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Herpes and Varicella Zoster

Herpetic Lesion Eyelid

INTRODUCTION Herpes zoster (shingles) and varicella zoster (chickenpox) are both systemic infections with manifestations caused by herpes virus varicellae. The virus is an obligate human parasite requiring person-to-person transmission for its survival. Varicella most commonly occurs in children and is almost always a mild, self-limited disease however, when the disease occurs in adults it is often a much more severe process. Zoster, meaning belt or girdle in Greek, is felt to be a reactivation of a previous varicella infection within a single dermatome. Herpes zoster is most prevalent in middle to late adulthood however, it can occur in children and rarely even in infants, in whom it is usually a mild disease. Eyelid symptoms result from involvement of the first or ophthalmic division of the trigeminal (5th cranial) nerve and are seen in up to 10 of cases of zoster infections. Adults with herpes zoster are contagious during the early stages and often transmit the virus to susceptible...

Herpes ZosterDRG Category 272

(Shingles) I I erpes zoster, also known as shingles, is a common viral skin eruption that is estimated to affect 300,000 to 500,000 persons a year in the United States. Approximately 95 of adults in the United States have antibodies to the varicella zoster virus (VZV), which means they have been exposed to it. The virus causes acute unilateral inflammation of a dorsal root ganglion. Each nerve innervates a particular skin area on the body called a dermatome, which bends around the body in a pattern that has been mapped corresponding to the vertebral source. Generally, herpes zoster eruptions occur in the thoracic region and, less commonly, affect a single cervical, facial (trigeminal nerve), lumbar, or sacral ganglion. 422 Herpes Zoster (Shingles)

Conditions That May Simulate Herpes Zoster

HSV in a linear distribution may be clinically impossible to distinguish from herpes zoster. Linear lesions are more common in children and with HSV on the extremities. Groups of lesions in different stages of evolution and pain or dysesthesia favor zoster. Culture, RIF, and PCR testing will distinguish the two. Vesicular poison oak (ivy, etc.) can be very similar to early zoster with minimal acute neuritis. Both may be linear and segmental, both may itch, and the morphology of the primary lesions is virtually identical. Pain or lack of pruritus favors zoster. Satellite lesions outside the primary dermatome or at distant sites favor rhus dermatitis. Tzanck smear helps to rapidly distinguish many cases, but it is not infallible. If the Tzanck smear is negative, RIF testing is indicated.


5 Anthonie's fire erysipelas , the shingles (Gerard), who made the same claim for OLIVE branches, leaves and tender buds . A Hertfordshire remedy was to mix the blood from a black cat's tail with the juice of houseleek and cream, warm it all, and apply it three times a day (Jones-Baker. 1974). It sounds like the fusion of two traditions, for styes on the eye used to be treated in old wives' lore by rubbing them with the tail of a black cat. (see Woodforde for example). Homeopathic doctors sometimes prescribe POISON IVY for the complaint (Homeopathic Development Foundation). A compress made of the infusion of SCENTED MAYWEED is another possibility (Fluck). Thomas Hill, in 1577 was of opinion that PURSLANE helpeth the shingles , so, he claimed, does CHICORY. WHITE HOREHOUND was made up in Wales as an infusion, to be used both externally and internally, for eczema and shingles (Conway), and MARIGOLD is still used by herbalists for both chickenpox and shingles (Warren-Davis).

Clinical manifestation

Zoster oticus (geniculate zoster, zoster auris, Ramsay-Hunt syndrome, Hunt syndrome) Meniere disease, Bell palsy, cer-brovascular accident or abscess of the ear beginning with otalgia and herpetiform vesicles on the external ear canal, with or without features of facial paralysis, resulting from facial nerve involvement, auditory symptoms (e.g., deafness), and vestibular symptoms Disseminated zoster generalized eruption of more than 15-25 extradermatomal vesicles, occurring 7-14 days after the onset of dermatomal disease occurs rarely in the general population, but commonly in elderly, hospitalized, or immunocompromised patients often an indication of depressed cell-mediated immunity caused by various underlying clinical situations, including malignancies, radiation therapy, cancer chemotherapy, organ transplants, and chronic use of systemic corticosteroids dissemination sometimes includes involvement of the lungs and central nervous system

Molecular Biology

The PRV genome is, for the most part, colinear with the IL arrangement of the HSV-1 genome. However, a peculiarity of the PRV genome is the presence of an inversion in the middle of the unique long (UL) region (0.07 and 0.39 map units) compared to HSV-1 and other alpha herpesviruses. On one side, the inversion occurs between the UL27 and UL26 genes (Tables 1 and 2). It appears that PRV lacks a sequence homologous to the HSV-1 UL45 gene at the BamHl-9 junction downstream of UL44 (gC). Due to the fact that in PRV the UL26 and UL44 genes are adjacent and their ends are conserved, the right border of the inversion must lie within their intergenic region. Most of the PRV genes are conserved relative to those of HSV-1, but there are notable differences. Some genes present in HSV-1 UL56, UL48 (VP16), UL45, US5 (gj), US10, US11 and US12 have not been detected in PRV, whereas the PRV gene, UL3.5, has also been found in the varicella-zoster virus (VZV), bovine herpesvirus 1 (BHV1) and equine...

