HERPES ZOSTER

                                                          

Herpes zoster or zoster or shingles or zona, is a viral disease characterized by a painful skin rash with blisters often in a stripe in a limited area on one side of the body. The initial varicella zoster virus (VZV) infection causes the acute (short-lived) illness chickenpox in children and young people. After chickenpox has resolved, the virus is not eliminated from the body but become latent in the nerve cell bodies and sometimes in non-neural satellite cells of dorsal root, cranial nerve or autonomic ganglion without causing any symptom. Years or decades after a chickenpox infection (after age of 50 years), the virus may break out of nerve cell bodies and travel down nerve axons to cause viral infection of the skin in the region of the nerve. The virus may spread from one or more ganglia along nerves of an affected segment and infect the area of skin supplied by the spinal nerve (called dermatome) causing a painful rash. Although the rash usually heals within three to five weeks, some sufferers experience residual nerve pain for months or years, a condition called post-herpetic neuralgia. Exactly how the virus remains latent in the body, and subsequently re-activates is not understood.

Signs and symptoms

The earliest symptoms of herpes zoster, which include headache, fever and malaise, are commonly followed by burning pain, itching, hyperesthesia (oversensitivity) or paresthesia ("pins and needles" sensation, tingling, pricking or numbness). The pain may be mild to extreme in the affected dermatome, sometimes aching, throbbing and quick stabbing, agonizing pain occurs. The pain radiates along the path of a single spinal nerve (a dermatomal distribution). In children, herpes zoster is often painless.

The initial phase of 2 days to 3 weeks is followed by the appearance of the skin rash. The pain and rash mostly occurs on the body but can appear on the face, eyes or other parts of the body. At first the rash may simulate to hives but herpes zoster skin changes are limited to a dermatome normally resulting in a stripe or belt-like pattern that too, to one side of the body and it never crosses the midline. Zoster sine herpete is a condition “zoster without herpes" where a patient who has all of the symptoms of herpes zoster except the characteristic rash.

Later the rash is tuned into painful, small blisters filled with serous exudates, with the fever and general malaise. The vesicles become cloudy or darkened as fill with blood. They crust over within seven to ten days; which fall off and the skin heals, but sometimes, after severe blistering, scarring and discolored skin remain.

Depending on the dermatome involved some additional symptoms may occur. Herpes zoster ophthamicus   involves the orbit of the eye, due to the virus reactivating in the ophthalmic division of trigeminal nerve. The symptoms may include conjunctivitis, keratitis, uveitis and optic nerve palsies that can sometimes cause chronic ocular inflammation, loss of vision, and debilitating pain. Herpes zoster oticus, or Ramsay Hunt syndrome type II ( It has variable presentation which may include Bell’s palsy, deafness, vertigo and pain) involves the ear. Here the virus spreads from the facial nerve to the vestibulo-cochlear nerve. Symptoms include hearing loss and vertigo (rotational dizziness).

 Most people have history of episode of chickenpox in child hood. Repeated attacks of herpes zoster are rare and rarely a patient suffers more than three recurrences. Although it can occur at any age, but most commonly occurs after the age of 50 years. In contrast to herpes simplex virus the latency of VZV is poorly understood. The virus has not been recovered from human nerve cells by cell culture and the location and structure of the viral DNA is not known. Virus-specific proteins continue to be made by the infected cells during the latent period, so true latency, as opposed to a chronic low level infection, has not been proven. Although VZV has been detected in autopsies of nervous tissue, there is no method to find dormant virus in the ganglia in living people.

Uncompromised immune system suppresses reactivation of the virus and prevents herpes zoster. Why this suppression sometimes fails is not known, but aging, immunosuppressive therapy, psychological stress, or other factors impair immune system.

A person has no immunity to Varicella zoster virus may get chickenpox but not shingles immediately.  Until the herpes rash has developed crusts, a person is extremely contagious. A person is not infectious before blisters appear, or during post herpetic neuralgia (pain after the rash is gone).

Diagnosis:

Diagnosis is mostly made by a visual examination of the rash, since the rash in a dermatomal pattern. In absence of rash (early or late in the disease, or in the case of zoster sine herpete, a condition in which pain occurs without appearance of rash), herpes zoster can be difficult to diagnose.

