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What is localised and disseminated Herpes zoster

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localised disseminated Herpes zoster clinical features

Harrison's Principles of Internal Medicine, Twenty First Edition

Page 5574

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Herpes zoster rash dermatomal disseminated

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Herpes Zoster: Localised vs. Disseminated

Herpes zoster (shingles) results from reactivation of latent Varicella-Zoster Virus (VZV) in the dorsal root or cranial nerve ganglia. It presents along a spectrum from localised dermatomal disease to widespread disseminated infection.

Localised (Dermatomal) Herpes Zoster

Definition: Zoster confined to one or two adjacent dermatomes on one side of the body.
Pathophysiology:
  • Latent VZV in a single sensory ganglion reactivates, travels down the sensory nerve, and erupts in the corresponding dermatomal skin distribution.
Clinical Features:
  • Prodrome (2–4 days before rash): Dermatomal pain, burning, itching, or hyperaesthesia; may be accompanied by fever, malaise, and headache.
  • Rash: Erythematous maculopapules → vesicles on an erythematous base → pustules → crusting over 7–10 days.
  • Distribution: Strictly unilateral, does not cross the midline. Most commonly affects the thoracic dermatomes (T3–L3), trigeminal nerve (V1 = ophthalmic branch), and lumbosacral dermatomes.
  • Special forms:
    • Herpes zoster ophthalmicus (HZO): V1 involvement; risk of keratitis, uveitis, and vision loss. Hutchinson's sign (tip/side of nose lesion) predicts ocular involvement.
    • Ramsay Hunt syndrome: Geniculate ganglion (CN VII + VIII); facial palsy, ear pain, vesicles in the external auditory canal/pinna, and ipsilateral hearing loss.
Course:
  • Scabbing complete in ~2–3 weeks in immunocompetent patients.
  • Lesions continue to form for >1 week in immunocompromised individuals.

Disseminated Herpes Zoster

Definition: Widespread cutaneous dissemination defined as >20 vesicles outside the primary and immediately adjacent dermatomes, often accompanied by visceral involvement.
Pathophysiology:
  • Occurs when viral viraemia is not contained by the host immune response, allowing VZV to spread haematogenously to skin and internal organs.
  • Seen predominantly in immunocompromised patients (HIV/AIDS, haematological malignancies, transplant recipients, high-dose corticosteroid use).
Cutaneous Dissemination:
  • Develops in approximately 40% of patients with Hodgkin's disease or non-Hodgkin's lymphoma with zoster (Harrison's, p. 5574).
  • The rash resembles chickenpox (widespread, polymorphic vesicular eruption) superimposed on the primary dermatomal rash.
Herpes zoster ophthalmicus with cutaneous dissemination — note the dense dermatomal eruption in V1 (left forehead/eye) alongside discrete vesicles scattered across the chest, shoulders, and arms
Herpes zoster ophthalmicus with cutaneous dissemination. Dense confluent vesicles in the V1 dermatomal distribution (left forehead, supraorbital region, eyelid) with scattered discrete vesicles over the chest and upper extremities — characteristic of disseminated zoster in an immunocompromised host.
Visceral / Systemic Complications (risk increased 5–10× with cutaneous dissemination):
Organ SystemComplication
LungPneumonitis
CNSMeningoencephalitis, myelitis
LiverHepatitis
EyeRetinal necrosis (ARN/PORN)
GIOesophagitis, colitis
Prognosis: Even in immunocompromised patients, disseminated zoster is rarely fatal with antiviral therapy, though morbidity is significant (Harrison's, p. 5574).

Key Comparison Table

FeatureLocalisedDisseminated
Distribution1–2 dermatomes, unilateral>20 lesions beyond primary dermatome
HostImmunocompetent or mildly impairedImmunocompromised
Visceral involvementRareSignificant risk (pneumonitis, encephalitis, hepatitis)
Healing time2–3 weeks>3 weeks; ongoing new lesion formation
MortalityVery rareRare even in immunocompromised

Management Principles

  • Antivirals: IV Aciclovir (10 mg/kg every 8 hours) for disseminated or severe disease; oral valaciclovir/famciclovir for localised disease in immunocompetent patients.
  • Ophthalmology review: Mandatory for HZO.
  • Pain management: Analgesics, gabapentinoids for post-herpetic neuralgia prevention.
  • Infection control: Disseminated zoster carries airborne transmission risk (similar to chickenpox) — isolation is required in hospitalised patients.
  • Prevention: Live attenuated zoster vaccine (Zostavax) and recombinant subunit vaccine (Shingrix) reduce incidence and severity; Shingrix is preferred and can be used in immunocompromised patients.
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