Fast Five Quiz: Shingles

William James, MD


December 11, 2019

Herpes zoster (shingles) may begin with a systemic response (eg, fever, anorexia, and lassitude), although symptoms are frequently mild and may not be associated by either patient or physician with the classic manifestations of the condition. Symptoms typically include prodromal sensory phenomena along one or more skin dermatomes lasting 1-10 days (average, 48 hours), which usually are noted as pain or, less commonly, itching or paresthesias. Prodromal pain is typically described as muscle-like or toothache-like in origin but may simulate headache, iritis, pleurisy, brachial neuritis, cardiac pain, appendicitis or other intra-abdominal disease, or sciatica. This simulation can result in incorrect tentative diagnoses; however, the dermatomal distribution usually helps clarify the diagnosis.

Classic physical findings of shingles include painful grouped herpetiform vesicles on an erythematous base confined to the cutaneous surface innervated by a sensory nerve. Typically, the condition affects a single dermatome, most commonly a thoracic dermatome, on one side of the body. Regional lymphadenopathy may be present. The frequency of multiple, disseminated, and visceral zoster is increased in the immunocompromised population.

Postherpetic complications are more common in herpes zoster ophthalmicus than in other manifestations of zoster. In particular, PHN is observed in more than half of these patients and can be severe and long-lasting. Scarring also is more common, probably as a result of severe destructive inflammation.

The reason why some patients with zoster experience PHN and others do not is not fully understood, but it is clear that patients who are older (> 60 years), particularly those who are debilitated or arteriosclerotic, are affected far more frequently than younger patients. In addition, PHN is observed more frequently after cases of herpes zoster ophthalmicus and in instances of upper-body dermatomal involvement.

Read more about the presentation of herpes zoster.


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