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Fast Shingles Cure Summary


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Herpes Zoster Clinical Summary

Herpes zoster is a dermatomal, unilateral reactivation of the varicella zoster virus. Pain, tenderness, and dysesthesias may present 4 to 5 days prior to an eruption composed of umbilicated, grouped vesicles on an erythematous, edematous base. The vesicles may become purulent or hemorrhagic. Nerve involvement may actually occur without cutaneous involvement. Ophthalmic zoster involves the nasociliary branch of the fifth cranial nerve and presents with vesicles on the nose and cornea (Hutchinson sign). Ramsay Hunt syndrome is a herpes zoster infection of the geniculate ganglion that

Varicella Zoster Virus

Varicella-zoster virus (VZV) is the etiological agent of chickenpox. Von Bokay was the first to observe that susceptible children might develop varicella after exposure to the herpes zoster virus. Joseph Garland, a long-term editor of the New England Journal of Medicine, was the first to suggest that zoster reflected activation of a latent varicella virus. '118 In 1954, Thomas Weller confirmed von Bokay's observation that children develop varicella following exposure to patients with herpes zoster by demonstrating, with tissue culture and antibody studies, that the two diseases were caused by the same virus. '119 The likelihood of developing zoster increases with advancing age, a phenomenon attributed to immune senescence and a decline in the VZV-specific T-lymphocyte population.' 1 Varicella, or chickenpox, results from the initial exposure to VZV, and approximately 1 in 1000 to 4000 patients with varicella develop neurological complications of...

Varicella and Herpes Zoster

Herpes zoster is a reactivation of the neurotropic varicella virus, typically in a dermatomal distribution. This is more common in elderly or immunocompromised patients but can occur in healthy people as well. Patients with zoster may note generalized malaise, hyperesthesia, numbness, tingling, and pain in the skin before development of a rash. The appearance of the rash is the same as for chickenpox, although most often isolated to a unilateral dermatome. The diagnosis of herpes zoster is clinical based on the history and the classic appearance of the rash. In immunocompromised patients, however, the rash may not be dermatomally isolated. When the diagnosis is unclear, viral culture can be obtained from the base of a lesion. The rash of zoster is infectious to the touch. Patients should be advised to keep the rash covered until all the lesions have crusted. Zoster of the trigeminal nerve can extend to the eye and warrants immediate ophthalmologic intervention. A vaccine to prevent...

Shingles Not Just on Your Roof

Most of us have had chicken pox in our lives. Shingles are caused from the same virus, Varicella zoster also known as herpes zoster. Once you've had chicken pox, this virus may lie dormant in your body until a serious illness, emotional trauma, or prolonged stress weakens your immune system. Each year, 850,000 Americans are diagnosed with shingles. The first sign of shingles may be chills or fever, followed by an eruption of tiny blisters that may be extremely painful and sensitive to the touch so sensitive that something as light as a bedsheet may feel unbearable to the skin. These blisters form crusty scabs that look like roof shingles and eventually fall off. For some, this is the end of the bout, but for about 20 percent of all patients, the pain travels through the nerves. This condition is called post-zoster pain, which is a quite painful condition that can continue for a long time, especially in those with immune deficiencies. I have seen patients with severe pain spreading...

Herpes Zoster Shingles

Zoster is caused by the reactivation of the varicella-zoster virus (VZV, human herpesvirus 3, HHV-3, chickenpox). After the primary infection, VZV lies dormant in the dorsal root ganglia. The time between the onset of primary chickenpox and reactivation can be any time but usually decades later. Approximately 10 to 20 of the U.S. population eventually develop one or more cases of zoster in their lifetime. The incidence is much higher in immunocompromised patients and older adults. These rates are likely to decrease over time now that a VZV vaccine is given as part of the routine immunization schedule in children. Figure 33-55 Herpes zoster in dermatomal pattern. Richard P. Usatine.) Figure 33-55 Herpes zoster in dermatomal pattern. Richard P. Usatine.) Antiviral therapy such as acyclovir, valacyclovir, and famciclovir should be started within the first 3 days of onset of symptoms, to reduce the severity and duration of symptoms and skin lesions. Early treatment may also reduce the...

Zoster Vaccine

Later in life, approximately 15 of the population will develop herpes zoster (shingles). Zoster is the reactivation of latent varicella zoster virus in the sensory ganglia. It produces a classic rash along a single nerve track. Approximately 20 of persons with herpes zoster will develop postherpetic neuralgia, which is a painful debilitating condition that can persist for months after resolution of the herpes zoster rash. Adults get a boost in immunity with repeated exposure to children with the chickenpox. Zoster most frequently occurs in the elderly and immunocompromised individuals who have decreased circulating antibodies to varicella zoster virus.19 Zoster vaccine is a more concentrated form of the varicella vaccine. It is recommended for use in individuals 60 years of age and older. Use of the zoster vaccine has shown a 60 reduction in the incidence of zoster and postherpetic neuralgia. There is decreased effectiveness of the vaccine with increasing age. The varicella vaccine is...