Indicated Supporting Diagnostic Data

In most instances, herpes zoster can be diagnosed clinically on the basis of the skin lesions and associated symptoms. There are times, however, when special circumstances make laboratory confirmation desirable. Biopsy of a zoster lesion shows pathognomonic features, but is usually done only to investigate a lesion that is clinically atypical. Biopsy does not distinguish HZV from HSV-1 or HSV-2, and adds nothing if the lesions are clinically diagnostic.

Future Perspectives

Widespread vaccination of children (both normal and immunocompromised) with the attenuated, live varicella vaccine should reduce the incidence and severity of varicella. The increase in humoral and cellular immunity after vaccination of elderly patients suggests that the vaccine might also reduce the frequency and severity of zoster and a large clinical trial is being planned to test this hypothesis. Because of the potential for the live vaccine to cause zoster, subunit vaccines (containing viral glycoproteins) may prove preferable.

Natural Antibodies To Cytokines

Natural Ab against IFN in humans were first reported in 1981 as a case of neutralizing IFN-a Ab in a patient with varicella-zoster (13). Later, IFN-a Ab were found in patients with other viral infections, with neoplastic and autoimmune diseases, and in a patient with chronic graft versus host disease (6,7,13-24). The prevalence of IgG anti-IFN-a Ab in these patients is about 10 .

Properties of the Virion

The morphology of the varicella-zoster virus (VZV) virion is similar to that of other herpesviruses. The virion is 180-200 nm in diameter and is made up of four structurally distinct elements. The linear duplex viral DNA genome is packaged in a central 75 nm core, contained within an icosahedral nucleocapsid 100 nm in diameter, with 5 3 2 axial symmetry. The nucleocapsid is composed of 162 hexameric and pentameric capsomeres with central hollows wider on the outside than the inside. A proteinaceous tegument surrounds the nucleocapsid and is, in turn, surrounded by a lipid bilayer potentially derived from a number of cellular membranes, including the nuclear membrane and Golgi membranes. This lipid coat contains at least six virus-encoded glycoproteins which are visualized by electron microscopy as spikes or studs approximately 8 nm in length.

Viruses that Promote Apoptosis DNA viruses

Herpesviridae Varicella zoster virus (VZV) induces apoptosis as part of the lytic cycle. Protection of cells from apoptosis may lead to latency, but cannot be accomplished by bcl-2. HSV-1 has been shown to induce apoptosis in activated, peripheral blood lymphocytes, especially CD4+, but not CD8+, lymphocytes. This may underlie the immunosuppres-

History of Herpesvirus Discovery

Diseases caused by herpesviruses have been known since ancient times, but it was not until the beginning of the twentieth century that the viruses causing these diseases were detected. Human alphaherpesviruses (members of subfamily Alphaherpesvirinae) such as herpes simplex virus (HSV) and varicella-zoster virus (VZV) were the first to be propagated in cell culture and visualized by electron microscopy. Later, betaherpesviruses (members of subfamily Betaherpesvirinae) such as human cytomegalovirus (HCMV) and gammaherpesviruses (members of subfamily Gammaherpesvirinae) such as Epstein-Barr virus (EBV) were discovered and studied in detail. EBV was the first herpesvirus whose genome was cloned in bacteria and completely sequenced. In the middle of the last decade of the twentieth century, the complete genome sequences of roughly 40 herpesvirus species had accumulated in public databases. These human and animal her-pesviruses had previously all been cultured, and their physical,...

Viruses Affecting the Heart

Commonly e.g. enteroviruses, human immunodeficiency virus (HIV) and, if acquired congenitally, rubella whereas others are uncommon e.g. varicel-la-zoster, cytomegalovirus (CMV) and hepatitis B . Many of these viruses involve the heart as part of a clinically obvious generalized infection (e.g. varicella, mumps and rabies) whereas in others, cardiac disease is the primary presenting clinical feature. The more common causes of viral heart disease are discussed below, but some of those occurring less commonly are listed in Table 1.

