Herpes zoster

from Wikipedia, the free encyclopedia
Classification according to ICD-10
B02 Herpes zoster
ICD-10 online (WHO version 2019)
Shingles (herpes zoster)
Shingles on the neck along the C3 with pain behind the right ear

Herpes zoster , also known as zoster for short , in German shingles , colloquially also known as head rose or face rose , is a viral disease that mainly manifests itself as a painful, striped rash with blisters or blisters on one side of the body. The vesicular rash occurs when inflammation spreads from a nerve (e.g. a ganglion ) to the surrounding dermatome (skin area).

The disease is caused by the varicella zoster virus (VZV), which belongs to the Herpesviridae family . It usually occurs in older people or those with a weakened immune system (due to stress , as a result of other diseases such as AIDS, or due to special immunosuppressive therapy). The virus is often transmitted in childhood and causes chickenpox as the primary infection . Herpes zoster is always an endogenous , ie internally generated reactivation of an old VZV infection ( pathogen persistence ).

This article or paragraph presents the situation in Germany . Help us to describe the situation in other countries.

The zoster vaccine Shingrix has been approved since the beginning of 2018 to prevent herpes zoster. Admission is valid for all persons aged 50 and over. In December 2018, the STIKO recommended varicella vaccinations for people aged 60 and over. Since this vaccination became a statutory health insurance service in May 2019, the number of vaccinations had more than doubled by 150 percent to 217,000 vaccine doses in the following month.

etymology

The popular German name for shingles came about because the reddish rash, in particularly pronounced manifestations, loops around the body on one side or in a belt-like manner, starting from the spine, and causes a sore there . It is erysipelas archaic expression of an acute, localized dermatitis, which was often used indiscriminately for various diseases of different causes.

The term herpes zoster (formerly herpes zoster ) is derived from ancient Greek ζωστήρ zoster ('belt' in relation to the "belt-like" course for the first time in Pliny the Elder ). Compare also ancient Greek ἕρπειν herpein , German 'crawl' .

In English the herpes zoster is called shingles , which is borrowed from the Latin cingulum for 'belt', in French zona and zoster .

Old names include fever lichen and “fire belt” ( Latin Zona ignea ), in France and England also zone or zona , and the otherwise used expression for ergotism (“Antoniusfeuer”) Ignis sacer (“holy fire”). Zoster herpes to be called also belt rash and Gürtelflechte and Zona serpiginosa .

The abbreviated terms zoster (for herpes zoster , triggered by the varicella zoster virus (VZV)) and herpes (for herpes simplex , a disease caused by herpes simplex viruses ) are often confused, even though they are two different diseases which differ significantly in the pathogen and especially in the secondary diseases.

Pathophysiology of Herpes Zoster as was poliomyelitis acute posterior of poliomyelitis acute anterior (polio) compared.

Epidemiology

In Germany, around 350,000 to 400,000 people develop herpes zoster every year , around 2/3 of them are over 50 years old. The most recent study for Germany has shown that more than 306,000 people over the age of 50 develop herpes zoster every year . This results in an incidence of 9.6 per 1000 people per year.

Since around 98% of the population had contact with the varicella-zoster virus up to the age of 40, usually either clinically manifest in the form of chickenpox or in the form of a silent celebration , almost all adults are at risk. This is due to the fact that the varicella zoster viruses remain inactive in the body for life. Around 25 to 30% of the population will suffer from zoster in the course of their life. 50% of the 85-year-olds have already experienced an illness. The changes brought about by the introduction of the vaccination, which has been recommended since 2004, in the first year of life are not yet known.

The likelihood of herpes zoster infection increases with age, and women get sick more often. Other risk factors are diseases that are associated with a weakened immune system:

Pathogen

The varicella zoster virus (VZV) - also known as human herpes virus-3 (HHV-3) - has been proven to cause this disease. This virus is an enveloped, double-stranded DNA virus (dsDNA) and belongs to the family Herpesviridae , the subfamily Alphaherpesvirinae and the genus Varicellovirus . All viruses in this family are equipped with an icosahedral capsid that is surrounded by a virus envelope . In between there is a special feature of the tegument made of various functional proteins. The varicella zoster virus is relatively closely related to the herpes simplex viruses, but there is no cross protection . It is estimated that around 90 percent of Europeans over the age of 14 are carriers of varicella zoster viruses due to chickenpox infections.