Health Care Infection Control Practices

A patient may be in isolation or on special precautions, which indicates that he or she is suffering from a contagious disease, such as tuberculosis or varicella-zoster virus infection or is colonized with a multidrug-resistant organism. Health-care providers should consult the institutional infection control manual for guidelines regarding restrictions on entry into the patient's room and on protective attire.

Nervous About Nerve Pain

V Stop the sting of shingles This chapter will help you check out your wiring and see how Oriental Medicine deals with some potentially devastating conditions such as Bell's palsy, multiple sclerosis, and strokes. We also will look at the nerve pains of shingles and trigeminal neuralgia. All of these conditions involve damage to the nervous system.

Evidence Based Screening Guidelines

Immunizations are an important part of well-woman care. All patients benefit from disease prevention, and women are often caregivers for children or elderly persons, who are at higher risk from vaccine-preventable illnesses. Vaccines recommended by the U.S. Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) include tetanus diphtheria pertussis (Tdap), herpes zoster, and influenza for adults over age 50 and human papillomavirus vaccine for women 26 and younger.

Emergency Department Treatment and Disposition

Uncomplicated cases of herpes zoster can be managed with supportive care, especially pain control. Admission to the hospital for intravenous acyclovir is usually reserved for complicated cases involving multiple dermatomal distributions or the ophthalmic branch of the trigeminal nerve, disseminated disease, or immunocompromised patients. Acyclovir, famciclovir, or valacyclovir hasten the healing and decreases the pain if started within 72 hours of vesicle appearance. These agents have also been shown to reduce the duration of postherpetic neuralgia. Prednisone may also prove useful. Herpes zoster keratitis requires immediate ophthalmologic consultation to avoid any potential vision loss. Herpes Zoster. Umbilicated, grouped, dermatomal vesicles on an erythematous base in a patient with herpes zoster. (Photo contributor Selim Suner, MD, MS.) Herpes Zoster. This eruption consists of a dermatomal distribution of umbilicated vesicles on an erythematous base. Note the occasional cluster of...

Epidemiology and etiology

Encephalitis may result from a number of viral, bacterial, parasitic, and other noninfectious causes. Herpes simplex virus (HSV) is the most common cause of encephalitis in the United States, accounting for 10 of all cases.9 The annual incidence of viral encephalitis is estimated to be 3.5 to 7.4 infections per 100,000 persons.9 Other pathogens include common bacterial meningitis causes, Ricksettsia species, enteroviruses, arboviruses, varicella-zoster virus, rotavirus, coronavirus, influenza viruses A and B, West Nile virus, and Epstein-Barr virus may be associated with a meningo-encephalopathic presentation.10 Approximately 20,000 hospitalizations each year are secondary to encephalitis accounting for 650 million in health care costs.11 Over the past 10 to 20 years, mortality secondary to encephalitis has remained constant correlating well with the increased number of people living with HIV and AIDS. HIV infection is concurrent in nearly 20 of patients dying from encephalitis.12

Inflammatory Neuropathies

Several opportunistic infections of the PNS may result from HIV infection. The HIV itself, cytomegalovirus, and herpes zoster are most common. Painful sensorimotor polyneuropa-thies or demyelinating polyradiculoneuropathies occur during the early and late stages of HIV disease. Symptomatic relief of neuropathic pain may be achieved with antidepressants (e.g., amitriptyline) or anticonvulsants (e.g., carbamazepine).

Infectious diseases causing vasculitis

Varicella zoster virus vasculopathy Varicella zoster virus (VZV) can lead to stroke due to viral infection of the cerebral artery walls (for review see Nagel et al. 25 ). Two different types of infection can be differentiated depending on the immune status of the patient. Immunocompromised individuals, e.g. organ transplant or AIDS patients, show a diffuse inflammation of cerebral blood vessels of all sizes. Immunocompetent patients may develop herpes zoster associated cerebral angiitis, a granulomatous angiitis that usually affects larger arteries. In both cases, histopathological features include multinu-cleated giant cells, Cowdry A inclusion bodies, and VZV particles. Randomized clinical trials for standard treatment are lacking. Based on expert opinion, current treatment includes intravenous acyclovir in combination with steroids. A vaccination for VZV is available and has significantly diminished VZV-related morbidity and mortality in children. Prevention of herpes zoster by...

Epidemiology and Incidence

The sporadic reactivation of the virus as shingles is unrelated to exposure to exogenous infection and, in general, is uncommon even in populations in which practically all have had chickenpox. Its peak incidence is after age 50. Of those who develop shingles, only 1 percent have two attacks. Patients with impaired cellular immunity are at risk, and herpes zoster is not uncommon in those suffering from malignant disease.

