herpes zoster
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Herpes zoster
Herpes zoster is an infectious disease that is caused by the varicella-zoster virus
It is postulated that during the course of primary infection with VZV, the virus migrates to the dorsal root or cranial ganglia
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
Herpes zoster
In some individuals the virus may reactivate and travel along peripheral or cranial sensory pathways to the nerve endings, producing the pain and skin lesions characteristic of shingles
The reason for reactivation ?decrease in cell-mediated immunity
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
Risk factorsSuffering from malignancies (particularly lymphoma)Receiving immunosuppressive therapy
(chemotherapy, steroids, radiation)
Generally debilitated by chronic diseasesPatients older than 60 years
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
SIGNS AND SYMPTOMS
Herpetic pain: 5-7 day before of skin lesions May be accompanied by flu-like symptoms Progresses from a dull, aching sensation to unilateral,
Segmental, band-like dysesthesias and hyperpathia Burning pain , hyperesthesia, allodynia Zoster sine herpete
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
SIGNS AND SYMPTOMS
From a mild self-limited problem to a debilitating, constantly burning pain that is exacerbated by light touch, movement, anxiety,and/or temperature change
Can lead to suicide
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
TREATMENT
Relief of acute pain and symptoms
Prevention of complications, includingpostherpetic neuralgia
Earlier treatment less likely postherpetic neuralgia
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
TREATMENT
Sympathetic neural blockade appears to be the treatment of choice to relieve the symptoms of acute herpes zoster as well as to prevent the occurrence of postherpetic neuralgia
Noordenbos "fiber dissociation"
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
TREATMENT
Herpes zoster in trigeminal nerve & geniculate, cervical, and high thoracic regions: stellate ganglionblockade with
LA daily basisHerpes zoster thoracic, lumbar, and sacral regions: epidural neural blockade with LA
daily basis
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
TREATMENT
• If the pain is not as severe, NSAIDs or acetaminophen may be all that is needed
• In acute eruption oral narcotics may be administered in the short term, especially
with (NSAIDs)
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
TREATMENT
Narcotic analgesics may be useful in relieving the aching pain
Antidepressants will help : Alleviate the significant sleep disturbance Ameliorate the neurotic component of the pain May exert a mood-elevating May cause urinary retention and constipation
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
TREATMENT
Anticonvulsants
May be of value as an adjunct to sympathetic neural blockade They may be particularly useful in persistent paresthetic or
dysesthetic pain
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
TREATMENT
Anxiety may be treated
HydroxyzineBehavioral interventions(e.g., monitored relaxation training and hypnosis)
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
TREATMENT
Antiviral agents:Acyclovir , valacyclovir, famcyclovir and perhaps
interferon have been shown to shorten the course of acute herpes zoster
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
Zoster sine herpete
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
Classic zoster sine herpete (ZSH) is defined clinically as dermatomal distribution pain without rash
First defined by Lewis(1958) who described zoster patients with dermatomal distribution pain in areas outside that affected byzoster rash
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
Gilden and colleagues reported 2 men aged62 and 66 years who had had chronic thoracic
distribution radicular pain in whom PCR-amplifiable VZV DNA was detected in the CSF 5 and 8 months after the onset of pain (1994)
Treatment with IV acyclovir produced marked improvement
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
A third man over 60 years old withsimilar chronic radicular pain was subsequently
reported in whom the VZV etiology was proved by detection of VZV DNA in blood mononuclear cells (MNCs) (1996)
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
R. Nau, MD M. Lantsch, MD M. Stiefel, MD T. Polak, MDH. Reiber, PhD
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
Departments of Neurology and Neuroradiology
University of Gttingen, Germany
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
42-year-old immunocompetent man no history of herpes zostersuddenly experienced dys- and hypesthesia in
his left handfluctuating paresis of the flexion and extension
of the fingers of the left handincreased tendon reflexes on the left at the
upper and lower extremities were notedDr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
Within the next 10 days, the hypesthetic region expanded to the fingers and the left forearm, and he noticed progressive distal weakness of his left upper extremity
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
ESR was 17 mm in the first and 33 mm in the second hour.
Serologic tests (c- and p-ANCA, rheumatoid factor, antibodies against DNA, the Sjogren-associated nuclear antigens SS-A and SS-B, and antibodies against extractable nuclear antigens Sm, RNP, Scl-70, and
Jo-1) and a rectum biopsy did not reveal any evidence for systemic vasculitis
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
On MRI, multiple ischemic lesions in the territory of the right middle cerebral artery (MCA) were detected
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
MR angiography revealed a proximal stenosis of the right MCA
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
Lumbar CSF contained 5 leukocytes/pL (predominantly mononuclear cells), and a normal total protein and lactate concentration
The CSF-to-serum concentration quotient of total IgG, for vzv resulting in an antibody index (AI)
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
The AI against herpes simplex virus was 3.8The polymerase chain reaction (PCR) for VZV
DNA in CSF was negative
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
High-dose IV acyclovir (750 mg IV three times daily for 10 days)
corticosteroids (1,000 mg IV daily for 3days, and 100 mg daily for another 10 days)
No immediate improvement but stopped the progression of the disease
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
During the next 6 months, the motor and sensory functions of the left upper extremity slowly improved
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
Neurology 76 February 1, 2011D.T. Blumenthal, MDE. Shacham-Shmueli, MDF. Bokstein, MDD.S. Schmid, PhDR.J. Cohrs, PhDM.A. Nagel, MDR. Mahalingam, PhDD. Gilden, MD
From the Oncology Division (D.T.B., E.S.-S., F.B.), Tel-Aviv
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
In 2008, a 77-year-old man developedright C8-distribution zoster; he was not treated with an antiviral agent or
steroids and his rash and pain resolved completely
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
One year later he developed colon cancer and was treated
every other week for 7 months with a protocol using leucovorin, 5-fluorouracil, oxaliplatin, and folinic acid
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
In November 2009, right C7–8-distribution pain recurred, but in the absence of rash
In December 2009, he developed a painless right foot drop
In February 2010, neurologic examination revealed C7–8 thigmesthesia and allodynia and an incidental right peroneal palsy.
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
All deep tendon reflexes were reduced or absent
Cervical MRI :degenerative changes at C5–6 and C6–7 without root compression
The CSF was acellular; cytology was negative, and CSF protein was 87 mg %
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
A presumptive diagnosis of ZSH was madehe was treated with valacyclovir, 1 g 3 times daily for 14 days, and pregabalin, 150 mg at night
A few days after treatment, he experienced a dramatic reduction in pain,
and 2 months later, was pain-free
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
Virologic studies of the CSF and serum obtained before antiviral treatment
revealed no amplifiable VZV DNA and no anti-HSV IgG antibody
In contrast, anti-VZV IgG antibody was presentThe serum/CSF ratio of anti-VZV IgG antibody was markedly reduced
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
It is important to identifypatients with ZSH since their
symptoms and signs may respond to IV acyclovir
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
In patients with prolonged radicular pain without rash to verify the diagnosisof zoster sine herpete CSF should be examined for both
VZV DNAanti-VZV IgG antibody
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
negative PCR for VZV DNA in the CSF does not exclude the diagnosis of VZV vasculopathy
1-Blood MNCs for VZV DNA2- CSF VZV DNA3- CSF Anti-VZV IgG antibody
Dr Mehran Rezvani pain fellowship anesthesiologist & acupuncturist
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