Herpes Zoster

• • 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

Epidemiology

• • 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

Symptoms and Signs

• • 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

Laboratory Findings

• • Multinucleated giant cells on Tzanck smear

Imaging Findings

• • Normal

• • 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

Rule Out

• • Diseases that may require surgery

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

• • CBC

  • Basic chemistries

  • Amylase and lipase

  • UA

  • Abdominal x-rays

When to Admit

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

  • Treatment of zoster otherwise performed as an outpatient

When to Refer

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

  • Chronic pain clinics best manage postherpetic neuralgia

• • 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

Surgery

Indications

• • None

Medications

• • 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

Treatment Monitoring

• • Symptomatic improvement

Complications

• • Postherpetic neuralgia

  • Anesthesia of affected area

  • Scarring

Prognosis

• • Postherpetic neuralgia develops in 15% of patients

References