Shingles: Herpes Zoster Transmission, Symptoms, Treatment and Complications

Herpes zoster, commonly known as shingles, is a viral and infectious disease.

What is shingles and why does it occur?
Do you know how it manifests itself, besides being painful, and how it is transmitted?
Can herpes zoster lie latent or dormant, i.e. show no signs of a rash?
It is treated with antibiotics or antivirals.
Will herbs help? What about rashes and taking showers?

The answers to these frequently asked questions are given in the article below.

Shingles is caused by the varicella zoster virus - VZV. It is also responsible for a typical childhood disease called chickenpox.

Varicella zoster virus, also called VZV or Human alphaherpes virus 3 (HHV-3).

It is a DNA virus of the family Herpesviridae, subfamily Alfaherpesviridae (α-herpes virus). There are several subspecies of herpesvirus.

Herpes viruses are found worldwide.

Primary VZV infection, i.e. the first infection, manifests as varicella (chickenpox). Most people overcome chickenpox in childhood. Only about 2% of cases happen at the age of 20 and above.

After healing, the virus is not completely eliminated, i.e. removed, from the body.

However...

The virus survives in a latent, i.e. dormant form, in the ganglia of the sensory nerves of the cranial or posterior spinal roots. In other words, the virus sleeps until it is reactivated.

Ganglion - nerve nodes that form clusters of specific nerve cells (neurons).

The virus can be reactivated in various circumstances, such as by weakened immunity, other illness or surgery. Excessive stress can also be a trigger.

The virus can be found in several places in the nervous system. Restarting its reproduction may present some difficulties, depending on its location.

These can be nerve cells in the following areas:

• trigeminal nerve
• thoracic spine
• lumbar spine
• acral spine
• genital area
• and others

The virus will start to multiply again under suitable conditions. The process spreads along nerve fibres - skin dermatomas. In the affected area, it causes unpleasant pain and a typical rash, e.g. sores.

A dermatome is an area of skin innervated by nerve fibres from a single spinal root.

Let's talk some facts...

We know that there are many herpesviruses. They have different biological properties. Their common thing is - the ability to survive unseen, i.e. dormant or latent, inside the host's cell, i.e. infected the person.

Intermittent or recurring symptoms occur for various reasons, such as weakened immunity, other illness, surgery, injury or excessive stress and physical activity.

As far as infection is concerned, the incubation period of approximately 14 days is indicated.

In the latency period, i.e. while the virus is sleeping, the virus is not infectious. Blisters that appear as a result of herpes zoster are highly infectious.

It has been reported that virus reactivation after chickenpox occurs in about 10-20% of cases only once in a lifetime is stated.

The second reactivation occurs less frequently, i.e. in approximately 5% of cases.

Shingles is an infectious disease that occurs at all ages and genders. According to available data, the virus breaks out in men more frequently.

It rarely flares up in children.

About 3% of patients with zoster are hospitalized.2,5 Few studies provide valid data relating to zoster mortality, with only ∼0.25 per million population in the United States and Europe, mostly among the elderly. Reported rates of recurrent zoster vary from 3% to 5% lifetime to 6.2% over 8 years,2 and are clearly associated with decreased immune competency. For individuals with HIV, the recurrence rate can be as high as 13% to 26%. Source: The global epidemiology of herpes zoster (nih.gov)

People over the age of 50 are more susceptible, with about two-thirds of patients in this age group.

The risk of outbreaks of shingles in people over the age of 65 is 25% and in people over the age of 85 up to 50%.

In young people, it is necessary to think about immune disorder conditions and HIV.

Learn more in the article Mouth ulcers.

Infectiousness of Shingles

Shingles is an infectious disease. Herpes does not spread during the latency period - as there are no symptoms. When it is multiplying in nerve cells, it is spreading to the skin.

Virus-filled blisters form on the skin.

After they burst, they are transmitted by air or touch. Susceptible people, i.e. people without prior contact with VZV, are at risk of a chickenpox outbreak.

