The prompt administration of large doses of steroids or corticotropin (ACTH) can dramatically transform herpes zoster into “quite a minor affair,” the chief of neurology at Pennsylvania Hospital, Philadelphia, told the American College of Physicians last month in Atlantic City. Questions identified respondents’ treatment practices given the clinical scenario of a patient with signs of recurrent HZO (stromal keratitis and anterior uveitis). His work was with rheumatoid arthritis and since 1929 he had noticed that rheumatoid arthritis improved in pregnancy and jaundice. Attempts have been made to increase the beneficial effects and reduce the adverse effects by modifying the steroid nucleus and side groups. Treatment with intravenous acyclovir was universal in all 7 patients and in 2 cases systemic corticosteroids were also administered. There are unfortunately many situations where treatment of doubtful efficacy has produced severe side effects. The infection is contracted in childhood, which manifests as chickenpox and the child develops immunity.
Keratitis occurs in over half of all cases of HZO; hypoesthesia is a common finding in these individuals. After the age of 50, it becomes increasingly more common as you get older. Clinical features In herpes zoster ophthalmicus, frontal nerve is more frequently affected than the lacrimal and nasociliary nerves. Prolonged use of corticosteroids may produce posterior subcapsular cataracts, glaucoma with possible damage to the optic nerves, and may enhance the establishment of secondary ocular infections due to fungi or viruses. The Hutchinson’s rule, which implies that ocular involvement is frequent if the side or tip of nose presents vesicles (cutaneous involvement of nasociliary nerve), is useful but not infallible. Administration of live or live, attenuated vaccines is contraindicated in patients receiving immunosuppressive doses of corticosteroids. Clinical phases of H.
zoster ophthalmicus are : i. Acute, which may totally resolve. The appearance of these features is extremely variable; some patients seem able to tolerate prednisolone 30 mg/day while others become cushingoid on less than one half of this. These effects are mediated through the glucocorticoid receptor (GR), an intracellular protein acting as a nuclear transcription factor regulating the expression of a diverse range of genes. iii. Relapsing, where the acute or chronic lesions reappear sometimes years later. Clinical features of herpes zoster ophthalmicus include general features, cutaneous lesions and ocular lesions.
Topical capsaicin reduces pain once skin lesions have healed. Occasionally, two or three nerves next to each other are affected. The onset of illness is sudden with fever, malaise and severe neuralgic pain along the course of the affected nerve. Chicken pox and measles, for example, can have a more serious or even fatal course in non-immune children or adults on corticosteroids. B. Similarly, corticosteroids should be used with great care in patients with known or suspected Strongyloides (threadworm) infestation. Cutaneous lesions (Fig.
5.10) in the area of distribution of the involved nerve appear usually after 3-4 days of onset of the disease. To begin with, the skin of lids and other affected areas become red and oedematous (mimicking erysipelas), followed by vesicle formation. Hormone replacement therapy has been shown to have a beneficial effect on osteoporosis in post-menopausal and amenorrhoeic women on corticosteroids8 (see below). The list of conditions below clearly illustrates the diverse range of benefits that are possible. The active eruptive phase lasts for about 3 weeks. Main symptom is severe neuralgic pain which usually diminishes with the subsidence of eruptive phase; but sometimes it may persist for years with little diminution of intensity. There occurs some anaesthesia of the affected skin which when associated with continued post-herpetic neuralgia is called anaesthesia dolorosa.
C. The picture shows a scabbing rash (a few days old) of a fairly bad bout of shingles. Ocular complications usually appear at the subsidence of skin eruptions and may present as a combination of two or more of the following lesions: 1. Steroids should be used with caution in nonspecific ulcerative colitis, if there is a probability of impending perforation, abscess or other pyogenic infection; diverticulitis; fresh intestinal anastomoses; active or latent peptic ulcer; renal insufficiency; hypertension; osteoporosis; and myasthenia gravis. It may occur as mucopurulent conjunctivitis with petechial haemorrhages or acute follicular conjunctivitis with regional lymphadenopathy. Therefore, the dose of methylprednisolone should be titrated to avoid steroid toxicity. 2.
Zoster keratitis occurs in 40 percent of all patients and sometimes may precede the neuralgia or skin lesions. It may occur in several forms, which in order of chronological clinical occurrence are (Fig. Hormone replacement therapy may be considered for post-menopausal and amenorrhoeic women. STEROID TREATMENT CARD I am a patient on steroid treatment which must not be stopped suddenly. These unlike dendritic ulcers of herpes simplex are usually peripheral and stellate rather than exactly dendritic in shape. It contrast to Herpes simplex dendrites, they have tapered ends which lack bulbs. Nummular keratitis is seen in about one-third number of total cases.
