Herpes zoster physical examination: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
No edit summary
 
(13 intermediate revisions by 2 users not shown)
Line 1: Line 1:
__NOTOC__
__NOTOC__
{{Herpes zoster}}
{{Herpes zoster}}
{{CMG}}; L. Katie Morrison, MD; '''Associate Editor(s)-In-Chief:''' {{CZ}}; {{JH}}.
{{CMG}}; L. Katie Morrison, MD; '''Associate Editor(s)-In-Chief:''' {{CZ}}, {{JH}}, {{DN}}.
 
==Overview==
The characteristic physical examination finding of herpes zoster is the [[maculopapular]] rash. The rash in typically unilateral and its distribution is confined to one or two adjacent [[dermatomes]]. As the rash crusts and heals in 7-10 days, a post-inflammatory hyperpigmentation of the skin may result. Other findings, such as cranial and peripheral nerves involvement depend on the location of the [[dorsal root ganglia]] involved.


== Physical Examination ==
== Physical Examination ==
People with herpes zoster most commonly have a rash in one or two adjacent dermatomes (localized zoster). The rash most commonly appears on the trunk along a thoracic dermatome. The rash does not usually cross the body’s midline. However, approximately 20% of people have rash that overlaps adjacent dermatomes. Less commonly, the rash can be more widespread and affect three or more dermatomes. This condition is called disseminated zoster. This generally occurs only in people with compromised immune systems. Disseminated zoster can be difficult to distinguish from varicella.
Physical examination findings of herpes zoster depend on the location of the rash, as well as the stage of the disease:
===Rash===
The rash of herpes zoster virus is typically unilateral and does not cross the midline. It follows the distribution of one or two adjacent dermatomes. The rash can involve any area of the body, but the most common sites are the face ([[ophthalmic]] division of [[trigeminal nerve]]), neck ([[cervical]] [[dorsal root ganglia]]) or chest ([[thoracic]] [[dorsal root ganglia]]). The rash is initially an erythematous, [[maculopapular]] rash, but over the next 7-10 days, it progresses to pustules and ulceration, with crusts, scabbing or both. Post-inflammatory hyperpigmentation may develop along the affected dermatome(s) as part of the healing process. In the immunocompromised individuals, the rash may be complicated by skin necrosis and scarring.<ref name="pmid23785227">{{cite journal |vauthors=Cohen KR, Salbu RL, Frank J, Israel I |title=Presentation and management of herpes zoster (shingles) in the geriatric population |journal=P T |volume=38 |issue=4 |pages=217–27 |year=2013 |pmid=23785227 |pmc=3684190 |doi= |url=}}</ref><ref name="pmid10375341">{{cite journal |vauthors=Cohen JI, Brunell PA, Straus SE, Krause PR |title=Recent advances in varicella-zoster virus infection |journal=Ann. Intern. Med. |volume=130 |issue=11 |pages=922–32 |year=1999 |pmid=10375341 |doi= |url=}}</ref>
 
