Complications
Occurs if virus infects the trigeminal nerve. Infection may cause conjunctivitis, keratitis, corneal ulceration, iridocyclitis, glaucoma, and blindness. All patients should be treated with antivirals. Antiviral medicine given within 72 hours after the onset of the rash reduces the incidence of complications by 25%.[120] Lubricating eye ointment should be given to patients when the blinking reflex has been affected, to prevent damage to the corneal epithelium.
Secondary infection of the lesions, usually with staphylococcal or streptococcal bacteria. Bacterial superinfection can cause cellulitis, osteomyelitis, or life-threatening complications such as necrotising fasciitis and sepsis. Symptoms include pain, redness, and swelling in the affected area. Lesions may develop pus. Antibiotics should be given to treat the infection.
Usually occurs a few days after the rash onset, but in some cases the onset may occur several months after an HZ episode. Presents with headache, meningismus, fever, ataxia, and seizures. Chronic encephalitis is seen almost exclusively in immunocompromised individuals. Its onset is usually a few months after resolution of the rash. Patients usually present with subacute symptoms including headache, fever, and mental status changes. However, patients may have focal symptoms including hemiplegia and aphasia. The prognosis is poor. Magnetic resonance imaging scan findings include infarcts of cortical and sub-cortical grey and white matter and small vessel vasculitis.
Occurs when varicella-zoster virus is reactivated in the geniculate ganglion of cranial nerve VII (facial nerve). Occurs in <1% of zoster cases and is more common among those over 60. The classic triad of Ramsay Hunt syndrome is otalgia, vesicular rash of the ear (herpes zoster oticus) and ipsilateral facial paralysis. Ramsay Hunt syndrome is distinctive in having a motor component (ipsilateral facial paralysis), which occurs due to nerves from the motor nucleus of the facial nerve passing through the geniculate ganglion. Other symptoms can include tinnitus, hearing loss, nausea, vomiting, vertigo and nystagmus which relates to involvement of the vestibulocochlear nerve. Combination treatment containing antiviral agents and steroids is recommended for the treatment of Ramsay Hunt syndrome. Prompt diagnosis and treatment (ideally within 72 hours) leads to improved outcomes.[121][122]
Common in immunocompromised people, and usually occurs after thoracic HZ. Weakness usually occurs in the same spinal cord segment as the rash. The primary symptom is usually urinary retention. Magnetic resonance imaging shows evidence of myelitis in the segment of infection.
Acute retinal necrosis can occur in immunocompetent and immunocompromised patients. It is usually unilateral and presents as acute onset of vision loss with possible redness, photophobia, pain, floaters and flashes. Inflammation can be severe. Progressive outer retinal necrosis generally only occurs in patients with HIV infection and CD4 count <100 cells/mm3. It is usually bilateral and minimal inflammation is seen. Peripheral lesions in the outer retinal layers merge, causing full-thickness retinal necrosis and possible retinal detachment.[13][123][124]
Treatment is with antivirals, and involvement of an experienced ophthalmologist is strongly recommended.
Common in severely immunocompromised patients. The vesicular rash involves several dermatomes, and visceral involvement may also occur. Patients should be treated with intravenous aciclovir until infection is controlled, then switched to oral antiviral medicine for the remainder of the treatment course.
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