Herpes Zoster (Shingles)

by Carlo Raj, MD

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    00:01 Our topic here is shingles.

    00:03 In other words, herpes zoster.

    00:05 So what then happened here? The etiology would be the VZV.

    00:08 So you have a patient that has had chicken pox.

    00:12 And as you know, as far as your VZV, it likes to hide in the dorsal root ganglion.

    00:18 And as we get older, shall we say that we may then become less immunocompetent.

    00:24 And as we become less immunocompetent or you have an individual that is under such immense stress -- Wells Fargo comes to mind, but anyhow, such intense stress to perform that at some point in time, you might have reactivation that’s talking place of the VZV in the dorsal root ganglion.

    00:40 And then you can imagine that this particular virus is making its way down the dermatome, and when it does, whoa, man, this thing hurts.

    00:50 Welcome to shingles.

    00:51 Mostly like in the U.S., elderly individual, immunocompromised individual, severe stress, to the point where there’s reactivation of your varicella zoster virus.

    01:02 Welcome to herpes zoster or shingles.

    01:06 Morphology: Well, you can imagine that if this is herpes, then what are you going to find? These fluid-filled type of structures called vesicles.

    01:14 So you have a reticular pain followed by your vesicles and ultimate crusts.

    01:21 Rarely disseminated in immunocompromised patients.

    01:27 If you take a look at the dermatome in this particular individual, you’ll notice that you have vesicle type of formation that’s taking place on the skin and it’s usually some type of history of immunocompromise in this patient and it hurts.

    01:38 Most common in elderly.

    01:41 Immunity to VZV.

    01:43 Also could be seen with immunosuppression.

    01:48 With herpes, you automatically think about, well, Tzanck smear as we shall see.

    01:54 Not typically diagnosed.

    01:55 You could tell by the history of your patient this is what’s taking place.

    01:59 Fresh lesions can be scraped with your blade.

    02:03 Examined in clinic using perhaps Giemsa and Wright, but result is called or from your Tzanck smear.

    02:11 Both HSV and VZV will show, as you seen in this picture, multinucleated keratinocytes on Tzanck smear.

    02:19 That’s where you focus on immediately.

    02:21 Herpes zoster or herpes in general.

    02:23 You should be thinking Tzanck and you should be thinking multinucleated cells and here, specifically, if it’s in the skin and in your keratinocytes, as you see in this image.

    02:37 Management: Oral acyclovir.

    02:41 Treatment is not useful once the lesions have crusted, that’s important.

    02:46 Elderly patients may be treated with oral steroids to decrease the risk of post herpetic neuralgia.

    02:55 Post-herpetic neuralgia may last months or years and they treat it with agents used in chronic pain including amitriptyline or even gabapentin.

    03:04 Keep these in mind when dealing with shingles.

    03:07 That pain is ridiculous.

    03:09 And that pain that then occurs down the dermatome has to be properly managed in these patients.

    03:16 Post-herpetic neuralgia is something that you want to keep in mind.

    About the Lecture

    The lecture Herpes Zoster (Shingles) by Carlo Raj, MD is from the course Infectious Skin Diseases.

    Included Quiz Questions

    1. Thoracic dermatomes
    2. Trigeminal dermatomes
    3. Ulnar dermatomes
    4. Lower limb dermatomes
    5. Radial dermatomes
    1. Tzanck smear
    2. Gram stain
    3. Skin biopsy
    4. Potassium hydroxide
    5. Immunofluorescence
    1. Oral valacyclovir
    2. Oral steroids
    3. Oral antibiotics
    4. Topical steroids
    5. Hydroxychloroquine

    Author of lecture Herpes Zoster (Shingles)

     Carlo Raj, MD

    Carlo Raj, MD

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