Ocular Disease Caused by DNA Viruses

Varicella zoster virus, the etiologic agent of chickenpox and shingles, rarely causes keratouveitis with primary infection (chickenpox). However, vision-threatening keratitis, uveitis, and less commonly, retinal necrosis, are complications of varicella zoster virus reactivation in the distribution of the fifth cranial nerve (zoster ophthalmicus). Lid ulceration with frank tissue loss or lid malposition leads to corneal exposure and ulceration. Optic neuritis and cranial nerve paresis can accompany onset of the zoster rash. Sectoral iris atrophy is pathognomonic for zoster ophthalmicus. Postinfectious corneal anesthesia and secondary sterile corneal ulceration may follow herpes simplex types 1 and 2, but are most severe in zoster ophthalmicus. Chronic scleritis, keratitis, uveitis and glaucoma may ultimately limit the visual acuity. Varicella zoster virus (HHV3)

Opportunistic Infections and Malignancies Associated with HIV Infection

HIV-associated OI or malignancy, or less commonly 'uncovering' of previously unrecognized and untreated diseases. Shingles (re-emergence of the chicken pox virus, Varicella zoster virus), other Herpes viruses, and mycobacterial infections are especially common in IRIS. With better global access to HAART, including Africa and Asia, an increasing number of cases of IRIS are being reported especially in areas with high prevalence of diseases like tuberculosis.

Pathology and Histology

Varicella lesions are readily recognized in the skin and mucous membranes. However, similar lesions also occur in the mucosa of the respiratory and gastrointestinal tracts, liver, spleen and any tissue, and remain unrecognized except in severe cases. With severe disease there is inflammatory infiltration of the small vessels of most organs. Zoster causes inflammation and necrosis of the sensory ganglia and its nerves, and skin lesions which are histopathologically identical to those seen with varicella.

Conditions That May Simulate Toxicodendron Dermatitis

Herpes Zoster Peculiar as it may seem, early acute zoster can be very similar to early toxicodendron dermatitis. Both eruptions can show a linear dermatomal pattern. Zoster with minimal acute neuritis may be pruritic rather than painful. Early toxicodendron dermatitis may exhibit only modest itching. Both conditions may have an orange-peel surface and similar-sized vesicles (see Photo 28). History of recreational exposure helps. Dysesthesia rather than itching, unilateral distribution, and umbilication of the vesicles suggest zoster. Intense pruritus, widespread satellites, and extension over the midline favors toxicodendron dermatitis. When in doubt, a Tzanck smear or rapid immunofluorescence (RIF) test for herpesvirus will help distinguish between them.

Remedial Approaches The Cognitive Module

Awareness of units in spoken language develops as early as nursery school. First, children are able to recognize and repeat rhyming words. Subsequently, by age three or four years, they can identify syllables in multisyllabic words. Finally, some (but not all) children can identify phonemes. Phonemes are not as easily recognizable as rhymes or syllables because in speech, phonemes overlap each other much like the shingles on a roof. In recent times, sensitivity to phonemes has come to be described under the label of phoneme awareness. The ability to recognize rhymes and syllables, along with phoneme awareness, is collectively referred to as phonological awareness. A good deal of research shows that sensitivity to phonemes and word recognition skills are closely related. Although it is uncertain whether phoneme awareness results in

Immunization Vaccination

See also Adenoviruses (Adenoviridae) Animal viruses, General features, Malignant transformation and oncology, Molecular biology Antivirals Cytomegaloviruses (Herpesvlrldae) Animel cytomegaloviruses, General features (human), Molecular biology (human), Murine cytomegaloviruses Epstein-Barr virus (Herpesvlridae) General features, Molecular biology Hepadnaviruses (Hepad-naviridae) Hepatitis B Virus General features, Molecular biology Hepatitis C virus (Flaviviridae) Herpes simplex viruses (Herpesvlridae) General features, Molecular biology Immune response Cell mediated immune response, General features Polyomaviruses - murine (Papovaviridae) General features, Molecular biology Respiratory viruses Varicella-Zoster virus (Herpesvlridae) General features, Molecular biology.

Viruses Affecting the Pancreas

Nevertheless, studies on children with disseminated fatal viral infections showed that pancreatic lesions, often with islet cell destruction, were present in patients with coxsackie B, CMV, varicella-zoster and congenitally acquired rubella. In addition, pancreatitis has been observed following mumps and, less commonly, following Epstein-Barr virus (EBV) infection and hepatitis B virus infections. The finding that hepatitis B surface and core antigens have been detected in the acinar cells of patients with hepatitis B antigenemia suggests that this virus may replicate in pancreatic tissue. Although such filoviruses as Marburg and Ebola induce generalized infections with severe hepatic involvement, some patients develop clinical features of acute pancreatitis, and postmortem studies have demonstrated areas of focal pancreatic necrosis.

Taxonomy and Classification

Varicella-zoster virus (VZV) is a member of the Alphaherpesvirinae subfamily, genus Varicellovirus of the family Herpesviridae. Other alphaherpes-viruses that infect humans include herpes simplex viruses 1 and 2, and rarely cercopithicine herpesvirus (B virus). All of these agents exhibit relatively short VARICELLA-ZOSTER VIRUS (iHERPESVIRIDAE)

Diagnostic Highlights

Viral culture Negative culture Positive for herpes zoster Demonstrates presence of Other Tests Tzanck smear (obtained from lesions but cannot differentiate between herpes zoster and herpes simplex), direct immunofluorescence assay (can distinguish herpes zoster from herpes simplex), monoclonal antibody tests.

