Herpes zoster: A Review of Clinical Manifestations and Management

Abstract

The Varicella-zoster virus (VZV) or human herpes virus 3 is a neurotropic human alpha herpes virus responsible for chickenpox/varicella and shingles/herpes zoster (HZ). This review will focus on HZ. Since HZ is secondary to varicella, its incidence increases with age. In children and youngsters, HZ is rare and associated to metabolic and neoplastic disorders. In adults, advanced age, distress, other infections (such as AIDS or COVID-19), and immunosuppression are the most common risk factors. HZ reactivation has recently been observed after COVID-19 vaccination. The disease shows different clinical stages of variable clinical manifestations. Some of the manifestations bear a higher risk of complications. Among the possible complications, postherpetic neuralgia, a chronic pain disease, is one of the most frequent. HZ vasculitis is associated with morbidity and mortality. Renal and gastrointestinal complications have been reported. The cornerstone of treatment is early intervention with acyclovir or brivudine. Second-line treatments are available. Pain management is essential. For (secondary) prophylaxis, currently two HZV vaccines are available for healthy older adults, a live attenuated VZV vaccine and a recombinant adjuvanted VZV glycoprotein E subunit vaccine. The latter allows vaccination also in severely immunosuppressed patients. This review focuses on manifestations of HZ and its management. Although several articles have been published on HZ, the literature continues to evolve, especially in regard to patients with comorbidities and immunocompromised patients. VZV reactivation has also emerged as an important point of discussion during the COVID-19 pandemic, especially after vaccination. The objective of this review is to discuss current updates related to clinical presentations, complications, and management of HZ.

How to recognize and treat herpes zoster infection?

“…Transmisija VZV se odvija inhalacijom infektivnog respiratornog sekreta ili aerosolizovanih virusnih partikula koje potiču iz tečnosti vezikula, kao i direktnim kontaktom sa nesasušenim kožnim lezijama 4 . Period inkubacije kreće se u rasponu od 10 do 21 dan, obično 14 do 16 dana 4,6 . Primarna infekcija je obično bolest dečjeg doba (90% slučajeva se javlja pre 10. godine života) i manifestuje se kao varičela 7 .…”

“…Bolest je kod imunokompetentne dece obično benignog toka, dok se kod odraslih i imunodeficijentne dece javljaju teže forme bolesti, sa mogućim zahvatanjem centralnog nervnog sistema (CNS), pluća i drugih visceralnih organa 7 . Oboleli od varičele se smatraju kontagioznim 1-4 dana pre pojave kutanih manifestacija, pa sve do formiranja kruste 6 . Ekspozicija VZV dovodi do produkcije virus-specifičnih IgG, IgM i IgA antitela, od kojih IgG antitela perzistiraju doživotno.…”

“…Nakon primarne infekcije, VZV se stacionira u senzitivnim ganglionima kranijalnih nerava i zadnjih korenova kičmene moždine, autonomnim ganglionima enteričnog nervnog sistema i astrocitima, gde dugo ostaje u latentnom stanju 6,8 . Navode se dva potencijalna mehanizma širenja virusa do ciljnih nervnih ćelija: hematogena diseminacija u sklopu viremijskog stadijuma infekcije ili retrogradno širenje virusa aksonskim putem sa inficirane kože 9 .…”

“…Reaktiviran virus se prvobitno umnožava u senzitivnim ganglionima, gde izaziva inflamaciju i hemoragičnu nekrozu nervnog tkiva 13 . U daljem toku dovodi do zapaljenja senzitivnih nerava, preko kojih se širi do dermatoma, odnosno područja kože koje taj nerv inerviše, gde izaziva karakterističnu vezikuloznu erupciju 6 . Kao i kod varičele, nakon formiranja kruste, obolele osobe više nisu kontagiozne za okolinu 14 .…”

What Do Antibody Studies Tell Us about Viral Infections?

“…In case of infection reactivation, the virus is transported down the nerve to the correlating dermatome, which results in zoster. Due to VZV neurotropism, the infection can provoke long-lasting postherpetic neuralgia, especially in elderly and immunocompromised individuals [ 15 , 16 ]. Availability of accurate methods for serodiagnostics of VZV-specific antibodies is needed for the timely treatment of clinical cases, implementation of quarantine measures, vaccination effectiveness control and routine epidemiological surveillance of VZV.…”