As with smallpox, the virus no longer spreads after the blisters have dried off and crusted.

Data suggest that the transmission rate of shingles is slightly lower than in chickenpox.

The cause of shingles is the secondary reactivation of the varicella zoster virus. It survives in latent/dormant form in the nerve cells of the ganglia after being infected by and overcoming chicken pox.

When the disease flares up again, the virus multiplies and spreads along the nerve fibres. It then moves to the skin and causes typical symptoms.

The disease occurs by reactivation or reinfection with a virus in an already immunized person.

The exact cause of virus reactivation is not fully understood.

There are various risk factors, such as:

• excessive emotional stress
• excessive physical activity
• chronic fatigue
• malnutrition
• advanced age, especially above 65 years of age
• injury
• surgery
• acute disease
• shock
• immunosuppression, i.e. weakened immune system
  • immune disorder
  • treatment - immunosuppressive, chemotherapy, radiotherapy
  • chronic diseases
  • oncological diseases, Hodgkin's disease, lymphoma
  • HIV/AIDS

Shingles is mostly known for its skin manifestations. However, this is just one of the symptoms it causes.

In the first days, it starts itching before the appearance of the rash. Itching occurs during the course of disease of the affected nerve fibres.

Itching may be associated by a stinging or burning sensations, intense pain, and loss of sensation on the skin.

Next, after a few days, a rash and blisters appearon the skin. The area around the affected part is red and the area is painful.

Blisters typically burst, get wet and bleed.

At this time, secondary bacterial infection presents a risk, similar to chickenpox streptococci or staphylococci.

The risk remains throughout the rash period with blisters and the VZV virus keep spreading until the blisters dry out and crust over.

The symptoms of the disease and the skin rash are usually present unilaterally, i.e. on one side of the body.

During the entire course of the rash, there are several stages - lesion, rash, vesicle, wet lesions, crusting and scabs.

The rash appears in various forms:

1. macule - a flat skin lesion
2. papule - small raised bump protruding 1 cm
3. vesicle - fluid-filled sac
4. pustule - patch of skin full of pus
5. crust - dried pus

Skin defects dry out in about 10 days. In total, the course can last up to 4 weeks.

Herpes zoster can occur anywhere in the human body:

• often the torso, chest, lumbar area in the front or back area
• sciatic muscle area
• thighs
• genitals
• shoulders
• head - trigeminal nerve area
  • ear, ear canal
  • risk of eye damage, blindness

Summary of the main symptoms of shingles:

• itching, stinging and burning of the skin
• skin sensitisation in the area
• intense skin pain
  • the pain is worsened when moving, getting dressed
• skin rashes after blisters
• drying, crusting
• enlargement and pain in the regional nodes
• hypopigmentation (pale skin) or skin hyperpigmentation
• later on, persistent neuralgia, painful
• elevated body temperature
• fatigue, exhaustion
• loss of appetite
• feeling sick in the stomach - nausea
• vomiting

The disease significantly reduces the quality of life. The affected person is isolated or suffer from anxiety or depression. Showering or getting dressed and other normal life activities are difficult.

• tiredness
• sleep disorder
• loss of appetite
• being less active
• anxiety, depression
• unable to concentrate
• limited social life

Types of Shingles

Herpes zoster is divided into a primary and a secondary form.

The primary form is also referred to as idiopathic, which means the cause is not known. Secondary means that it is mostly the cause of other diseases, for example oncological diseases, diabetes, liver and kidney diseases, immune disorders or HIV/AIDS.

Table: Classification Based on the Dermatoma / Affected Part of the Innervation

Another classification is based on the ongoing clinical picture:

• herpes zoster bullosus - scars may form
  • presence of vesicles - blisters
  • containing a thick liquid
  • pus
  • pinhead to walnut-sized - in case of wet blisters
• herpes zoster haemorrhagicus - bleeding blisters may be present
• herpes gangraenosus et necroticus - the base of the blisters has died off
  • brown to black crusts are formed
  • scabs left behind after healing
• herpes zoster cum impetiginisatio as a result of secondary superinfection

Herpes Zoster Can Cause Various Complications

The incidence of complications is reported to be in the range of 10-50%.