It typically occurs as multiple tiny granular deposits surrounded by a halo of stromal haze. Also, to be safe and not risk passing on the virus to others who may not have had chickenpox, you should not share towels, go swimming, or play contact sports such as rugby whilst you have a shingles rash. Neuroparalytic ulceration may occur as a sequelae of acute infection and Gasserian ganglion destruction. Persons who are on immunosuppressant doses of corticosteroids should be warned to avoid exposure to chickenpox or measles. Mucous plaque keratitis develops in 5% of cases between 3rd and 5th months characterised by sudden development of elevated mucous plaque with stain brilliantly with rose bengal. If after a reasonable period of time there is a lack of satisfactory clinical response, MEDROL should be discontinued and the patient transferred to other appropriate therapy. Episcleritis and scleritis occur in about one-half of the cases.
These usually appear at the onset of the rash but are frequently concealed by the overlying conjunctivitis. 4. Early in the disease the plain xray and computed tomography scan may be normal and a bone scan shows only non-specific changes. Inhibitory effects (leukocytes, macrophages, cytokines). 5. Acute retinal necrosis may occurs in some cases. 6.
Anterior segment necrosis and phthisis bulbi. Pain may be eased by cooling the affected area with ice cubes (wrapped in a plastic bag), wet dressings, or a cool bath. 7. Alternate day therapy is a corticosteroid dosing regimen in which twice the usual daily dose of corticoid is administered every other morning. It may occur due to trabeculitis in early stages and synechial angle closure in late stages. Increasing levels of ACTH stimulate adrenal cortical activity resulting in a rise in plasma cortisol with maximal levels occurring between 2 am and 8 am. Associated neurological complications.
Herpes zoster ophthalmicus may also be associated with other neurological complications such as : 1. Motor nerve palsies especially third, fourth, sixth and seventh. A predisposition to bacterial, viral, fungal, and candidal infections can all occur. Prednisolone is excreted in small amounts in breast milk and is unlikely to cause systemic effects in the infant unless doses exceed 40 mg daily. 3. Encephalitis occurs rarely with severe infection. Treatment Therapeutic approach to herpes zoster ophthalmicus should be vigorous and aimed at preventing severe devastating ocular complications and promoting rapid healing of the skin lesions without the formation of massive crusts which result in scarring of the nerves and postherpetic neuralgia.
The following regime may be followed: I. An antiviral medicine is most useful when started in the early stages of shingles (within 72 hours of the rash appearing). Oral antiviral drugs. During conventional pharmacologic dose corticosteroid therapy, ACTH production is inhibited with subsequent suppression of cortisol production by the adrenal cortex. In order to be effective, the treatment should be started immediately after the onset of rash. The benefits of ADT should not encourage the indiscriminate use of steroids. Acyclovir in a dose of 800 mg 5 times a day for 10 days, or Valaciclovir in a dose of 500mg TDS 2.
Analgesics. Pain during the first 2 weeks of an attack is very severe and should be treated by analgesics such as combination of mephenamic acid and paracetamol or pentazocin or even pethidine (when very severe). If active tuberculosis is found it can be treated in the usual manner while corticosteroids are started. Systemic steroids. They appear to inhibit development of post-herpetic neuralgia when given in high doses. However, the risk of high doses of steroids in elderly should always be taken into consideration. Steroids are commonly recommended in cases developing neurological complications such as third nerve palsy and optic neuritis.
4. A short course of steroid tablets (prednisolone) may be considered in addition to antiviral medication. 5. Amitriptyline should be used to relieve the accompanying depression in acute phase. II. 6) The maximal activity of the adrenal cortex is between 2 am and 8 am, and it is minimal between 4 pm and midnight. Antibiotic-corticosteroid skin ointment or lotions.
These should be used three times a day till skin lesions heal. 2. Not all seronegative patients on corticosteroids will require zoster immunoglobulin. Cool zinc calamine application, as advocated earlier, is better avoided, as it promotes crust formation. III. Local therapy for ocular lesions 1. For zoster keratitis, iridocyctitis and scleritis i.
Topical steroid eye drops 4 times a day. Can shingles be prevented? Cycloplegics such as cyclopentolate eyedrops BD or atropine eye ointment OD. iii. Topical acyclovir 3 percent eye ointment should be instilled 5 times a day for about 2 weeks. 2. To prevent secondary infections topical antibiotics are used.
3. For secondary glaucoma i. In 1976 Conn and Blitzer29 reported combined data from 50 randomised clinical trials where corticosteroids had been given for a variety of diseases and found neither the prevalence of PUD nor its complications to be significantly greater in patients treated with corticosteroids than in controls. ii. Acetazolamide 250 mg QID. 4. For neuroparalytic corneal ulcer caused by herpes zoster, lateral tarsorrhaphy should be performed.
5. For persistent epithelial defects use : i. Lubricating artificial tear drops, and ii. Bandage soft contact lens. 6. Keratoplasty. It may be required for visual rehabilitation of zoster-patients with dense scarring.
However, these are poor risk patients.