Varicella-zoster virus
Peter M. Lydyard, Michael F. Cole, John Holton, William L. Irving, Nino Porakishvili, Pradhib Venkatesan, Katherine N. Ward in Case Studies in Infectious Disease, 2010
The clinical features of shingles are protean, and depend to a large extent on the location of the nerve cell body in which reactivation arises. The shingles rash is acutely painful, and occurs in a dermatomal distribution (see above, and Figure 5). The commonest and most distressing complication is post-herpetic neuralgia (PHN), defined as pain persisting for at least 3 months (although the precise time period may vary between different studies) in the area of a zoster rash after the rash itself has disappeared. The pathogenesis is poorly understood, but it can persist for months or even years, and can have a significantly detrimental effect on the patient’s quality of life. The risk of PHN increases with increasing age of the patient, and is also related to the intensity of the shingles rash (i.e. the number of lesions). Other complications depend on the anatomic location of the rash. Ophthalmic zoster (occurring in the ophthalmic branch of the trigeminal nerve) is particularly serious, as virus may gain access to the cornea, giving rise to an ulcerating zoster keratitis. While mostly thought of as a disease of sensory nerves, motor nerve damage can also arise in zoster, giving rise to lower motor neuron paralysis, for example zoster of the facial nerve (seventh cranial nerve) may give rise to a Bell’s palsy (facial nerve paralysis).
Answers
Andrew Schofield, Paul Schofield in The Complete SAQ Study Guide, 2019
Shingles is a human herpes virus which usually lies dormant in the dorsal root ganglion, or in the case of ophthalmic shingles, the trigeminal nerve root ganglion. This dormant episode follows primary infection as a child with chickenpox. Ophthalmic shingles usually occurs in the elderly population. Approximately 50% of cases of ophthalmic shingles will have nasociliary nerve involvement (Hutchinson’s sign). This is a bad prognostic sign, as it means the possibility of eye involvement. On examination, the patient will have an absence of the blink reflex when the cornea is touched lightly with some cotton wool. This then leaves the cornea exposed to abrasion. Examination of the cornea with blue light and fluorescein is needed to look for the characteristic dendritic ulcers associated with ophthalmic shingles. Management of ophthalmic shingles is specialist-led and may involve antivirals, topical steroids or topical antibiotics.
Postherpetic Neuralgia
Gary W. Jay in Practical Guide to Chronic Pain Syndromes, 2016
This live, attenuated varicella vaccine was developed with the goal of conferring an immunologic boost to the age-related waning immunity of older adults. This is especially important in light of the fact that natural immune boosting opportunities will eventually decline as mentioned above. The Shingles Prevention Study—a large, multicenter, randomized, placebo-controlled trial—was conducted to evaluate the efficacy and safety of herpes zoster vaccination (46). The results of the trial indicated that the herpes zoster vaccine reduces the likelihood of developing herpes zoster in immunocompetent individuals 60 years of age or older. Important results of this study included a decrease in the incidence of herpes zoster by 51.3%, a reduction in the overall burden of illness by 61.1%, and a decrease in the incidence of PHN by 66.5% (47). The effect on decreasing the incidence of herpes zoster was less in older subjects, but the effect on reducing the severity of illness was greater in older subjects. Therefore, the overall reduction in burden of illness, the primary end point of the study, was maintained across all age groups. On the basis of these data, the FDA approved the use of the herpes zoster vaccine in individuals 60 years and older. This live, attenuated vaccine is contraindicated in children, pregnant women, and immunocompromised individuals.
Recalcitrant Herpes Zoster Ophthalmicus in a Patient Discovered to Have Underlying Functional Natural Killer Cell Deficiency
Published in Ocular Immunology and Inflammation, 2022
Brent J. Deibert, Kurtis C. Johnson, Luke W. Desilet, Andrew C. Rorie
Natural killer cells are a vital part of the innate immune response. These cells are especially important in the body’s protection from viral infections. Varicella zoster virus (VZV) is essentially ubiquitous in the aging population. In those who experienced a childhood infection with VZV, known as chicken pox, the virus typically reactivates as the immune system wanes with age and is unable to keep the dormant virus contained. The re-activation of this virus causes the disease shingles, which presents as painful, dermatomal, vesicular lesion. This disease can affect almost every part of the body and is especially problematic when the eye is affected. In cases of immunodeficiency the course of the disease can be altered regarding age of onset or re-occurrence of the disease. Despite appropriate response from the adaptive immune system, deficiencies in cells of the innate response that preform viral surveillance can have a large impact on the disease course that would normally be self-limited.
Rhabdomyolysis after recombinant zoster vaccination: a rare adverse reaction
Published in Journal of Community Hospital Internal Medicine Perspectives, 2021
Nishan Rajaratnam, Swati Govil, Rutwik Patel, Mohamed Ahmed, Sameh Elias
Herpes zoster, or shingles, is a frequent late sequela of varicella infection causing a painful rash. To prevent this outcome, the shingles vaccination has been recommended for older adults in the USA since 2006 in the form of an attenuated vaccine. In 2017, a new recombinant vaccine was approved, even for patients who had already received the attenuated version. It is recommended for adults above 50 years and reduces the risk of shingles by about 90% [1]. The vaccine is commonly known to cause mild, rather than severe, side effects such as injection site pain and erythema, headache, and nausea [1]. Rhabdomyolysis is classified as acute muscle injury that causes a release of electrolytes, myoglobin, and enzymes such as creatine phosphokinase (CPK) into circulation. It typically presents as muscle soreness, fatigue and may lead to kidney injury. We present a rare case of a patient developing rhabdomyolysis after administration of the recombinant zoster vaccination.
Using Individuals as (Mere) Means in Management of Infectious Diseases without Vaccines. Should We Purposely Infect Young People with Coronavirus?
Published in The American Journal of Bioethics, 2020
Alberto Giubilini
The case they analyze is yet different, though only slightly so. Malm and Navin discuss the strategy of exposing children to the varicella virus in order to benefit only the elderly who are at risk of shingles. This is a clear example of using the first group merely as a means to benefit the second: children do not get any significant benefit out of it and in any case cannot give valid consent. The strategy they discuss is based on the Exogenous Boosting Hypothesis (EBH) and has been adopted by some countries (e.g. by not subsidizing the varicella vaccine) including the UK, Norway, and the Netherlands. The varicella virus causes chickenpox, and shingles occurs when the inactive varicella virus that remains in an individual’s nerve cells after the individual recovers from chickenpox is reactivated. According to the EBH, people who had chickenpox can gain protection against shingles by being exposed again to the same virus: this exposure would boost the immune system response to the varicella virus so that it would not result in shingles. Chickenpox is an infectious disease that typically occurs in children, while shingles typically occurs in older adults. Therefore, as Malm and Navin correctly notice, “an EBH-informed vaccination strategy essentially requires that children become worse off, in this case by enduring the risks and harms of active chickenpox infection, so that a different group—in this case the vulnerable elderly—becomes better off” by being more likely to be exposed to the exogenous boosting.
Related Knowledge Centers
- Chickenpox
- Immunosuppression
- Paresthesia
- Postherpetic Neuralgia
- Rash
- Varicella Zoster Virus
- Visual Impairment
- Peripheral Neuropathy
- Viral Disease
- Virus Latency