===[[Herpes zoster ophthalmicus]]===
When the rash involves the [[ophthalmic]] division of the [[trigeminal]] nerve, the same characteristic rash will be present in addition to several [[occular]] and head and neck findings which may or may not accompany the rash. These include<ref name="pmid23785227">{{cite journal |vauthors=Cohen KR, Salbu RL, Frank J, Israel I |title=Presentation and management of herpes zoster (shingles) in the geriatric population |journal=P T |volume=38 |issue=4 |pages=217–27 |year=2013 |pmid=23785227 |pmc=3684190 |doi= |url=}}</ref><ref name="pmid18657721">{{cite journal |vauthors=Mueller NH, Gilden DH, Cohrs RJ, Mahalingam R, Nagel MA |title=Varicella zoster virus infection: clinical features, molecular pathogenesis of disease, and latency |journal=Neurol Clin |volume=26 |issue=3 |pages=675–97, viii |year=2008 |pmid=18657721 |pmc=2754837 |doi=10.1016/j.ncl.2008.03.011 |url=}}</ref><ref name="pmid16009918">{{cite journal |vauthors=Karmon Y, Gadoth N |title=Delayed oculomotor nerve palsy after bilateral cervical zoster in an immunocompetent patient |journal=Neurology |volume=65 |issue=1 |pages=170 |year=2005 |pmid=16009918 |doi=10.1212/01.wnl.0000167287.02490.76 |url=}}</ref><ref name="pmid12449270">{{cite journal |vauthors=Shaikh S, Ta CN |title=Evaluation and management of herpes zoster ophthalmicus |journal=Am Fam Physician |volume=66 |issue=9 |pages=1723–30 |year=2002 |pmid=12449270 |doi= |url=}}</ref>:
*Hutchinson's sign: a rash on the tip of the nose is a strong predictor of eye involvement
*[[Blepharoconjunctivitis]]: edema and inflammation of the outer eyelids
*[[Keratitis]]: presents with signs of corneal inflammation, which presents with eye pain, redness and [[photophobia]]
*[[Uveitis]]: presents with eye redness and elevated intraocular pressure
*Cranial nerve palsies: herpes zoster virus may involves cranial nerves III, VI and less commonly, IV. Involvement of these cranial nerves may present with pain on eye movement ([[ophthalmoplegia]]), as well as pupillary dilatation with a sluggish reaction to light when cranial nerve III is involved.<ref name="pmid18657721">{{cite journal |vauthors=Mueller NH, Gilden DH, Cohrs RJ, Mahalingam R, Nagel MA |title=Varicella zoster virus infection: clinical features, molecular pathogenesis of disease, and latency |journal=Neurol Clin |volume=26 |issue=3 |pages=675–97, viii |year=2008 |pmid=18657721 |pmc=2754837 |doi=10.1016/j.ncl.2008.03.011 |url=}}</ref><ref name="pmid16009918">{{cite journal |vauthors=Karmon Y, Gadoth N |title=Delayed oculomotor nerve palsy after bilateral cervical zoster in an immunocompetent patient |journal=Neurology |volume=65 |issue=1 |pages=170 |year=2005 |pmid=16009918 |doi=10.1212/01.wnl.0000167287.02490.76 |url=}}</ref>
 
===[[Ramsay Hunt Syndrome]]===
Rarely, herpes zoster may present with a [[maculopapular]] rash in the external auditory canal (zoster opticus) or the tympanic membrane. [[Ramsay Hunt Syndrome]] refers to zoster rash in the external auditory canal, the [[tympanic membrane]], the ipsilateral anterior two-thirds of the tongue or hard palate, associated with ipsilateral weakness or paralysis of the facial muscles, due to involvement of cranial nerve VII. Syndrome may be associated with signs of hearing loss, involuntary eye movements and nystagmus.<ref name="pmid23785227">{{cite journal |vauthors=Cohen KR, Salbu RL, Frank J, Israel I |title=Presentation and management of herpes zoster (shingles) in the geriatric population |journal=P T |volume=38 |issue=4 |pages=217–27 |year=2013 |pmid=23785227 |pmc=3684190 |doi= |url=}}</ref><ref name="pmid18657721">{{cite journal |vauthors=Mueller NH, Gilden DH, Cohrs RJ, Mahalingam R, Nagel MA |title=Varicella zoster virus infection: clinical features, molecular pathogenesis of disease, and latency |journal=Neurol Clin |volume=26 |issue=3 |pages=675–97, viii |year=2008 |pmid=18657721 |pmc=2754837 |doi=10.1016/j.ncl.2008.03.011 |url=}}</ref><ref name="pmid11459884">{{cite journal |vauthors=Sweeney CJ, Gilden DH |title=Ramsay Hunt syndrome |journal=J. Neurol. Neurosurg. Psychiatr. |volume=71 |issue=2 |pages=149–54 |year=2001 |pmid=11459884 |pmc=1737523 |doi= |url=}}</ref>