Prevention and Control

VZIG prevents or attenuates varicella in seronegative persons. The preparation has no effect in modifying zoster. VZIG is recommended for individuals (1) with recent, close contact to patients with varicella or zoster, (2) who are susceptible to varicella, and (3) who fall in a high-risk category. The last group includes premature or certain newborn infants, pregnant women, and patients with congenital or acquired cellular immune deficiencies. The live, attenuated varicella vaccine (Oka strain) was licensed in the USA in 1995 and is recommended for vaccination of all children and some susceptible adults. The vaccine protects normal children and adults, as well as children with malignancies, from clinical varicella. Most children develop adequate humoral and cellular immunity to varicella after a single dose of vaccine additional doses enhance the degree of immunity and are recommended for adults. A rash may follow vaccination. It is usually mild, but can be severe if the vaccine is...

Pathways of the Central Nervous System Invasion

Viruses have been shown to enter the nervous system both along nerves and from the blood. The first experimental studies of viral invasion employed rabies, herpes simplex or polioviruses, all of which under experimental circumstances can penetrate the nervous system along peripheral nerves. The precise mechanism of neural spread remained a mystery for many years, since it was thought that the axoplasm slowly oozed in an anterograde direction. It was proposed that virus might move in perivascular lymphatics, by ascending infection of the supportive cells within the peripheral nerve, or even by replication in axons a speculation that is now untenable because of the observed lack of ribosomes or protein synthesis within axons. In the 1960s active anterograde and retrograde axon transport systems were found. Viruses or other particles can be taken up in vesicles at the nerve terminals and transported to the cell body of the sensory or motor neuron (Fig. 1). This neural route of entry is...

Gender Ethnicracial And Life Span Considerations

Herpes zoster can occur at any age and in both genders, although it is uncommon in healthy children or young adults. Prevalence doubles in patients over the age of 50, and approximately 80 of all cases occur in people older than 20 years. It is hypothesized that 50 of all people who live to the age of 85 will have an attack and that 10 may suffer from more than one occurrence. Of those people who have been exposed to chickenpox, African Americans are 25 less likely than whites to develop herpes zoster.

Human Demographics and Behavior

In some cases, the emerging viruses themselves have contributed to other viruses emerging and reemerging in the population. This is especially true of human immunodeficiency virus (HIV), the cause of acquired immune deficiency syndrome (AIDS), which rapidly spread following its emergence in the early 1980s to infect more than 40 million people worldwide by the end of the twentieth century. Because of its severe effects on the immune system, the virus leads to numerous other infections in the HlV-infected population. For example, picobirnaviruses, that had been detected in fecal samples from chickens and rabbits, were difficult to detect in human fecal samples until a cohort of men with AIDS was examined, and in these humans picobirnavirus was detected for the first time. Some rare diseases have become common in persons with AIDS. For example, the human polyomavirus known as JC virus can cause the rare brain disorder known as progressive multifocal leukoencephalopathy (PML). Normally,...

Classification and Evolution

The current list of nonhuman primate alphaherpesviruses is shown in Table 1 . Nonhuman primate alphaherpes-viruses belong to genus Simplexvirus (with human herpes simplex virus (HSV) types 1 (HSV-1) and 2 (HSV-2)), with the exception of SVV (Cercopithecine herpesvirus 9), which belongs to genus Varicellovirus (with human varicella-zoster virus, VZV). The marked genetic similarities

Ocular Complications of AIDS

Some ocular infections, including CMV retinitis (Fig. 4), Pneumocystis carinii, fungal and mycobacterial choroiditis, and microsporidial keratoconjunctivitis are seen almost exclusively in AIDS. Cytomegalovirus retinitis is a major cause of morbidity in AIDS patients. Other infections, such as toxoplasmosis retinochoroiditis, ocular syphilis, herpes zoster ophthalmicus, and molluscum conta-giosum of the eyelids are seen in immunocompetent as well as immunosuppressed individuals, but may be more severe and leave more profound deficits in HIV-infected patients. Herpes zoster ophthalmicus in young patients may be the first clinical clue to HIV infection. Acute retinal necrosis due to herpes simplex virus types 1 or 2, or varicella zoster virus, occurs more commonly in HIV-infected than in otherwise normal patients and can result in unilateral or bilateral blindness despite antiviral therapy.

Postherpetic Neuralgia

This is a common and severe form of neuropathic pain in the elderly, caused by reactivation of the varicella zoster virus, usually a childhood infection. The incidence of postherpetic neuralgia (PHN) after herpes zoster varies between 9 and 15 , with 35-55 of patients continuing to have pain three months later, and 30 having intractable pain for one year. The dermatomal distribution and frequencies of PHN are as follows.