transmission

The initial infection of a healthy person usually manifests itself in the widespread childhood disease chickenpox. The highly contagious pathogen viruses are transmitted by droplet infection , i.e. direct inhalation of exhalation droplets (exhalation droplets) of infected people, or via contact infection or smear infection with the viruses of the infectious expiratory droplets that have fallen on objects or body surfaces, if they then immediately via the mucous membranes, for example in the mouth, nose or eyes get into the body. Since the pathogens are only infectious for about ten minutes in the air, there is generally no risk of transmission through clothing or toys lying around. A smear infection is also possible due to the virus-containing vesicle content of the rash. The saliva and tear fluid (conjunctival fluid) of infected people are also infectious. The possibility of transplacental transmission of the varicella zoster virus from the pregnant woman to the fetus is very rare . It can lead to fetal varicella syndrome in around one to two percent of varicella diseases in pregnant women.

Even if those affected are usually immune to the disease for life after they have contracted chickenpox, the virus remains in the body after the symptoms have subsided and can later, for example, triggered by stress or a weakened immune system , in rare cases also by exposure to the sun (UV- Light) to be reactivated. The virus remains latent in the nerve roots of the spinal cord, the spinal ganglia and in the ganglia of the cranial nerves. Herpes zoster cannot be transmitted directly; An infection that has already occurred is only reactivated (“No zoster without prior chickenpox”) or a vaccination with a live vaccine against varicella. Herpes zoster is therefore not an infection in the true sense of the word, but the reactivation of the varicella zoster virus after a more or less long latency period. People who had chickenpox in childhood and who have a fully active immune system (i.e. immunocompetent and not immunocompromised ) are usually not at risk of contracting herpes zoster. In herpes zoster, the virus is only transmitted through the contents of the vesicle containing the virus (smear infection), but not via the respiratory tract as a droplet infection. The patient remains infectious through the contents of the vesicles only until the vesicles become encrusted. Herpes zoster - without a previous chickenpox disease or live chickenpox vaccination - can then trigger chickenpox in the event of infection.

Course of the disease / symptoms

Course of herpes zoster. a) skin surface; b) nerve fiber; c) activated viruses; d) inactive viruses

course

In the latency phase of the disease there is a reactivation of the varicella-zoster viruses that remained in the spinal ganglia after the initial infection. This phase is characterized by an inflammation of the nerve tissue. There is typically severe pain and other symptoms such as burning sensation in the area of ​​skin supplied by the nerve cord . Pain that occurs before or during the dermatomal rash is called zoster-associated pain. In contrast, the pain that occurs after the skin symptoms and is often permanent is called postherpetic or postherpetic neuralgia (PHN).

In 80% of cases, the manifestation of zoster on the skin is preceded by an early stage (prodromal stage). This takes about three to five days. The symptoms at this stage can vary widely. In most cases, general symptoms such as mild fever, tiredness and fatigue (also called B symptoms ) are reported. Rarer complaints such as burning sensation, paresthesia and pain of different character are often the cause of misdiagnoses such as herniated disc, renal colic, heart attack, appendicitis, cholecystitis and biliary colic, depending on the affected dermatome.

The nervous tissue becomes inflamed when the latent virus reactivates. Symptoms are burning and sometimes severe pain in the skin area that is supplied by the affected nerve cord, and in the nerve cord itself. General symptoms such as fatigue and tiredness can also occur in the early stages. The pain often occurs before the skin symptoms appear, which usually follows two to three days later. In the affected nerve segment, unilaterally occurring, painful small raised areas with reddening of the skin develop in bursts ( 1 ). In the following twelve to 24 hours, tense, tense vesicles ( 2 ) that are up to the size of a grain of rice and contain a water-clear liquid often form in groups in this erythema . This stage is usually completed after two to three days. A fusion (confluence) of these vesicles occurs after another two to four days. The vesicles can become cloudy on the third day. The vesicles then fill with lymph and break open ( 3 ) and can normally dry out over about seven to twelve days. They then dry out within two to seven days, and a yellow-brown bark forms ( 4 ). This phase can last one to four weeks, but the zoster usually heals within two to three weeks. Patients with weakened immune systems occasionally suffer from a chronic course with skin changes that have persisted for months and repeated vesicular eruptions. Frequently scars form, especially after a second infection, e.g. B. by bacteria. In very rare cases, however, the rash may not appear at all.

