Herpes zoster 嘉義長庚藥劑科林慧媚

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1 Herpes zoster 嘉義長庚藥劑科林慧媚

2 Outline Introduction Epidemiology Pathogenesis Symptoms and Signs Diagnosis Risk factor Complication Treatment Prevention

3 Introduction Varicella-zoster virus (VZV) infection causes two clinically distinct forms of disease: varicella (chickenpox) and herpes zoster (shingles). Primary VZV infection results in the diffuse vesicular rash of varicella or chickenpox.

4 Pathogenesis Clinical resolution is followed by the establishment of latent infection within the sensory dorsal root ganglia. Reactivation of this neurotropic virus leads to herpes zoster, or shingles, a painful, unilateral vesicular eruption in a restricted dermatomal distribution Spinal cord Dorsal root ganglion VZV moves along the sensory nerve to the dorsal root ganglion Chickenpox (VZV) rash Skin VZV establishes latency in the dorsal root ganglion

5 Herpesviruses That Infect Humans

6 Epidemiology in USA There are more than 1 million cases of herpes zoster in the United States each year, with an annual rate of 3 to 4 cases per 1000persons. 85 years of age have a 50% risk of herpes zoster. Up to 3% of patients with the disease require hospitalization. 管理您的信箱 ( 五 ): 擷取備份或分享郵件

7 Epidemiology in Taiwan ( ) Overall, 34,280 patients were diagnosed with zoster (incidence 4.89/1000 person-years) A total of 4543 patients (13.3%) had persistent neuralgia one month after the start of the zoster rash (incidence 0.64/1000 person-years), 2944 patients (8.6%) developed postherpetic neuralgia 3 months after the start of the zoster rash (incidence 0.42/1000 person-years). overall hospitalization rate for zoster was 16.1 cases per 100,000 person-years. Acta Derm Venereol 2009; 89:

8 Epidemiology in Taiwan

9 Symptoms and Signs 1. Acute neuritis 75 percent prodromal pain in the dermatome where the rash subsequently appears. burning", "throbbing", or "stabbing" sensation, pruritus,allodynia 2.Rash erythematous papules vesicles or bullae more pustular or occasionally hemorrhagic

10 Symptoms and Signs-site

Diagnosis The diagnosis of VZV infection is usually a clinical diagnosis based on the characteristic vesicular lesions additional diagnostic information may be useful in the following situations: 1.

11 Diagnosis The diagnosis of VZV infection is usually a clinical diagnosis based on the characteristic vesicular lesions additional diagnostic information may be useful in the following situations: 1.Atypical rash in an immunocompromised host 2.Possible disseminated disease in an immunosuppressed host without cutaneous lesions POLYMERASE CHAIN REACTION DIRECT FLUORESCENT ANTIBODY VIRAL CULTURE SEROLOGIC TESTING

12 RISK FACTOR Age human immunodeficiency virus infection, neoplastic diseases, organ transplantation, use of immunosuppressive drugs, other conditions that cause a decline in cell-mediated immunity

13 COMPLICATIONS 併發症

Complication Aseptic meningitis Bacterial superinfection Bell s palsy Eye involvement (herpes zoster ophthalmicus) Hearing impairment Motor neuropathy Postherpetic neuralgia Ramsay Hunt syndrome

14 Complication Aseptic meningitis Bacterial superinfection Bell s palsy Eye involvement (herpes zoster ophthalmicus) Hearing impairment Motor neuropathy Postherpetic neuralgia Ramsay Hunt syndrome Transverse myelitis Vasculopathy (encephalitis) Headache, meningismus Manifestations Streptococcus, staphylococcus cellulitis Unilateral facial paralysis Keratitis, episcleritis, iritis, conjunctivitis,uveitis, acute retinal necrosis,optic neuritis, acute glaucoma Deafness Weakness, diaphragmatic paralysis, neurogenic bladder Pain persisting after the rash has resolved Ear pain and vesicles in the canal,numbness of anterior tongue,facial paralysis Paraparesis, sensory loss, sphincter impairment Vasculitis of cerebral arteries, confusion, seizures, TIAs, stroke 管理您的信箱 ( 五 ): 擷取備份或分享郵件