Discharge And Home Healthcare Guidelines

Explain that there is no means for eliminating the varicella virus from the nerve ganglia. (A varicella vaccine, however, is currently under development and may help with prevention of primary chickenpox and therefore might help with decreasing the incidences of herpes zoster.)

Transmission and Tissue TVopism

VZV is transmitted by the respiratory route. VZV has been detected by PCR in room air from patients with varicella or zoster. Intimate, rather than casual, contact is important for transmission. Chickenpox is highly contagious about 60-90 of susceptible household contacts become infected. Herpes zoster is less contagious than chickenpox. Only 20-30 of susceptible contacts develop varicella. Patients with varicella are infectious from 2 days before the onset of the rash until all the lesions have crusted. Figure 2 Histopathology and clinical findings of varicella-zoster virus infections. (A) Eosinophilic intranuclear inclusions from a skin biopsy in a patient with herpes zoster original magnification x400. (B) Chickenpox in a child. (C) Localized zoster in an adult. (D) Disseminated zoster in a patient with chronic lymphocytic leukemia. (Reproduced with permission from Straus SE, Ostrove JM, Inchauspe G et a (1988) Varicella-zoster virus infections biology, natural history, treatment,...

Adiantum capillusveneris Southern maidenhair Venushair fern

'Imbricatum' (overlapping), known in the trade as 'Green Petticoats', is a magnificent cultivar with layers of cascading bright green shingles of foliage. Spores breed true for this strictly indoor plant, which is at its best as a coveted d cor in humid greenhouses. It is a challenging beauty. For best results, water the pot and not the fronds.

Serologic Relationships and Variability

Antibodies detected by the complement fixation test and virus-specific IgM antibodies decline rapidly after convalescence from varicella. Other, more sensitive serologic tests recognize antibodies that persist for life, including immune adherence hemagglutination (IAHA), fluorescence antibody to membrane antigen (FAMA) and enzyme linked immunosorbent assay (ELISA). VZV-specific antibodies are boosted both by recrudescent infection (zoster) and by exposure to others with varicella.

Clinical Application Questions

A 75-year-old man in good general health presents at your office regarding a blistering rash on the right face and nose of 48 hours' duration. Lancinating pain was noted for 2 or 3 days before the rash. He also complains of diminished visual acuity in the right eye. You diagnose herpes zoster of the ophthalmic division of the trigeminal nerve. 1. What are the primary lesions of herpes zoster 2. What secondary lesions occur in herpes zoster

Pathways of the CNS Invasion

Rabies Spreads Diagrams

Viruses have been shown to enter the nervous system both along nerves and from the blood. The first experimental studies of viral invasion employed rabies, herpes simplex, or polioviruses, all of which, under experimental circumstances, can penetrate the nervous system along peripheral nerves. The precise mechanisms of neural spread remained a mystery for many years, since it was thought that the axoplasm slowly oozed in an anterograde direction. It was proposed that virus might move in perivascular lymphatics, by ascending infection of the supportive cells within the peripheral nerve, or even by replication in axons, a speculation that is now untenable because of the observed lack of ribosomes or protein synthesis within axons. In the 1960s active anterograde and retrograde axon transport systems were found. Viruses or other particles can be taken up in vesicles at the nerve terminals and transported to the cell body ofthe sensory or motor neuron (Figure 1). This neural route of...

Detection of Viral Antigens

Antigen detection methods are especially recommended in the case of virus reactivation, for example, for herpes simplex and varicella zoster virus diagnosis where the sero-logical response can be very weak. Antigen detection assays are also widely used in respiratory tract infections like influenza and respiratory syncytial virus infections. A simple test for the demonstration of rotavirus and adenovirus antigens in children with gastroenteritis is also available.

Polystichum vestitum Prickly shield fern

Stipes are one-third or more of the frond. Polystichums are noted for their heavy sheathes of stipe scales, like shingles protecting a roof, and this species is among the most decorated of all with broad and brilliant golden-brown dark-centered scales. The blades are

Face and Head Neuralgias

Paroxysmal deep ear pain with a trigger point in the ear of unknown etiology. It may be related to varicella zoster virus infection Continuous trigeminal pain in the hypalgesic or analgesic territory of the nerve. It occurs after percutaneous radiofrequency lesions or ophthalmic herpes zoster

Upright St Johns Wort

In such high esteem was valerian held that in the Middle Ages it was even reckoned to be efficacious against the plague itself (Trevelyan). As Gerard said, the dry root is put into counterpoysons and medicines preservative against the pestilence . It was used for many slighter ailments, too. Thomas Hill, in 1577, listed some of them valerian provoketh sweat, and urine, amendeth stitches, killeth mice, moveth the termes, prevaileth against the plague, helpeth the straightnesse of breath, the headache, fluxes, and Shingles, procureth clearnesse of sight and healeth the piles . Gerard was able to add more, such as cuts

Latent and slow persistent viral infections

After an infection has passed, a virus may sometimes remain in the body for long periods, causing no harm. It may be reactivated, however, by stress or some change in the individual's health, and initiate a disease state. Well known examples of latent viral infections are cold sores and shingles, both caused by members of the herpesvirus family. A virus of this sort will remain with an individual throughout their lifetime.

