From the Guidelines
Herpes zoster with nervous system involvement is a serious complication of shingles where the varicella-zoster virus (VZV) reactivates and affects the nervous system, potentially leading to conditions such as postherpetic neuralgia, cranial nerve palsies, meningitis, encephalitis, myelitis, and vasculopathy. This condition occurs when the VZV reactivates from its dormant state in sensory ganglia and spreads to involve the central or peripheral nervous system 1. The most common neurological complication is postherpetic neuralgia, characterized by persistent pain lasting more than 90 days after the rash heals. Other serious neurological manifestations include cranial nerve palsies, meningitis, encephalitis, myelitis, and vasculopathy that can lead to stroke.
Key Characteristics
- The virus establishes latency in sensory ganglia after primary infection (chickenpox) and can reactivate years later when immunity wanes, particularly in older adults or immunocompromised individuals 1.
- Herpes zoster typically causes a unilateral, vesicular eruption with dermatomal pain that often precedes the skin findings by 24–72 hours 1.
- Lesions in otherwise healthy hosts continue to erupt for at least 4–6 days, with the entire disease duration being approximately 2 weeks 1.
Treatment
- Treatment typically involves high-dose antiviral therapy with acyclovir, valacyclovir, or famciclovir 1.
- For severe cases with central nervous system involvement, intravenous acyclovir is preferred.
- Pain management is crucial and may include gabapentin, pregabalin, tricyclic antidepressants, or opioids for severe pain.
- Corticosteroids may be added in cases with significant inflammation 1.
Prevention
- Recipients of allogeneic blood and bone marrow transplants routinely take acyclovir or valacyclovir during the first year following transplant for the prevention of VZV and HSV reactivation 1.
From the FDA Drug Label
In a similar double-blind, placebo-controlled study, acyclovir (800 mg 5 times daily for 7 days) shortened the times to complete lesion scabbing, healing, and cessation of pain; reduced the duration of new lesion formation; and reduced the prevalence of localized zoster-associated neurologic symptoms (paresthesia, dysesthesia, or hyperesthesia)
Herpes zoster with nervous system involvement is characterized by neurologic symptoms such as:
- Paresthesia
- Dysesthesia
- Hyperesthesia These symptoms are associated with localized zoster infection and can be reduced with acyclovir treatment 2.
From the Research
Definition of Herpes Zoster with Nervous System Involvement
Herpes zoster, also known as shingles, is a viral infection caused by the Varicella Zoster virus (VZV) that affects the skin and nervous system 3. The infection can lead to various complications, including postherpetic neuralgia (PHN), which is a type of nerve pain that can persist after the initial rash has resolved 4, 5.
Nervous System Involvement
The nervous system involvement in herpes zoster can manifest in different ways, including:
- Postherpetic neuralgia (PHN): a type of nerve pain that can persist after the initial rash has resolved 4, 5
- Encephalitis: a rare but serious complication of herpes zoster 3
- Destructive myelitis: a rare but serious complication of herpes zoster 3
- Delayed contralateral hemiparesis/hemiplegia: a manifestation of vasculitis due to direct VZV invasion of the cerebral arteries 3
- Ophthalmoparesis/plegia: a complication of herpes zoster that can affect the eyes 3
Treatment and Management
The treatment and management of herpes zoster with nervous system involvement typically involve antiviral medications, such as valacyclovir, acyclovir, and famciclovir, which can help alleviate symptoms and reduce the risk of complications 6, 4, 7. Additionally, combination therapy with gabapentin and valacyclovir has been shown to be effective in reducing the incidence of postherpetic neuralgia 5.
Key Points
- Herpes zoster is a viral infection that affects the skin and nervous system 3
- Nervous system involvement can manifest in different ways, including postherpetic neuralgia, encephalitis, and destructive myelitis 4, 5, 3
- Treatment and management typically involve antiviral medications and combination therapy with gabapentin and valacyclovir 6, 4, 7, 5