SUPERVISOR dr. ROSMINI MAROLA, Sp.

KK
ADVISOR dr. RATNA WULANDARI PRESENTED BY Anis Nadzirah Zainuddin C111 08 772 Norlisa Zakirai @ Zakaria C111 08 806 Ayu Nurmuliawati Hanapi C111 08 328

HERPES ZOSTER
Commonly known as shingles.
Herpes zoster is a viral disease

characterized by a painful skin rash with unilateral and segmental blisters distribution.

Epidemiology
Increasing age Immunosuppression
Bone marrow and solid organ transplantation Patients with hematological malignancies

and solid tumors HIV Immunosuppressive medications Early varicella (in utero, infancy): Increased risk of zoster in childhood

Etiology
Reactivation of varicella zoster virus

(VZV) The structure of the virus has icosahedral nucleocapside surrounded by a lipid envelope. 150-200 nm in diameter and has a molecular weight of about 80 million

Pathophysiology
Varicella Zoster Virus (VZV) Spreads by hematogenic or neural retrograd transport VZV establishes permanent latent infection in dorsal root and cranial nerve ganglion

During primary varicella infection, the virus in the blood will replicate in the regional lymphnodes for 3-4 days. Secondary viremia develops after the second cycle of viral replication in the liver, spleen, and other organs

Epidermal capillary endothelial cells around 14-16 days

From the skin and mucosal lesions to invade the dorsal root ganglion

The reactivation of the virus replicates and then damage the sensory ganglion inflammation

1. Pre-eruptive or Pre-herpetic Neuralgia

(PHN) phase Prodromal symptoms: -Hyperaesthesia at subcutaneous area -Fever, lymphadenopathy, malaise & headache Prodromal sign usually negative for children

2. Eruptive phase Erythematous plaque/maculopapular appeared following the nerve dermatomes within 12-24 hours. Vesicle appeared at the middle of plaque after 2-4 days and the vesicle confluent with each other. After 72 hours, they evolved to pustule . The confluent of vesicle after they ruptured, it turns to crust and it takes 2-3 weeks.

3. Chronic or Post-herpetic Neuralgia This phase begin as all the lesion become crusted or acute infection or recurrent of disease occurred. Pain in PHN divided into 2 type: -burning sensation + hyperaesthesia -shooting spasmodic Syndrome that cause from Herpes Zoster: -Trigeminal Herpes zoster, Motoric involvement, Trigeminal Herpes Zoster, Opthalmicus Herpes Zoster, Oticus Herpes Zoster, Ramsay-Hunt syndrome

Ophthalmicus Herpes Zoster

Lagophthalmus and Bell Palsy appearance in Herpes Zoster

Laboratory examination
Tzank test
Biopsy PCR Virus Culture Serologic test
Datia cell or multinuclear cell appearance

Subcorneal vesicle with multinuclear squamous cell

Diagnosis
HERPES ZOSTER
Efflorescence: Lesion are Polymorphic,

unilateral and follow the dermatome that involved. Reactivation of VZV after primary infection occurs. Tzank test and histopathologic examination are positive Datia cell or multinuclear giant cell or Lipschutz bodies

Differential Diagnosis
1.Herpes Simplex 2.Contact dermatitis 3.Insect bite

Treatment and Management

1. Topical therapy
Cold compress Reduce the lesion

symptoms Lidocaine patch maximally applied as much as 3 patches per day

2. Systemic therapy Antivirus For normal patient: - Acyclovir (5 x 800 mg for 7 days) - Famciclovir (500 mg every 8 hours for 7 days) - Valaciclovir (1 g 3 times per day for 7 days)

For immunosuppressive patient: - Acyclovir (10 mg/kg Intravenously every 8 hours within 7 -10 days)

3. Corticosteroid Prednison - Starting dosage: 60 mg, given everyday for 7 days. Then, tapper the dosage as much as 30 mg and given for 7 days. The dosage tappered until 15mg for 7 days. After that, stop the treatment with corticosteroid.

4. Analgetic

Opiod analgetic (oxycodone) - Starting dosage: 5 mg every 4 hours.

Given when necessary Tramadol - Starting dosage: 50 mg once/twice per day

Complication
Ocular - Conjunctivitis, ptosis paralytic, epithelial

keratitis, scleritis, iridocyclitis, uveitis, glaucoma Skin - Scarring, keloid, granulomatosis dermatitis, granulomatosis vasculitis, comedo Neurology - Post herpetic neuralgia (PHN)

Prognosis
Generally, the prognosis is good. For ophthalmic herpes zoster, the prognosis is

based on early diagnosis and treatment. The lesion of herpes zoster usually subside within 10 to 15 days. For older patients, they are tend to develop PHN, bacterial infection, and scarring.