As a result of shingles, neurological pain can persist for a long time. The occurrence of such (post-therapeutic) neuralgia has not yet been adequately clarified. Damage to the nerves is suspected.

localization

Localization on the chest

The location of the shingles is determined by the supply area of ​​the affected nerves. The intercostal nerves (in the thoracic region ) are more frequently than average (in 50–56% of cases ). The back, arms or legs can also be affected less frequently. With deep inflammation of the skin one speaks of zoster gangrenosus .

In ophthalmic zoster , the face and eyes are affected ( ophthalmic nerve from the trigeminal nerve ). If the eyes are affected, partial or total blindness can result from corneal scarring. If the facial nerves ( nervus facialis ) are affected , there may be temporary symptoms of paralysis or loss of the sense of taste.

Zoster oticus describes an involvement of the ear canal and / or the auricle. Possible consequences here are, in addition to the severe pain typical of zoster, hearing loss ( cochlear nerve ) and disorders of the sense of balance ( vestibular nerve ). Also in the context of a can zoster oticus a neuralgia along with a facial palsy occur ( Ramsay Hunt syndrome / Ramsay Hunt neuralgia). If left untreated, permanent hearing impairment or deafness can result.

Zoster generalisatus refers to an involvement of the entire nervous system; this form of disease is life-threatening, but usually only occurs when the immune system is severely weakened (e.g. AIDS , leukemia or other forms of cancer ).

Genital zoster occurs in the genital area. It extends over the entire genitalia such as the penis , labia and clitoris over a large area down to the thighs. It is not uncommon for activated lymph nodes to be detected in the lymphatic drainage area of ​​the affected skin area.

For zoster Disseminated occurs in spread of viruses in the blood. However, this is only the case in one to two percent of patients with a healthy immune system . It is seen more frequently in immunocompromised patients.

Usually only one dermatome is affected by the characteristic zoster rash (zoster segmentalis). However, overlaps in the involvement of the dermatomes have also been described. Zoster duplex, in which the midline of the body is exceeded, is rather rare. In very rare cases, several skin segments are affected asymmetrically, especially if there is a second infection, e.g. B. comes from bacteria.

Complications

Ophthalmic zoster of the face and eyes

Herpes zoster complications are relatively common with over 20% of cases. In particular, post- therapeutic neuralgia (PHN), also known as post-zoster neuralgia (PZN), is extremely common and leads to severe pain, often described as burning. In the worst case, the PZN / PHN can even persist for life and is sometimes unbearable for those affected. The rarer forms of zoster such as generalized zoster, ophthalmic zoster (10–15%, of which with eye involvement 30–40%) and oticus are occasionally counted among the complications. It is not uncommon for the vesicles to heal only with pigmentation disorders and scarring (in contrast to chickenpox, unless these have caused scarring through scratching). Other complications are less common and usually only affect severely immunocompromised people. The complications include herpes zoster meningitis ( inflammation of the meninges ), herpes zoster encephalitis ( inflammation of the brain tissue ) and herpes zoster myelitis ( inflammation of the spinal cord ).

Peripheral nerves, especially the facial nerve, are also often paralyzed . However, the symptoms of paralysis usually recede.

Herpes zoster infection is an indicator of a slightly increased risk of cardiovascular diseases such as stroke and heart attack . This should be taken into account when planning preventive medical examinations.

Diagnosis and differential diagnosis

Herpes zoster is primarily a diagnosis based on clinical symptoms. Special virological detection methods are only necessary for complicated courses (involvement of the central nervous system, generalized zoster) or for uncertain clinical signs. In all cases, direct virus detection by means of PCR , either from the affected tissue or tissue fluid or from the punctured vesicle contents, is leading. Since this is a reactivation, serological methods for the detection of specific antibodies are only of limited information. When the VZV is reactivated, the anti-VZV IgA can be detectable for several months while the anti-VZV IgM is negative.

In the differential diagnosis, if typical vesicles appear on the skin, an atypical location of a herpes simplex infection should also be considered. This form of herpes simplex, which mimics the zoster, is also known as "zosteriform herpes simplex". Conversely, an irregularly localized zoster as "herpetiform zoster" can also imitate a herpes simplex infection. Hailey-Hailey's disease is another possible cause of skin vesicles that keep reappearing .