15 Postherpetic neuralgia(phn) There are three phases of pain associated with herpes zoster: Acute herpetic neuralgia :pain,rash 30 days Subacute herpetic neuralgia : within four months of onset PHN :beyond three or four months Thoracic (especially T4 to T6), cervical, and trigeminal nerves are most commonly affected. Pain: Burning, sharp, or stabbing constant or intermittent

16 Postherpetic neuralgia(phn) Risk factors: older age, greater acute pain, and greater rash severity. Advanced age is associated with increasing severity and persistence of symptoms. Immunocompromised individuals may be increased

17 Postherpetic neuralgia(phn) Additional factors supporting the diagnosis are : Advanced age Severe prodromal pain with acute herpes zoster Severe preceding rash Distribution in trigeminal or brachial plexus dermatomes The presence of allodynia

18 Treatment The principal goals of the treatment of HZ are reduction of pain in immunocompetent patients and cessation of viral replication in immunocompromised patients and those with ophthalmic HZ.

19 Treatment-Antiviral therapy The goals of antiviral therapy are to : Lessen the severity and duration of pain associated with acute neuritis Promote more rapid healing of skin lesions Prevent new lesion formation Decrease viral shedding to reduce the risk of transmission Prevent PHN ( less clear )

20 Treatment-Antiviral therapy Indications for Antiviral Treatment for Patients with Herpes Zoster 50 years old Moderate or severe pain Severe rash Involvement of the face or eye Other complications of zoster Immunocompromised persons While antivirals may benefit additional patients with zoster, they are primarily recommended by experts for these 6 groups who either have complications or who are at increased risk of complications from zoster. Cohen JI: Herpes zoster. N Engl J Med 2013;369:1766-7

21 Treatment-Antiviral therapy 72 hours after onset Antiviral therapy should be initiated within this time frame to maximize the potential benefits of treatment >72 hours after onset There is likely minimal benefit of antiviral therapy in the patient who has lesions that have encrusted.

22 Acyclovir Acyclovir (9-[2-hydroxymethyl]guanine) is a nucleoside analog that selectively inhibits the replication of herpes simplex virus types 1 and 2 (HSV-1, HSV-2) and varicella-zoster virus (VZV).

24 Acyclovir mechicine

25 Treatment-Antiviral therapy Schmader K: Clin Geriatr Med 2007; 23:

26 Treatment-Antiviral therapy

27 Acyclovir Intravenous acyclovir may cause reversible nephrotoxicity in up to 5% to 10% of patients because of precipitation of aciclovir crystals in the kidney. Acyclovir crystalline nephropathy is more common when acyclovir is given as a rapid infusion and in patients with dehydration and preexisting renal impairment. Adequate hydration, a slower rate of infusion, and dosing based on renal function may reduce this risk.

28 Glucocorticoids The addition of glucocorticoids to antiviral therapy has not been shown to reduce the incidence of postherpetic neuralgia. Avoided in patients with hypertension, diabetes mellitus, peptic ulcer disease, or osteoporosis; particular caution is warranted in the case of elderly patients, who are atincreased risk for serious adverse events. Prednisone is used for the treatment of certain CNS complications of herpes zoster, such as vasculopathy or Bell s palsy in nonimmunocompromised patients. Jeffrey I. Cohen, M.D. Herpes Zoster n engl j med 369;3 nejm.org july 18, 2013

Eye disease associated with zoster In the V1 distribution of the trigeminal nerve (including lesions on the forehead and the upper eyelid,nose or new visual symptoms (ophthalmologist) In addition to

29 Eye disease associated with zoster In the V1 distribution of the trigeminal nerve (including lesions on the forehead and the upper eyelid,nose or new visual symptoms (ophthalmologist) In addition to antiviral therapy, including 1.mydriatics to dilate the pupil and reduce the risk of scarring (synechiae) 2.topical corticosteroids for keratitis, episcleritis, or iritis, medications to reduce ocular pressure for glaucoma, 3. intravitreal antiviral therapy for immunocompromised patients with retinal necrosis.

