Updated: 1/31/2020

Varicella Zoster Virus

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Snapshot
  • A 60-year-old man presents to an urgent care clinic for a rash on his right arm. He reports that this rash suddenly occurred about 1 day ago. He has been in 10/10 pain from this rash. He reports that he had chickenpox during his childhood and that his physician had recommended that he receive a shingles vaccine; however, he had not had a chance to do so. He has not been sleeping well, as he is currently going through a divorce. On physical exam, there is a vesicular rash in a dermatomal distribution on his right upper arm. He is sent home with the appropriate treatment.
Introduction
  • Classification
    • varicella-zoster virus (VZV)
      • an enveloped, linear, double-stranded DNA virus
      • also known as human herpesvirus-3
      • transmitted via
        • respiratory secretions
        • direct contact with skin lesions
      • causes chickenpox, herpes zoster (shingles), encephalitis, meningitis, and pneumonia
  • Epidemiology
    • demographics
      • herpes zoster in elderly population
      • chicken pox in children
      • encephalitis and pneumonia in the immunocompromised
      • men > women
    • risk factors
      • immunosuppression
      • advanced age
      • previous infection with VZV
  • Pathogenesis
    • the virus infects T-cells
    • the virus is often latent in the dorsal root ganglia or trigeminal ganglia
    • reactivation of the latent virus causes herpes zoster
      • often precipitated by immunocompromise or stress
  • Prevention
    • herpes zoster
      • recombinant vaccine
        • adults > 50 years of age
      • live vaccine
        • adults > 60 years of age
    • chickenpox
      • live vaccine
        • adults and children 1 year or older
  • Prognosis
    • complete healing may take more > 1 month
    • chickenpox is often self-resolving in children
Presentation
  • Herpes zoster
    • painful unilateral vesicular/pustular skin eruption along a single dermatome
      • does not cross midline
    • preceded by prodrome of itchiness or tingling at the site
    • may involve the eye
      • herpes zoster opthalmicus
      • distribution of cranial nerve V
    • may involve the ear
      • Ramsay-Hunt syndrome or herpes zoster oticus
      • distribution of cranial nerve VII
  • Chicken pox
    • asynchronous vesicular rash
      • very itchy but not painful
      • starts on the head and trunk and spreads to the extremities
      • eventually develops a crust
    • fever and malaise
Studies
  • Labs
    • Tzanck smear
      • positive if multinucleated giant cells are seen  
    • polymerase chain reaction
    • direct fluorescent antibody staining
  • Making the diagnosis
    • most cases are clinically diagnosed
    • in atypical cases, laboratory examination may be useful
Differential
  • Herpes simplex virus
    • distinguishing factor
      • typically does not present in a dermatomal fashion
  • Contact dermatitis
    • distinguishing factor
      • typically is more itchy than painful
Treatment
  • Management approach
    • for herpes zoster, antivirals are first-line therapy
    • for chickenpox, treatment is centered around symptomatic relief
  • Conservative
    • soothing creams
      • indication
        • immunocompetent patients with chickenpox
  • Medical
    • oral antivirals
      • indications
        • all patients with shingles
        • immunocompromised patients with chickenpox
      • drugs
        • valacyclovir
        • famciclovir
        • acyclovir
    • intravenous antivirals
      • indication
        • patients with visceral or central nervous system disease
      • drugs
        • acyclovir
    • analgesics
      • indication
        • all patients
      • drugs
        • do not give aspirin for risk of Reye syndrome
 Complications
  • Disseminated disease
    • in immunocompromised patients
    • often involves the viscera
  • Post-herpetic neuralgia
    • incidence
      • very common
  • Fetal complications
    • blindness
    • scarring
    • limb hypoplasia
  • Vision loss or keratitis
    • from herpes zoster opthalmicus
 

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Questions (4)
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(M1.MC.13.1) A 68-year-old male presents to his dermatologist with a painful rash above his right nipple as shown in Figure A. Which of the following is the most likely etiology of the patient's rash: Tested Concept

QID: 101304
FIGURES:
1

Excessive fibrosis and collagen deposition

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(1/319)

2

Superficial bacterial skin infection

2%

(5/319)

3

Autoimmune IgG antibody against desmosomes

3%

(11/319)

4

Virally mediated epidermal hyperplasia

3%

(10/319)

5

Reactivation of latent virus

91%

(290/319)

L 1 E

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