Herpes Zoster: (Shingles)

Presentation

The most common presentation is a dermatomal rash and pain. Prodromal symptoms, which occur infrequently, may include malaise, nausea and vomiting, headache, and photophobia. Less commonly there may be fever. During the prodromal stage, which can last several days, patients commonly experience preherpetic neuralgia.

Patients complain of symptoms that range from an itch or tingling to severe lancinating pain, tenderness, dysesthesias, paresthesia, or hypersensitivity that covers a specific dermatome. This discomfort may be precipitated by minor skin stimulation from the patient’s clothes and is characteristic of this type of neurologic pain. After 1 to 5 days, the patient may develop a characteristic unilateral rash. The discomfort may be difficult for the patient to describe, often alternating between an itch, a burning, and even a deep aching pain. Prior to the onset of the rash, zoster can be confused with pleuritic or cardiac pain, cholecystitis, or ureteral colic. The pain may precede the eruption by as much as a few weeks, and occasionally pain alone is the only manifestation (zoster sine herpete). Although almost exclusively a unilateral disease, in one study approximately 1% of patients had bilateral involvement.

The early rash consists of an eruption of erythematous macules and papules that usually appear posteriorly first and then spread anteriorly along the course of an involved nerve segment. In most instances, clusters of clear vesicles on an erythematous base will appear within the next 24 hours ( Figs. 172.1, 172.2, and 172.3 ). These continue to form for 3 to 5 days and then evolve through states of pustulation, ulceration, and crusting.

The skin eruption usually is limited to a single dermatome; the most commonly involved dermatomes are the thoracolumbar region and the face. Lesions may involve more than one dermatome and occasionally may cross the midline. With seventh cranial nerve involvement (causing weakness of all facial muscles on one side), the rash will be found in the ipsilateral external ear (called zoster oticus) ( Fig. 172.4 ), or vesicles may be seen on the hard palate. Bell palsy (see Chapter 5 ) following zoster dermatitis of the external ear canal is well known and can be part of the Ramsay Hunt syndrome. The virus invades the facial nerve, especially the geniculate ganglion, and occasionally the auditory nerve, and can produce the peripheral seventh-nerve palsy, along with hearing loss, vertigo, and taste dysfunction.