The rash develops into clusters of clear vesicles. New vesicles continue to form over three to five days and progressively dry and crust over. They usually heal in two to four weeks. There may be permanent pigmentation changes and scarring on the skin.
===Other neurological manifestations===
*[[Cervical]] dermatomal distribution: rash may be followed by a [[lower motor neuron]] ([[LMN]]) weakness in the arm or diaphragmatic weakness<ref name="pmid18657721">{{cite journal |vauthors=Mueller NH, Gilden DH, Cohrs RJ, Mahalingam R, Nagel MA |title=Varicella zoster virus infection: clinical features, molecular pathogenesis of disease, and latency |journal=Neurol Clin |volume=26 |issue=3 |pages=675–97, viii |year=2008 |pmid=18657721 |pmc=2754837 |doi=10.1016/j.ncl.2008.03.011 |url=}}</ref><ref name="pmid8891477">{{cite journal |vauthors=Merchut MP, Gruener G |title=Segmental zoster paresis of limbs |journal=Electromyogr Clin Neurophysiol |volume=36 |issue=6 |pages=369–75 |year=1996 |pmid=8891477 |doi= |url=}}</ref>
*[[Thoracic]] dermatomal distribution: may be associated with abdominal muscles weakness, which may result in abdominal [[herniation]]<ref name="pmid18657721">{{cite journal |vauthors=Mueller NH, Gilden DH, Cohrs RJ, Mahalingam R, Nagel MA |title=Varicella zoster virus infection: clinical features, molecular pathogenesis of disease, and latency |journal=Neurol Clin |volume=26 |issue=3 |pages=675–97, viii |year=2008 |pmid=18657721 |pmc=2754837 |doi=10.1016/j.ncl.2008.03.011 |url=}}</ref>


===Gallery===
===Gallery===
Line 169: Line 187:
</div>
</div>


==Gallery==
<gallery>
Image: Chickenpox31.jpeg| Skin disorder was found to be herpes zoster. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
Image: Chickenpox30.jpeg| Plantar foot rash was suspected to be smallpox related, but was later determined to be caused by herpes zoster virus. <SMALL><SMALL>''[http://phil.cdc.gov/phil/home.asp From Public Health Image Library (PHIL).] ''<ref name=PHIL> {{Cite web | title = Public Health Image Library (PHIL) | url = http://phil.cdc.gov/phil/home.asp}}</ref></SMALL></SMALL>
</gallery>
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


[[Category:Infectious skin diseases]]
 
[[Category:Viral diseases]]
[[Category:Herpesviruses]]
[[Category:Infectious disease]]
[[Category:Needs content]]
[[Category:Needs overview]]
[[Category:primary care]]
{{WH}}
{{WH}}
{{WS}}
{{WS}}

Latest revision as of 16:44, 24 October 2016

Herpes zoster Microchapters

Home

Patient Information

Overview

Historical Perspective

Pathophysiology

Causes

Differentiating Herpes zoster from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Herpes Zoster
Congenital Varicella Syndrome

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Herpes zoster physical examination On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Herpes zoster physical examination

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Herpes zoster physical examination

CDC on Herpes zoster physical examination

Herpes zoster physical examination in the news

Blogs on Herpes zoster physical examination

Directions to Hospitals Treating Herpes zoster

Risk calculators and risk factors for Herpes zoster physical examination

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; L. Katie Morrison, MD; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2], Jesus Rosario Hernandez, M.D. [3], Dima Nimri, M.D. [4].

Overview

The characteristic physical examination finding of herpes zoster is the maculopapular rash. The rash in typically unilateral and its distribution is confined to one or two adjacent dermatomes. As the rash crusts and heals in 7-10 days, a post-inflammatory hyperpigmentation of the skin may result. Other findings, such as cranial and peripheral nerves involvement depend on the location of the dorsal root ganglia involved.

Physical Examination

Physical examination findings of herpes zoster depend on the location of the rash, as well as the stage of the disease:

Rash

The rash of herpes zoster virus is typically unilateral and does not cross the midline. It follows the distribution of one or two adjacent dermatomes. The rash can involve any area of the body, but the most common sites are the face (ophthalmic division of trigeminal nerve), neck (cervical dorsal root ganglia) or chest (thoracic dorsal root ganglia). The rash is initially an erythematous, maculopapular rash, but over the next 7-10 days, it progresses to pustules and ulceration, with crusts, scabbing or both. Post-inflammatory hyperpigmentation may develop along the affected dermatome(s) as part of the healing process. In the immunocompromised individuals, the rash may be complicated by skin necrosis and scarring.[1][2]

Herpes zoster ophthalmicus

When the rash involves the ophthalmic division of the trigeminal nerve, the same characteristic rash will be present in addition to several occular and head and neck findings which may or may not accompany the rash. These include[1][3][4][5]:

  • Hutchinson's sign: a rash on the tip of the nose is a strong predictor of eye involvement
  • Blepharoconjunctivitis: edema and inflammation of the outer eyelids
  • Keratitis: presents with signs of corneal inflammation, which presents with eye pain, redness and photophobia
  • Uveitis: presents with eye redness and elevated intraocular pressure
  • Cranial nerve palsies: herpes zoster virus may involves cranial nerves III, VI and less commonly, IV. Involvement of these cranial nerves may present with pain on eye movement (ophthalmoplegia), as well as pupillary dilatation with a sluggish reaction to light when cranial nerve III is involved.[3][4]

Ramsay Hunt Syndrome

Rarely, herpes zoster may present with a maculopapular rash in the external auditory canal (zoster opticus) or the tympanic membrane. Ramsay Hunt Syndrome refers to zoster rash in the external auditory canal, the tympanic membrane, the ipsilateral anterior two-thirds of the tongue or hard palate, associated with ipsilateral weakness or paralysis of the facial muscles, due to involvement of cranial nerve VII. Syndrome may be associated with signs of hearing loss, involuntary eye movements and nystagmus.[1][3][6]

Other neurological manifestations

Gallery

Skin

(Images shown below courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA)

  • Herpes Zoster: Coalesced vesicles resulting from reactivation of HZV infection.

    Herpes Zoster: Coalesced vesicles resulting from reactivation of HZV infection.

  • Herpes Zoster: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

    Herpes Zoster: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

  • Herpes Zoster: Dermatomally distributed vesicles in patient with HZV infection.

    Herpes Zoster: Dermatomally distributed vesicles in patient with HZV infection.

  • Herpes Zoster: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

    Herpes Zoster: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

  • Shingles on waist

    Shingles on waist

  • Dermatomal involvement of rash

    Dermatomal involvement of rash

  • Dermatomal involvement of skin rash

    Dermatomal involvement of skin rash

  • Herpes zoster on the chest

    Herpes zoster on the chest

  • Varicella zoster

    Varicella zoster

  • Herpes Zoster. (Courtesy of Josh Fierer, M.D. and Charlie Goldberg, M.D.)

    Herpes Zoster.
    (Courtesy of Josh Fierer, M.D. and Charlie Goldberg, M.D.)

  • Herpes Zoster C3 Distribution: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

    Herpes Zoster C3 Distribution: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

  • Herpes Zoster C3 Distribution: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

    Herpes Zoster C3 Distribution: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

  • Shingles on face

    Shingles on face

  • Shingles on face

    Shingles on face

  • This 1968 image depicted a number of varicella, or chickenpox lesions on a patient’s back, which were displaying the characteristic “cropping” distribution, or manifesting themselves in clusters, each in a different developmental stage.

    This 1968 image depicted a number of varicella, or chickenpox lesions on a patient’s back, which were displaying the characteristic “cropping” distribution, or manifesting themselves in clusters, each in a different developmental stage.

  • This patient presented with what was differentially diagnosed as a herpes zoster outbreak in order to rule out syphilis.

    This patient presented with what was differentially diagnosed as a herpes zoster outbreak in order to rule out syphilis.

  • This skin disorder was found to be herpes zoster, not syphilitic in nature as was initially suspected.

    This skin disorder was found to be herpes zoster, not syphilitic in nature as was initially suspected.

  • These skin lesions on the forehead of an elderly woman are due to the herpes zoster virus on the 21st day of the illness.

    These skin lesions on the forehead of an elderly woman are due to the herpes zoster virus on the 21st day of the illness.

  • A case of shingles that demonstrates the typical dermatomal distribution, in this case C8/T1

    A case of shingles that demonstrates the typical dermatomal distribution, in this case C8/T1

Head
Trunk
Extremities
Neck
Genitourinary System
Skin

(Images shown below courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA)

  • Herpes Zoster: Coalesced vesicles resulting from reactivation of HZV infection.

    Herpes Zoster: Coalesced vesicles resulting from reactivation of HZV infection.

  • Herpes Zoster: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

    Herpes Zoster: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

  • Herpes Zoster: Dermatomally distributed vesicles in patient with HZV infection.

