Herpes zoster. Diagnosis, Complications, Treatment, Prevention 서울대학교병원 FM R2 임하연

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1 Herpes zoster Diagnosis, Complications, Treatment, Prevention 서울대학교병원 FM R2 임하연 1

2 2 Overview reactivation of lat ent VZV along sensory nerve VZV(varicella-zoster virus) Human herpes virus-3 Chickenpox, herpes zoster risk factor Elder Women whites, asian Summer family history of zoster Immunocompromised

3 3 Prevalence & Diagnosis 1 million cases in USA each year Annual rate of 3-4 /1000 persons(usa) Annual rate of 10.4/1000 persons(korea) Up to 3% with disease : require hospitalization symptoms does not cross midline preceded by tingling, itching, or pain for 2 ~ 3 days begins as macules & papules, evolve into vesicles & pustules, dries with crusting in 7~10 days

4 4 Complications Immunocompromised : disseminated skin disease, acute or progressive outer retinal necrosis, chronic herpes zoster with verrucous skin lesions, acyclovir-resistant VZV involve multiple organs (e.g., lung, liver, brain, and gastrointestinal tract), hepatitis or pancreatitis before rash appears.

5 5 Complications A meta-analysis of stroke risk following herpes zoster infection, Marra et al. BMC 2017 Fig. 2 Effect of herpes zoster on stroke risk by length of study follow-up Fig. 3 Effect of herpes zoster ophthalmicus on stroke risk by length of study follow-up

6 6 Treatment Antiviral Therapy Indications reduce formation of new lesions, viral shedding, severity of acute pain initiated within 72 hours after the onset of the rash, as early as possible usually given for 7 day Acyclovir 5 회투여, 신장배설, 생체이용률낮음, 과용량시 acyclovir 뇌증 Valacyclovir Famciclovir 3 회투여, acyclovir pro-drug 3 회투여, penciclovir pro-drug, 약크기작음, 신경학적증상 ( 어지러움 ) 발생적음 Immunocompromised : Intravenous acyclovir is recommended acyclovir-resist ant VZV : Foscarnet

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8 8 Treatment steroid improved performance of activities of daily living accelerated early healing reduction in time to complete healing not reduce incidence of postherpetic neuralgia Caution with HTN, DM, peptic ulcer disease, osteoporosis Cert ain CNS Cx : vasculopathy or Bell s palsy in nonimmunocompromised

9 9 Treatment Acute pain control NSAID, AAP : mild pain Opioids > gabapentin

10 10 Treatment Eye Disease Associated with Herpes Zoster should be evaluated by an ophthalmologist mydriatic eyedrops to dilate the pupil & reduce the risk of scarring (synechiae) topical glucocorticoids for keratitis, episcleritis, or iritis reduce intraocular pressure for the treatment of glaucoma intravitreal antiviral therapy for immunocompromised

11 11 Post herpetic neuralgia pain persisting at least 90 days after acute zoster rash 10 to 50% of persons with herpes zoster Risk fact or Age(>50yr) Severe skin lesions Severe acute zoster associated pain Preceded pain before skin lesion appearance immunocompramised three categories spontaneous pain that is ongoing (e.g., continuous burning pain) paroxysmal shooting or electric shock like pains evoked sensations that are pathologic amplifications of responses to light touch and other stimuli

12 12 Post herpetic neuralgia treatment Korean J Pain Vol. 17, Suppl., 차약물 : TCA, 항경련제, 국소 lidocaine 2 차약물 : 아편유사제, tramadol 3 차약물 : 국소 capsaicin, valproate N Engl J Med 2014;371: Our recommendations opioids as third-line therapy. Although some guidelines classify topical lidocaine as second-line treatment, we recommend topical lidocaine for first-line use usually in combination with oral drugs

13 13 Prevention Vaccine : approved by FDA in persons 50 years of age or older shorter in pain duration and less severe can be given to persons with a history of herpes zoster(after 6-12month later) optimal timing is uncertain : delay vaccination for 3 years in immunocompetent efficacy 50 to 59 : 70% 60 to 69 : 64% 70 or older : 38% Contraindication hematologic cancers not cured cytotoxic chemotherapy within 3 months HIV infection with CD4 cell count of 200 N Engl J Med. 2005;352:

14 14 Prevention [Q1] 대상포진백신도재접종이필요한가요? 현재대상포진백신은 1 회접종하며재접종은권고하지않습니다. 아직대상포진백신의장기면역원성및효능에대한자료는충분하지않으며현재까지의자료로는적어도 7 년까지는효능이유지되는것으로보입니다. 추후연구결과에따라재접종에대한권고가나올가능성이없는것은아니나현재는재접종을권고하지않습니다. [Q2] 대상포진의병력이있는사람도대상포진백신을접종받을수있나요? 대상포진의병력이있는사람도대상포진백신을접종받을수있습니다. 현재미국 ACIP 와대한감염학회에서도동일한권고를유지하고있습니다. 대상포진백신을접종하는경우세포매개면역이강화될수있으며이상반응또한증가하지않는다고보고되었기때문입니다. 다만대상포진이발병하게되면수두대상포진바이러스 (varicella-zostervirus,vzv) 에대한세포매개면역 (cell-mediatedimmunity) 이강화되어이후재발률은 1-5% 정도로높지않습니다. [Q3] 대상포진백신은누가, 언제맞아야하나요? 60 세이상성인은대상포진백신접종이권고됩니다 세성인은대상포진이나대상포진후신경통에민감하게반응할가능성이높다면의사의판단에따라대상포진백신을접종받을수있습니다.

15 15 Herpes zoster vs herpes simplex characteristic Herpes zoster Herpes simplex Sites of latent infections all sensory ganglia trigeminal & sacral sensory ganglia Viral gene expression during latency Symptomatic reactivation of latent virus Asymptomatic reactivation with asymptomatic virus shedding Proportion of rash Consequences of reactivation of latent virus Several immediate early & early VZV proteins Infrequent(rarely involves same dermatome) none Large(sensory fields of many neurons) Extensive ganglionic pathology & neuronal death No HSV proteins. Frequent(usually involves same dermatome) Frequent Postherpetic neuralgia common Extremely rare Small(often sensory field of single neuron) No obvious pathology & neuronal death Frequency of symptomatic reactivation Increasing with age Decreasing after primary infection

16 16 Thank you for listening! Reference : JAMA Intern Med. 2018;178(2): BMC Infectious Diseases (2017) 17:198 DOI /s n engl j med 369;3 nejm.org july 18, 2013 N Engl J Med 2014; 371: The Journal of the American Osteopathic association, June 2009, Vol. 109, S13-S17. Korean Journal of Medicine : Vol. 60, No. 3, 2001 Korean J Pain Vol. 17, Suppl., 2004 대한감염학회, 대상포진백신 Q&A, 2017 대상포진 up-to-date, 김연동외저, 2015