Genome Structure

The entire genome of EHV-1, strain Ab4, was sequenced and shown to be 150 223 bp in size and to contain 80 potential open reading frames (ORFs). The 63 ORFs of the unique long region are arranged colinearly with those in the genomes of herpes simplex virus and varicella zoster virus. Several genes mapping within the inverted repeat and unique short segments of the short region differ in arrangement from those of other alphaherpesviruses. In addition, EHV-1 contains a limited number of unique genes, i.e. genes that are present neither in HSV-1 nor in VZV and which might represent the virus' gene repertoire determining host specificity.

Herpes Simplex

Herpes Eyelid Infection

HISTOPATHOLOGY The histological features of herpes simplex virus (HSV), varicella, and herpes zoster virus skin infections are similar. In HSV, the earliest changes are seen in the epidermal cell nuclei, which enlarge, develop a homogenous ground glass appearance, and have peripherally clumped chromatin. Changes begin along the basal epidermal layer and progress to involve all layers. Intraepidermal vesicles soon form secondary to ballooning and acantholysis of keratinocytes. Subepidermal vesicles may result from destruction of the basal layer of epidermis. Multinucleated keratinocytes are more conspicuous in lesions that have been present for several days. The histopathological clue to diagnosis is eosinophilic nuclear inclusions, which are more common in the multinucleated cells. Diagnosis is confirmed using immunohistochemistry. DIFFERENTIAL DIAGNOSIS The differential diagnosis includes acute stye, insect bite, chickenpox, herpes zoster, contact dermatitis, and ulcerative...


Eyelid Infections Other Conditions

DIFFERENTIAL DIAGNOSIS The differential diagnosis includes discoid lupus erythematosus, chalazia, hordeola, epidermal inclusion cyst, xanthelasma, lipoid proteinosis, amyloidosis, sebaceous cyst, lichen planus, erythema nodosum, tuberculosis, leprosy, syphilis and parasitic, fungal, viral (molluscum contagiosum, herpes simples and herpes zoster), or bacterial infections.

Specific History

Cabeza Con Cuello Para Dibujar

Zoster attacks may occur in children and young adults, but are quite rare. The incidence starts to climb during the fifth decade of life and peaks in the seventh and eighth decades. Severe or prolonged attacks, especially in young persons, should raise concern about concomitant illness and immune status. An attack usually confers lifelong immunity in an otherwise healthy person. Most cases of herpes zoster present with pain that is variously described as shock-like or a continuous burning sensation with hyperalgesia. Other patients experience less Uncomplicated zoster in children usually is mild and often painless. It can run its entire course in 2 weeks or less, and normally clears without sequelae. In young adults, the average course is 2 to 3 weeks long, pain is mild to moderate, and sequelae are rare. Elderly, debilitated, or immunologically compromised patients often have a course of 3 to 4 weeks or longer, and are more prone to complications. In uncomplicated cases, the...


Varicella zoster virus (VZV) - The virus causes chickenpox (varicella) in childhood, becomes latent in the dorsal root ganglia, and reactivates decades later to produce shingles (zoster) in adults. Subacute encephalitis develops against a background of cancer, immunosuppression, and AIDS, and death is common


BIRCH leaves have always been used for treating skin complaints (Conway), and they can be treated with birch tar oil made up into a soothing ointment (Mitton) or can be used in medicated soaps (Gordon) to treat eczema. The complaint was treated in Dorset with NETTLE tea (Dacombe), which is a well-established East Anglian remedy for any skin complaint (Porter. 1974). The sap of the GRAPE VINE is collected in some country areas when growth starts in spring, to be used for eczema among other complaints (Shauenberg & Paris). Gypsies use an ointment made from the fresh leaves of FOXGLOVE to cure eczema (Vesey-Fitzgerald), and a compress made from MALLOW leaves or flowers is often used. A CHICKWEED poultice is used in Norfolk for quite severe dermatitis and eczema (V G Hatfield. 1994). A tea made from GROUND IVY used to be popular for this complaint in the north of Scotland. It was said that the fairies taught Donald Fraser, of Ross-shire, to use it (R M Robertson). A dozen or so BLACK...