Therapy (as of 2018)

The varicella zoster virus can be treated with antivirals . The earlier treatment starts, the higher the chances of reducing possible complications.

Early drug treatment with antivirals is important if the findings are very extensive, for example involvement of the eye or ear, and in particular if there is a pre-existing immune system (e.g. tumor disease , severe diabetes mellitus or HIV). Treatment usually takes place with acyclovir , brivudine , famciclovir or valaciclovir , mostly in tablet form. Medical studies suggest that the active ingredient brivudine, as well as valaciclovir and famciclovir, are more effective than acyclovir. Compared to aciclovir, valaciclovir and famciclovir, brivudine only needs to be administered once a day. However, brivudine should not be used for more than seven days, as prolonging the treatment beyond the recommended period of seven days is associated with an increased risk of developing liver inflammation (hepatitis). Famciclovir should not be used in children and adolescents.

In more complicated cases (involvement of the eye, ear, spinal cord), intravenous treatment with acyclovir is required. As a rule, the additional administration of strong painkillers is indicated. In some of the affected patients, the acute pain cannot be influenced by pain medication. Sometimes lidocaine patches or other local anesthetic applications are used.

The cases of post-therapeutic neuralgia described in the Complications section above are often difficult to treat. In addition to painkillers, antidepressants and anticonvulsants , and occasionally even surgical interventions, can be considered here . Treatment with electrotherapy ( galvanization , electrical stimulation or transcutaneous electrical nerve stimulation ) can relieve pain. However, skin lesions (vesicles and pustules ) must be taken into account.

Prevention / vaccination

Risks for unvaccinated pregnant women

People suffering from chickenpox or shingles must avoid contact with pregnant women who have not been vaccinated or who have not developed enough antibodies against the virus in their bodies. Chickenpox infection during pregnancy can lead to developmental disorders in the child; If the mother suffers an outbreak of chickenpox in the last few days before the birth, the child's life is even in danger.

Vaccinations for children against chickenpox (varicella)

In Germany, Varilrix and Varivax, two varicella vaccines approved from the first year of life, are recommended by the Standing Vaccination Commission as standard vaccines.

Vaccinations for people aged 50 and over against herpes zoster

In Germany, two vaccines against herpes zoster are approved and available for people aged 50 and over: the live vaccine Zostavax and the dead vaccine Shingrix with active enhancer.

  • The live vaccine Zostavax is currently (as of 2017) not recommended as a standard vaccination by the Standing Vaccination Commission (STIKO) due to its limited effectiveness and duration. Zostavax was approved by the FDA on May 25, 2006 in the United States . With such a vaccination, 51% of shingles disease cases can be prevented and PZN ( post-zoster neuralgia ) can be avoided by 66.5%. If shingles does occur despite the vaccination, it is usually much milder and with fewer complications. Only one dose of vaccine is required for this live vaccine.
  • Since December 2018, the Shingrix inactivated vaccine has been recommended by the Standing Vaccination Commission (STIKO) as a standard vaccination for people over 60 years of age and for people over 50 years of age who have an increased health risk or congenital or acquired immunodeficiency. It is usually not necessary to know whether the person has had chickenpox or not. Shingrix was approved in early 2018 and studies have shown that it is over 90% effective for all people aged 50 and over. This vaccine can also prevent the serious complication post-herpetic neuralgia (PZN). This dead vaccine is given in two doses two to six months apart. In contrast to the live vaccine, the inactivated vaccine also has a good effect in old age and can also be given after autologous stem cell transplantation . The recommendation to vaccinate for severe underlying diseases from the age of 50 follows from the design of the approval studies, but "there is no evidence that younger risk patients could not benefit from the vaccination."

Side effect of vaccination

Overall, the observed side effects are minor. Since the vaccine is very reactive, local reactions such as reddening of the skin, swelling or pain in the area of ​​the injection site as well as systemic reactions (fever, tiredness, myalgia and headache) were observed in 10% of the vaccinated . The side effects subside after 1 to 2 days.

literature

Web links

Commons : Herpes Zoster  - Album with pictures, videos and audio files
Wiktionary: Herpes Zoster  - explanations of meanings, word origins, synonyms, translations

Individual evidence

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