    Herpes Zoster: Dermatomally distributed vesicles in patient with HZV infection.

  • Herpes Zoster: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

    Herpes Zoster: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

  • Shingles on waist

    Shingles on waist

  • Dermatomal involvement of rash

    Dermatomal involvement of rash

  • Dermatomal involvement of skin rash

    Dermatomal involvement of skin rash

  • Herpes zoster on the chest

    Herpes zoster on the chest

  • Varicella zoster

    Varicella zoster

  • Herpes Zoster. (Courtesy of Josh Fierer, M.D. and Charlie Goldberg, M.D.)

    Herpes Zoster.
    (Courtesy of Josh Fierer, M.D. and Charlie Goldberg, M.D.)

  • Herpes Zoster C3 Distribution: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

    Herpes Zoster C3 Distribution: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

  • Herpes Zoster C3 Distribution: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

    Herpes Zoster C3 Distribution: Dermatomally distributed vesicles, many of which have coalesced, in patient with HZV infection.

  • Shingles on face

    Shingles on face

  • Shingles on face

    Shingles on face

  • This 1968 image depicted a number of varicella, or chickenpox lesions on a patient’s back, which were displaying the characteristic “cropping” distribution, or manifesting themselves in clusters, each in a different developmental stage.

    This 1968 image depicted a number of varicella, or chickenpox lesions on a patient’s back, which were displaying the characteristic “cropping” distribution, or manifesting themselves in clusters, each in a different developmental stage.

  • This patient presented with what was differentially diagnosed as a herpes zoster outbreak in order to rule out syphilis.

    This patient presented with what was differentially diagnosed as a herpes zoster outbreak in order to rule out syphilis.

  • This skin disorder was found to be herpes zoster, not syphilitic in nature as was initially suspected.

    This skin disorder was found to be herpes zoster, not syphilitic in nature as was initially suspected.

  • These skin lesions on the forehead of an elderly woman are due to the herpes zoster virus on the 21st day of the illness.

    These skin lesions on the forehead of an elderly woman are due to the herpes zoster virus on the 21st day of the illness.

  • A case of shingles that demonstrates the typical dermatomal distribution, in this case C8/T1

    A case of shingles that demonstrates the typical dermatomal distribution, in this case C8/T1

Gallery

References

  1. ↑ 1.0 1.1 1.2 Cohen KR, Salbu RL, Frank J, Israel I (2013). "Presentation and management of herpes zoster (shingles) in the geriatric population". P T. 38 (4): 217–27. PMC 3684190. PMID 23785227.
  2. ↑ Cohen JI, Brunell PA, Straus SE, Krause PR (1999). "Recent advances in varicella-zoster virus infection". Ann. Intern. Med. 130 (11): 922–32. PMID 10375341.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Mueller NH, Gilden DH, Cohrs RJ, Mahalingam R, Nagel MA (2008). "Varicella zoster virus infection: clinical features, molecular pathogenesis of disease, and latency". Neurol Clin. 26 (3): 675–97, viii. doi:10.1016/j.ncl.2008.03.011. PMC 2754837. PMID 18657721.
  4. ↑ 4.0 4.1 Karmon Y, Gadoth N (2005). "Delayed oculomotor nerve palsy after bilateral cervical zoster in an immunocompetent patient". Neurology. 65 (1): 170. doi:10.1212/01.wnl.0000167287.02490.76. PMID 16009918.
  5. ↑ Shaikh S, Ta CN (2002). "Evaluation and management of herpes zoster ophthalmicus". Am Fam Physician. 66 (9): 1723–30. PMID 12449270.
  6. ↑ Sweeney CJ, Gilden DH (2001). "Ramsay Hunt syndrome". J. Neurol. Neurosurg. Psychiatr. 71 (2): 149–54. PMC 1737523. PMID 11459884.
  7. ↑ Merchut MP, Gruener G (1996). "Segmental zoster paresis of limbs". Electromyogr Clin Neurophysiol. 36 (6): 369–75. PMID 8891477.
  8. ↑ 8.0 8.1 "Public Health Image Library (PHIL)".


Template:WH Template:WS

Retrieved from "https://www.wikidoc.org/index.php?title=Herpes_zoster_physical_examination&oldid=1263386"