It follows that these superstitions are mirrored in a number of houseleek's medicinal uses. They take away the fire of burnings and scaldings (Gerard), as one would be led to suspect. The leaves were used in Scotland to put on burns, like a plaster (Jamieson), and so they were in America (O P Brown). A Yorkshire remedy for burns and scalds was to use the leaves bruised with cream (Morris) and in fact the freshly gathered leaves are used to this day like this (and for corns, too). Similar ideas would account for its use against the fiery diseases - they are good against S. Anthonie's fire, the shingles, and other creeping ulcers and inflammations . (Gerard). A gypsy remedy for ringworm is to boil houseleek, and then to dab the affected part with the water, and there is an erysipelas cure that requires pounded houseleek in a little skimmed milk. The rash should be bathed with this several times each day (V G Hatfield. 1994). Rather more exotic is a shingles remedy from Hertfordshire,...


And in Scotland, though without the cider (Simpkins), to those who had measles (Dacombe). The marigold, it was said, helped to bring out the rash. Herbalists are still using the flowers, especially for heart disease they benefit the arteries and veins (A W Hatfield. 1973), and it is prescribed for chickenpox and shingles, too (Warren-Davis). Gerard was recommending them for heart trouble four hundred years ago.

Antiviral Prodrugs

The efficacies of several important antiviral drugs (including the nucleoside analogs acyclovir and penciclovir) are severely limited by poor oral bioavailability. One approach to this has been the synthesis of chemically modified derivatives that are rapidly converted to the nucleosides by the host metabolic enzymes. Valaciclovir, the prodrug for acyclovir, and famciclovir, the prodrug for penciclovir, are readily absorbed yielding high blood levels of the parent compound. Both are used widely for treating herpes simplex and varicella zoster infections. Similarly, other oral prodrugs have been developed the influenza drug oseltamivir, the HIV drugs tenofovir disoproxil fumarate and fosamprenavir, the HBV drug adefovir dipi-voxil and the HCV drug R1626. When new compounds are identified with antiviral activity, this kind of approach may be considered at an early stage of development. For example, famciclovir, rather than penciclovir, was used in the clinical trials and currently...


See also GREEN PURSLANE (Portulaca oleracea). One of the many supposed to be aphrodisiac (Haining). It has certainly been used as a medicine for a long time, as a cure for erysipelas, while Thomas Hill was of opinion that it helped the shingles . He also recommended it as helping the burning Fever. , for worms and for toothache. It also helpeth swolne eyes, and spitting of bloud it stayeth the bleeding at the Nose, and the head-ache (T Hill. 1577).

Mounted Ferns

Shingles (also known as slabs or plaques) cut from tree fern trunks and usually sold as mounts for epiphytic orchids serve equally well as supports for epiphytic ferns and fern relatives including Drynaria, Lycopodium, Belvisia, Pyrrosia, Asplenium nidus, Polypodium, and Davallia. The makers of tree fern shingles saw their product into rectangular or irregular shapes and sizes. Shingles about 7 or 8 inches (18 or 20 cm) wide and 10 or 11 inches (25 or 28 cm) long are serviceable for most ferns growable as mounts. A shingle thickness of 3 4 inch (19 mm) is typical avoid thinner shingles. Tree fern shingles resist decay, even with the constant watering of the plants they hold, and usually remain sound for many years. Shingled ferns growing outdoors appreciate daily watering with a garden hose, or a splash from a bucket-and-dipper. Here in the Philippines, I also grow a number of shingle-mounted ferns as houseplants hung on walls of pine boards these ferns receive water from a spray...

Butter Bean

Thornton actually said that they have been used internally for worms. Certainly, it would do the worms no good at all, but surely their host would suffer equally O Suilleabhain quotes an Irish use of the juice for jaundice. This must surely be our doctrine of signatures. Any yellow plant, or anything with yellow juice, would automatically recommend itself to treat the yellow disease. A homeopathetic tincture of buttercup is taken, internally, for shingles (Leyel. 1937), and there are early records from Ireland of its use for St Anthony's Fire, i.e., erysipelas. Earlier still, Apuleius seemed confident with a recipe using one of the buttercups For a lunatic, take this wort, and wreathe it with red thread about the man's swere neck , when the moon is on the wane, in the month which is called April, or in the early part of October, soon will he be healed (Cockayne). Perhaps we are still talking about counter-irritants


It was very much a liver (it was known as liver's friend) and jaundice plant (see Gerard, and Thornton). Gypsies use a root decoction for jaundice (Vesey-Fitzgerald), and chicory flowers were used for liver complaints (Pollock). Distilled water of the flowers has been recommended as a good eyewash (Genders. 1976) this may be a cosmetic, too, for an infusion of the whole plant has long been used as such - applied at bedtime, it will remove blemishes from the skin. There is nothing new about that, for Thomas Hill in 1577 wrote that Ciccorie cureth scabbed places, causeth a faire skin . He went on to claim that it helpeth the kings evill, the plague, burning agues and cureth the shingles . It has been recommended for easy childbirth (V G Hatfield. 1984), and Lupton quoted Mizaldus in making the extraordinary claim that if a woman anoint often her dugs or paps with the juice of succory, it will make them little, round and hard or if they be hanging or bagging, it will draw them together,...

