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PostPosted: 30 May 2014 03:22 
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Shingles -
Shingles occurs when the varicella-zoster virus (which causes chickenpox) is reactivated from latency in the central nervous system.

Complications include post-herpetic neuralgia, secondary infection, scarring, and ocular complications.
Unlike chickenpox, shingles can only be transmitted by direct skin contact with the affected area.

Only a person who has not had chickenpox or the varicella vaccine can 'catch' chickenpox from a person with shingles.

Diagnosis is usually made on clinical grounds as shingles occurs in 3 phases:

Prodrome (1–4 days before the rash) — fever and myalgia, with burning, tingling, numbness, or pruritus in the affected skin.

Acute (painful rash lasting 7–10 days) — macules and papules develop into vesicular lesions in a dermatomal distribution (commonly on the thorax), then burst, releasing varicella-zoster virus.

Healing (2–4 weeks) — the lesions crust over.

A person with shingles should be advised to:

Avoid direct skin contact (involving the affected area) with pregnant women (if they cannot recall having had chickenpox), immunocompromised people, and babies younger than 1 month of age (unless it is their own baby, who will have maternally-derived antibodies against the virus).

Keep the rash clean and dry to reduce the risk of infection.

Avoid use of topical antibiotics and adhesive dressings, as they can cause irritation and delay healing.

Seek medical advice if they have a fever, as this may indicate bacterial infection.

Avoid work, school, or day care if the rash is weeping and cannot be covered. This is unnecessary if the lesions have dried or the rash is covered.

To manage associated pain in adults, paracetamol alone or in combination with codeine or ibuprofen should be offered.
In severe pain, amitriptyline (off-label use) or pregabalin (or gabapentin) should be considered. Oral imipramine or nortriptyline may be considered as an alternative to amitriptyline (off-label use).

To manage severe pain, oral corticosteroids may be considered in the first 2 weeks following rash onset in immunocompetent adults (excluding certain groups, such as people with insulin dependent diabetes mellitus) with localized shingles, but only in combination with antiviral medication, and based on clinical judgment, taking into account the risks and benefits of corticosteroid therapy for each person.

To manage associated pain in children, paracetamol or ibuprofen should be offered. If these are not effective, specialist advice should be sought.

An oral antiviral drug (such as aciclovir)
should be started within 72 hours of rash onset for a certain group of people, such as people aged 50 years or older, people with non-truncal involvement (e.g. shingles affecting the neck, limbs, or perineum), and people with moderate or severe pain or rash.

If it is not possible to initiate treatment within 72 hours, antiviral treatment can be considered up to 1 week after rash onset, especially if the person is at higher risk of severe shingles or complications (e.g. continued vesicle formation, older age, immunocompromised, or severe pain).

For pregnant women, specialist advice should be sought regarding prescribing antiviral treatment.

For immunocompetent children with shingles, antiviral treatment is not recommended.

In all people with shingles, clinical judgment should be used to decide who to refer, who to refer to, and the urgency of the referral.
For example:
Urgent admission or specialist advice may be necessary if the person has a complication, is severely immunocompromised, or pregnant.


Less urgent referral may be necessary if new vesicles are forming after 7 days of antiviral treatment, healing is delayed, or if pain is inadequately controlled by oral analgesia.


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PostPosted: 01 Jun 2014 13:42 
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Hi Mohan

The pain in the acute stage is very agonising indeed. But physicians are confounded and confused when they get cases with pre and post herpetic pains. When patients come with post herpetic pain usually it is immediately after a herpetic lesion. Self explanatory. You treat with all sorts of pain killers and antidepressants and even anti epileptic like carbamazepine. Mostly you succeed and sometimes you may not. About two years ago I had a patient who came with pain left scapular region paroxysmal in nature. Present for so many years. Been to many doctors and got no relief. She told me that initially it used to be once in a way only. But of late more frequently and more severe. Not related to exertion and movement of the chest. No cough too. Due to periodicity and severity of the pain I thought that could be neurogenic and immediately I asked her whether she had herpes zoster any time, a sort of rash on one side of her chest near scapula. With wide eyes she told me yes and that was some 18 years ago. And the present pain almost from then only and at that part of the body only. The difference is that it is now more often and more severe. And she told me that she had almost forgotten that event of rash and no body asked her about it. I treated here with Clobazam (Frisium) 5 mg at night. She is OK now. Here no investigations of any kind would have helped her except the history taking.

Unlike the post herpetic, the pre-herpetic neuralgia is present only in the prodromal state of herpes zoster for a short period. But till the rashes appear both the patient and the doctor are in a perplexed state. It depends on where the patient lands with the acute pain. If it is a corporate multispecialty hospital, within three or four days time, an array of costly investigations including x-rays ECG, CT scans and blood tests would have eaten his purse depending upon which part of the body is involved. After the appearance of the rashes some may be discharged from ICUs where doctors were expecting some abnormal tracing in the ECG or increasing titre in the enzyme studies. And sometimes overenthusiastic surgeons would have their used their scalpels too only to find herpetic rashes in the postoperative period.

UA Mohammed


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PostPosted: 01 Jun 2014 22:10 
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Mohan and Mohammed,

Thank you for a good summary about Shingles and its treatment. A few days ago I went to see my GP for my yearly check. He advised me that I should be vaccinated for shingles as I have had chicken pox during my child hood. I was surprised and a little curious about this. Although I have seen several orthopaedic patients developing shingles while on the ward for an orthopaedic problem it just didn't occur to me that I was prone to get shingles. Do you see many cases in India? I am informed that 1 in 4 adults could develop shingles.

It is said that if you have had chicken pox in the past, the virus remains dormant in the nervous system and may reactivate later in life. This can happen particularly in older age group when the immune system weakens. The chances of developing shingles before the age of 50 is very low. Although it is unlikely that you will develop shingles for a second time there are some who develop recurrent attacks.

As Mohan mentioned the rash and later papules and vesicular lesions are seen in a dermatomal distribution, usually involving the trunk on one side. Sometimes the limbs can also be affected and rarely the eyelid or even the eye which can lead to blindness.

Although vaccination is not guaranteed to prevent an attack, it can lessen the symptoms and prevent post herpetic neuralgia.

Badri.


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PostPosted: 04 Jun 2014 08:23 
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I took the zoster vaccination ( Live virus) without any side effects. It is kept in the freezer and taken out and injected sub cutaneously. It gives immunity lifelong, Some say only for 10-15 years. The ID community is divided on this issue. The consensus is that it will prevent HZ or if you get it it will be a very mild form with no complications. After taking HZ vaccination one has to be careful as the virus is excreted in the stool for up to one months. So strict hand washing prior to coming into contact with immunosuppressed individuals, non-vaccinated infants etc are important.

_________________
Raghuthaman


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