Prevention:

A live vaccine for VZV exists. Adults also receive an immune boost from contact with children infected with varicell (chicken pox), a boosting method that prevents about a quarter of herpes zoster cases among unvaccinated adults,

In a controlled study it was found that intake of fresh fruit is associated with a reduced risk of developing shingles. People who consumed less than one serving of fruit a day had three times more risk than those who consumed more than three serving. For those aged 60 or more, vitamins and vegetable intake had a similar association.

Treatment

The aims of treatment are to limit the severity and duration of the episode and pain and reduce complications of post herpetic neuralgia. Post-herpetic neuralgia is very rare in people less than 50 years age and it wears off in time; even in people over 70 in 85% people the pain wore off one year after their shingles outbreak.

Homoeopathic medicines

Homoeopathic medicine is always prescribed on individualizing indications; the case given here is a good example. Iris versicolor was selected for the specific location of herpes that was right side of abdomen with acidity and constipation. Some of the homoeopathic medicines commonly indicated for herpes zoster/zona are –

Iris versicolor, Mercurius solubilis, Mezerium, Ranunculus bulbosus., Rhus toxicodendron, Arsenicum album, Carbolicum acidum., Clematis, Graphites, Heper sulphuricum, Kali bichromicum., Kali chlororicum., Lachesis, Natrum muriaticum, Nitricum acidum., Petroleum, Prunus spinosa., Sarsaparilla, Sepia, Silicea, Sulphur, Thuja, Variolinum.

Zona with neuralgic pain – Ars. alb., Dolichos, Kalmia, Mezerium, Ran.b., Stillingia sylvatica, Zincum metalicum.  

With stomach complaints – Iris. ver.

Cold application ameliorates – Apis melifica.

Warm application ameliorates – Ars. alb.

Prognosis

The rash and pain generally subside within three to five weeks, but about twenty percent patients develop post-herpetic neuralgia which is a very painful condition and often difficult to manage. Sometime there occurs zoster sine herpete due to reactivation of the virus. Sometimes complications affect several levels of the nervous system and cause many cranial neuropathies, polyneuritis, myelitis or aseptic meningitis. Other complications that may occur in some cases include partial facial paralysis  (usually temporary), ear damage or encephalitis. Chickenpox during pregnancy, may lead to infection of the fetus and complications in the newborn but chronic infection or herpes are not associated with fetal infection. Though the mechanism is not clear but after a herpes zoster infection an increased risk of developing cancer has been observed.                                                                                                                                                                                                                                                                                                                                                                      Other complications – Secondary bacterial infection, motor involvement – including weakness especially in "motor herpes zoster". Eye involvement – trigeminal nerve involvement (as seen in herpes ophthalmicus) should be treated early and aggressively as it may lead to blindness. Involvement of tip of the nose in the zoster rash is a strong predictor of herpes ophthalmicus.

Case – Mr. Ajit Bhatnagar     52 yrs.     Male    married      bank manager     hindu       nonvegetarian

Diagnosis – Herpes zoster.                                                                                                                                      

 The patient was suffering from painful herpes eruption on right side of abdomen for last three weeks which were persisting in spite of various treatments and medication. He was also having indigestion, burning, sour eructation and rumbling in abdomen with constipation.

 03/12/09 Rx 1. Iris vers.        30    twice a day for 5 days.  

                        2. P. L.               200   two doses at 10 minutes interval.                                                                                   

08/12/09 Pains were relieved after second dose of Iris. Eruptions started drying. Bowel clear and regular. Rumbling and eructation were relieved.    

                  Rx 1. Rubrum         30    twice a day for 5 days.

                       2. P. L.               200   two doses at 10 minutes interval.

14/12/09 No pain or burning. No more eruption except marks. The patient was continued on the last prescription for next 10 days. It was full recovery without after pains of herpes in last 20 months.

Dr. M. K. Tyagi

D.H.M.S., Dip. N.I.H.
Research Officer 

Sewa Mandir

Mobile" 09829157926

Email: manju_mkt2003@yahoo.co.in