Pointof Care Tests

Point-of-care tests (POC tests) are becoming increasingly common in clinical practice. Most of them are based on easy-to-use lateral-flow or latex particle technology and are able to give the result in a few minutes. POC tests are nowadays available for antibody screening of an increasing number of virus infections (HIV, hepatitis C virus (HCV), varicella-zoster virus (VZV), cytomegalovirus (CMV), Epstein-Barr virus (EBV)). Some authorities still question the validity of POC tests for clinical use although there is considerable evidence that many of the commercially available kits give reliable results.

White Horehound

Horehound has still more uses, one being as an application to wounds (Fluck). In Africa, it is used for fevers, especially typhoid (Watt & Breyer-Brandwijk) the Navajo, too, used it to reduce fever (Wyman & Harris). In Wales, the infusion of the chopped herb is used both externally and internally for eczema and shingles (Conway). Oedema is another condition to be remedied with this plant. A 16th century recipe from France reads pisser, neuf matins sur le marrube avant


PrV takes the formal species name Suid herpesvirus 1 and belongs to the subfamily Alphaherpesvirinae of the family Herpesviridae. Originally on the basis of serological studies, and later confirmed by molecular biological analyses and comparison of the deduced amino acid sequences of homologous proteins, PrV was shown to be most closely related to bovine herpesvirus 1 (BHV-1) and equine herpesvirus 1 (EHV-1), and also to varicella-zoster virus (VZV). This prompted its assignment to the genus Vari-cellovirus within the Alphaherpesvirinae. Alphaherpesviruses are characterized by rapid lytic replication, a pronounced neurotropism with establishment of latency in sensory ganglia, and a broad host range. All these features apply to PrV.

Scented Mayweed

(Matricaria recutita) An annual of waste places, with white flowers whose petals hang down soon after opening, a fact that makes sense of the specific name recutita, circumcised. A glance at the profile of the flower will soon tell one why. The main use of the plant is medicinal, though it is harvested in the Debrecsan region of Hungary, where it grows in great quantities, for inclusion in hair rinses (Clair). Mayweed, or Maydweed, is from OE maythe, from the word meaning maiden, for this and other similar plants bearing the name have been used in complaints like painful menstruation (Fluck). But the plant has many other uses, as a tea made from the dried flower heads is used for all stomach upsets (Fluck), as well as for such varied complaints as insomnia, rheumatism, sciatica, gout, and so on. Externally, the infusion is used in compresses applied to slow-healing wounds, and for skin eruptions like shingles and boils (Fluck), or eczema (W A R Thomson. 1978).

Black Nightshade

The main folk medicinal use is for skin complaints, an ancient practice. Dioscorides writeth, that Nightshade is good against S Anthonies fire, the shingles, . Gerard wrote, while still warning his readers of the dangers of using such a toxic plant. We find this use against erysipelas, for that is what St Anthony's fire is, in America, too. In Mexico, for instance, the Totonac grind the whole plant, add salt and lime juice to it, and apply it as a plaster (Kelly & Palerm). In South Africa, too, a paste made of the unripe berries is in general use as an application to ringworm (Watt & Breyer-Brandwijk). Sunburn is treated in Indiana by crushing the leaves and stirring them in a cup of cream. When ready, put the cream on the sunburned area (Tyler).

Future Prospects

Some bicyclic nucleoside analogs (BCNAs) had been found to be exceptionally active and selective for VZV. A lead compound is Cf 1743. Like ACV and PCV, Cf 1743 is activated by VZV TK but, unlike ACV and PCV, it seems not to act via its triphosphate. Therefore, it will be particularly interesting to evaluate this highly active compound for its ability to reduce postherpetic neuralgia (PHN) in patients with shingles. Cf 1743 as its


(Vacccinium oxycoccus) A Kansas wart charm is recorded which involves cutting a cranberry into halves. The wart has to be rubbed with each half, and they have then to be buried under a stone (Davenport). Although it is not quoted, surely the wart will disappear as the fruit rots. In a similar way, corns are treated by applying a poultice of freshly mashed cranberries (Hyatt). One interesting American usage is the application of cranberries to shingles. They say such a poultice will cure the condition (Turner & Bell), and cooked cranberries were sworn by in Kansas as effective rheumatic pain relievers (Meade).

Spread in the Host

Many viruses including herpes simplex (HSV), varicella zoster (VZV), rabies and certain strains of poliovirus, reovirus and coronavirus can spread through nerves in the infected host. This pathway of spread is particularly important for viruses that invade the CNS, but theoretically also provides a route for infection of virtually any organ. Neural

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