30 Treatment-PHN 2004 American Academy of Neurology: TREATMENT OF POSTHERPETIC NEURALGIA

31 Tricyclic antidepressant (TCA) moderate to severe pain from PHN Exceptions include patients with heart disease, epilepsy, or glaucoma. Tricyclic drugs should be used cautiously in older patients. Nortriptyline,Amitriptyline,Desiprmine,Imipramine

antidepressants, we suggest gabapentin or pregabalin.

32 Anticonvulsants For patients with moderate to severe PHN who have contraindications to or intolerance of tricyclic antidepressants, we suggest gabapentin or pregabalin. Gabapentin and pregabalin should be avoided in patients with renal insufficiency.

33 Opioids a risk of physical dependence, tolerance, addiction, and overdose second- or third-litmene treant options for PHN

Topical lidocaine For patients with mild to moderate localized pain from PHN and for patients with PHN who do not desire therapy with oral drugs, we suggest treatment with topical

34 Topical lidocaine For patients with mild to moderate localized pain from PHN and for patients with PHN who do not desire therapy with oral drugs, we suggest treatment with topical lidocaine. 使用部位僅限於未受損的皮膚每片 14 gm 貼片含 700 mg lidocaine amide-type 類化合物的局部麻醉劑, 藉由抑制神經衝動啟動及傳導所需之離子流動, 穩定神經細胞膜每 24 小時用一次, 每次最多可使用 3 片, 每次使用不超過 12 小時移除貼片後至少休息 12 小時才可再使用移除封套前可將貼片剪為小片使用

35 管理您的信箱 ( 五 ): 擷取備份或分享郵件

36 Prevention

37 Prevention Herpes Zoster and Postherpetic Neuralgia :Prevention and ManagementAmerican Family Physician Volume 83, Number 12 June 15, 2011

39 SUMMARY 1. The majority of herpes zoster cases occur among older adults because the incidence of herpes zoster and PHN increases. 2. Acute herpes zoster pain, other herpes zoster complications (e.g., ophthalmic zoster) and PHN may profoundly affect physical, psychological and social health and reduce quality of life in older people.

40 SUMMARY 3. Antiviral therapy should be initiated within 72 hours of onset of the rash. 4. Tricyclic antidepressant, tramadol, long-acting opioid, or anticonvulsant (i.e., gabapentin or pregabalin ), lidocaine patch (Lidoderm) should be selected to decrease the pain of postherpetic neuralgia. 5. Herpes zoster vaccine (Zostavax) should be given to most persons years and older to prevent herpes zoster(51%) and postherpetic neuralgia(67%).

41 1. Acta Derm Venereol 2009; 89: Epidemiological Features and Costs of Herpes Zoster in Taiwan:A National Study 2000 to Cohen JI: Herpes zoster. N Engl J Med 2013;369: Schmader K: Clin Geriatr Med 2007; 23: American Academy of Neurology: TREATMENT OF POSTHERPETIC NEURALGIA 5. Herpes Zoster and Postherpetic Neuralgia :Prevention and ManagementAmerican Family Physician Volume 83, Number 12 June 15, UPTODATE

42 THANK YOU

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<4D6963726F736F667420576F7264202D2030383132C3C4B0542DAA76C0F8AF70AF6CABE1AFABB867B568ADD7A7EF> 老人帶狀皰疹後神經痛江文心林珍芳一前言帶狀疱疹 (herpes zoster) 俗稱皮蛇 (shingles), 引起的病毒就是引起水痘的病毒 varicella-zoster virus(vzv), 水痘痊癒後少量病毒潛伏在體內感覺神經的背根神經節 (dorsal root ganglia)