infected with varicella. 

Prevention 

-A live attenuated varicella vaccine is available. 

-It is administered subcutaneously

-It is given in two doses; first dose at age 12 through 15 months, the second dose at age 4 through 6 years



Herpes Simplex Infections

Introduction 

Herpes simplex virus infections occur equally between the sexes throughout the year. 

-Penn State Students in State College are at high risk when they touch lesions of herpes

HSV-1 transmission typically occurs via oral-oral, oral-genital, or genital-genital contact.

HSV-2 lesions largely involve the genital tract, with the virus remaining latent in the sacral nerve root ganglia (S2–S5) 

Symptoms & Signs 

Both viral subtypes can cause genital and oral–facial infections

The infections caused by the two subtypes are clinically indistinguishable.

Gingivostomatitis and pharyngitis:   the most frequent clinical manifestations of primary HSV-1 infection; presents as small, grouped vesicles on an erythematous base, burning and stinging sensation, swollen and tender burning and stinging 

Genital: most genital infections are caused by HSV-2; presents with bilateral genital ulcerations and tender lymphadenopathy. 

Ocular disease: HSV keratitis presents with vision loss, pain, and discharge; it is a major cause of blindness from corneal scarring and opacity. 

Neonatal & Congenital infection: Neonatal HSV can present as excessive tearing, eye pain, conjunctival edema, vesicular lesions of the mouth, palate, tongue, seizures, irritability, fever, multiple organ failure

CNS Disease: Both viruses can cause encephalitis; the temporal lobe is often involved; it presents with 

the rapid onset of fever, headache, seizures, focal neurologic signs, and impaired consciousness

Bell’s Palsy: HSV-1 is a cause of Bell palsy (facial nerve paralysis)

Esophagitis & Proctitis: usually presents with dysphagia or odynophagia, fever, retrosternal chest pain 

Erythema multiforme: HSV infection is the most common cause of EM; Cutaneous eruptions occur 2 to 7 days after herpes simplex infection 

Diagnosis 

Diagnosis can be made by physical examination; Direct fluorescent antibody slide tests, viral culture, polymerase chain reaction 

Treatment 

Early antiviral therapy within 72 hours of symptom onset

Antiviral drugs: Acyclovir, Famciclovir, Valacyclovir 

Severe or frequent recurrences: Chronic suppressive therapy with antivirals 

Keratitis: The usage of topical corticosteroids may exacerbate the infection

Prevention 

Male circumcision is associated with a lower incidence of acquiring HSV-2 infection.

Prognosis 

Q. What is the most frequent sign of HSV reactivation disease? Herpes labialis 

Q. What is the most frequent etiologic agent of Erythema multiforme? Herpes simplex virus 

Q. What is the most common cause of fatal sporadic encephalitis in the United States? HSV-1 encephalitis