One of the most common complications is a secondary bacterial infection of skin defects. After healing, neuralgia, i.e. nerve pain, is present.

Damage to the eyes (visual impairment, blindness), brain damage (encephalitis, meningitis and various neurological disorders, movement disorders, etc.), damage to the liver, lungs - inflammation of the lungs and other organs may become serious.

Herpes zoster increases the risk of cardiovascular disease due to vascular damage with a possible consequence of myocardial infarction or stroke.

Complications arise mainly due to the presence of other diseases, i.e. oncological or immune.

Diagnosis is based mainly on the medical history and clinical picture.

If the case is not confirmed, laboratory diagnostics, e.g. a PCR test, also called a polymer chain reaction, swabs and direct evidence of the presence of the virus may be added to the screenings.

Differential diagnosis is important. It involves distinguishing a particular disease or condition from other conditions that present with similar clinical features.

For example, in case of a severe course of herpes simplex, other painful conditions, such as vertebrogenic algic syndrome (back pain), neuralgia, kidney stones or gallstones, coronary syndrome, and chest pain.

ONgoing health problems might mean cancer.

In such a case, the diagnosis may include other examinations, such as ECG, troponin and blood collection for other laboratory and inflammatory parameters, neurological examination, GFS - gastrofibroscopy, sonography (USG), CT, MRI, X-ray and others.

The course of the disease from the first symptoms to the drying of the last blisters can last up to 4 weeks.

First of all, before the skin rash appears, the affected person experiences itching or stinging on the skin. There may be other associated sensations. This is the onset of intense pain.

The pain can be preceded by 5 days before the rash.

After a few days, a typical rash appears. It has a characteristic shape and the area where one or more groups of defects are formed is sharply delimited.

The size of blisters is similar to that of a pinhead or a grain of rice. However, some of them may merge.

The skin is tight, filled with a clear liquid and later the contents become cloudy, grayish to yellowish.

The affected area goes through all stages of rash, i.e. from redness and blisters to crusting and scabs. This phenomenon is metaphorically called the starry sky pattern.

Rashes and blisters must not be scratched. There is a risk of secondary bacterial infection and scarring.

These skin defects themselves are painful. Pain is exacerbated by movement, showering or getting dressed quickly. Due to these difficulties and possible transmission, the affected person cannot go to work and needs to be isolated. The disease generally restricts the quality of life.

There are no reported severe states of anxiety or depression due to deteriorating health and social limitations.

The most typical place of occurrence of skin sowing is the trunk, with a direction to the upper or lower limbs. Herpes that appears on the head and face is dangerous.

In most cases, the symptoms develop unilaterally during the nerve receding from the respective root. However, bilateral herpes zoster - that is, on both halves of the body - also occurs. There are also cases with no skin manifestations or difficulties described sbove.

After treatment, nerve pain (neuralgia) may occur, which persists for a long time. The specific course depends on the complications and the place of disability.

Neuralgic postherpetic pain can last for months to years.

Shingles and Pregnancy

The problem is mainly an initial VZV infection during pregnancy, i.e when a pregnant woman who has not yet had chickenpox is exposed to the virus.

The virus goes through the placenta and can damage the fetus.

As already mentioned in an article on chickenpox, there is a risk of developmental defects of the fetus if the exposure is during the first trimester. The infection results in congenital varicella syndrome.

Likewise, the period before childbirth (approximately 2-3 weeks) and after childbirth is also high risk. A difficult course can be expected especially in the last 5 days before and shortly after childbirth. Then neonatal varicella develops.

It has been reported that after the 20th to 36th week of pregnancy, the disease will not affect the fetus. The mother's immune response will create a positive effect. The fetus is partially equipped with antibodies that have crossed the placenta.