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  • • Herpes zoster is an acute vesicular eruption due to reactivation of the varicella-zoster virus

    • Focal, often severe pain that upon careful questioning follows a dermatomal distribution

    • Delayed development (> 48 hours) of classic vesicular lesions along a specific dermatomal distribution

    • Positive Tzanck smear

    • The diagnosis may become clear in postoperative patients 1-2 days following a negative exploration

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Epidemiology

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  • • Usually occurs in adults

    • With rare exceptions, patients only suffer 1 attack

    • Generalized disease or occurrence in patients < 55-years-old raises the suspicion of an immunosuppressive disorder

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Symptoms and Signs

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  • • Pain precedes vesicular eruption by 48 hours or more

    • Pain may persist and actually increase in intensity after the lesions disappear

    • The dermatologic lesions consist of grouped, tense, deep-seated vesicles distributed unilaterally along a dermatome

    • Regional lymph nodes may be tender and swollen

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Laboratory Findings

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  • • Multinucleated giant cells on Tzanck smear

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Imaging Findings

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  • • Normal

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  • • Because of the severity of abdominal pain and its localized nature as well as the anatomic proximity to affected dermatomes, herpes zoster may be misdiagnosed as the following:

    • -Acute cholecystitis

      -Acute appendicitis

      -Incarcerated hernia

      -Ureteral colic

    • Generalized vasculitis

    • Abdominal wall tumor

    • Rectus sheath hematoma

    • Thoracolumbar spinal nerve root compression

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Rule Out

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  • • Diseases that may require surgery

    • -Prior to vesicle eruption, the diagnosis of zoster is presumptive

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  • • CBC

    • Basic chemistries

    • Amylase and lipase

    • UA

    • Abdominal x-rays

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When to Admit

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  • • Admit for observation and serial abdominal exams when a surgical diagnosis is contemplated

    • Treatment of zoster otherwise performed as an outpatient

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When to Refer

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  • • Dermatology consult to diagnose herpetic rash and perform Tzanck smear

    • Chronic pain clinics best manage postherpetic neuralgia

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  • • Exclude surgical etiology of abdominal wall pain

    • NSAIDs or narcotics for pain

    • Early institution of antiviral medications

    • Patient is infectious

    • -Isolate from immunocompromised patients

    • Evaluate for HIV or other immunocompromised states in patients younger than 55

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Surgery

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Indications

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  • • None

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Medications

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  • • Acyclovir, famciclovir, or valacyclovir

    • Early medical treatment of zoster may reduce the incidence of postherpetic neuralgia (controversial)

    • Nerve blocks for severe pain

    • Systemic corticosteroids for severe pain

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Treatment Monitoring

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  • • Symptomatic improvement

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Complications

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  • • Postherpetic neuralgia

    • Anesthesia of affected area

    • Scarring

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Prognosis

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  • • Postherpetic neuralgia develops in 15% of patients

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References

Balfour HH. Antiviral drugs. N Engl J Med. 1999;340:1255.  [PubMed: 10210711]

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