Clinical Manifestations and Pathology

Presumably the virus enters and replicates briefly in the cells of the respiratory mucosa followed by an intermittent viremia. The histopathology is identical with that described for herpes simplex infection. The virus is present in the vesicles. During viremia the virus travels from cutaneous sensory nerve endings to the posterior ganglia where it remains latent to be reactivated in some patients as herpes zoster. Then the dorsal ganglia show intense inflammation even with hemorrhagic necrosis, leptomeningitis, and myelitis of the posterior spinal columns. Although VZV has been isolated from ganglia during active disease, it has not been found during quiescent periods. An attack of herpes zoster may be ushered in with 1 or 2 days of fever, chills, malaise, and gastrointestinal symptoms before symptoms of local disease appear. Either with or without prodromal symptoms the patient becomes aware of some pain, at times with itching, in the area of the affected segmental nerves. After...

History and Geography

Rayer, in his 1845 treatise on diseases of the skin, described the microscopic contents of zoster vesicles and of the underlying skin. F. von Baren-sprung (1861-3) concluded that zoster was due to disease of the posterior roots. In the following years, several case reports of herpes zoster in which there were postmortem findings of inflammation of the posterior root ganglia appeared. Barensprung's suspicion that the Gasserian ganglion was affected in herpes zoster of the face was confirmed by O. Wyss (1872). A. W. Campbell and Henry Head (1900) established that herpes zoster results from a hemorrhagic inflammation of the posterior nerve roots and the homologous cranial ganglia. In 1925, Karl Kundra-titz described the inoculation of susceptible children with zoster vesicle fluid resulting in varicella.

Syndromes of Lesions Involving Peripheral Branches of Cranial Nerve V

Herpes zoster ophthalmicus (.Fig. 10.16 ), inflammation and vesicular eruption involving all branches of V1 as well as small arterioles within the gasserian ganglion may result in excruciating, lancinating pain in the periorbital region. y Symptoms of herpes zoster ophthalmicus typically begin 2 to 3 days before the appearance of vesicles and may diminish after 2 to 3 weeks. Hypalgesia and paresthesias may be noted during and after lesions heal. Pain may persist after the rash is gone only to evolve into post-herpetic neuralgia. This syndrome consists of burning, lancinating, aching pain in the V1 territory often in association with paresthesias and hyperpathia. As in trigeminal neuralgia, trigger points can evoke pain in response to cutaneous stimuli. y , y Figure 10-6 Acute (A) and resolving B) herpes zoster arrows). In A, there is selective involvement of the nasociliary branch of the trigeminal nerve.

Reason Of Pain In Lower Anterior Teeth And Lip After Rftc And Mental Block

Sphenopalatine Ganglion Block

Other reported uses of SPGB include back pain, sciatica, angina, arthritis, herpes zoster ophthalmicus, and pain from cancer of the tongue and the floor of the mouth.113 113 113 These are not true indications for SPGB but instead reveal the resourcefulness of this block for cases in which conventional therapies are ineffective.

Clinicopathologic Correlations


Acute multiple ulcers that are preceded by or associated with vesicles may have infective or immunologic causes. Primary herpes simplex, herpes zoster, coxsackievirus, and HIV are causative infective agents. Allergic stomatitis, benign mucous membrane pemphigoid, pemphigus vulgaris, Behcet's disease, and erythema multiforme are common immunologic causes. Radiation therapy or chemotherapy may predispose an individual to the development of acute multiple ulcers.

Autonomic Dysfunction Secondary to Focal Central Nervous System Disease

Facial flushing may result from the release of tonic sympathetic vasoconstriction, active sympathetic vasodilatation, increased parasympathetic activity via the greater petrosal nerve, and the release of vasoactive peptides. Gustatory sweating and flushing occur in the following conditions idiopathic hemifacial hyperhidrosis associated with hypertrophy of the sweat glands following bilateral cervicothoracic sympathectomy with reinnervation of the superior sympathetic ganglion by preganglionic sympathetic fibers destined for the sweat glands after local damage to the autonomic fibers traveling with the peripheral branches of the trigeminal nerve (e.g., in parotid or submaxillary gland surgery or V3 zoster) with reinnervation of sweat glands and blood vessels by parasympathetic vasodilator fibers destined for the salivary glands and accompanying peripheral neuropathies, most frequently diabetes mellitus. U

Painful Legs Moving Toes Syndrome

Painful legs-moving toes syndrome (PLMTS) is a movement disorder associated with significant sensory symptoms. The condition is idiopathic in origin but usually develops in association with back pain and often in the context of prior back injury or surgery. No specific pathophysiological mechanisms have been elucidated, and although a spinal cord or peripheral nervous system origin has been proposed, electrophysiological studies are often normal. y Because the condition sometimes follows herpes zoster infection, primary involvement of the posterior roots and ganglia has been suggested to explain the syndrome. The movements are not a response to the pain because after local anesthesia or sympathetic blockade, the movements promptly recur. Clinically, the condition involves continuous writhing movements of the toes and pain in the legs. The pain may range from mildly irritating to excruciatingly severe. y In most cases, it has a constant, boring quality, but it can be burning or...

Intracranial vasculopathies caused by virus and bacterial infection

Intracranial Infection

Varicella zoster virus vasculopathy Varicella zoster virus (VZV) vasculopathy may often be clinically silent but may present with stroke and can be diagnosed because of the following symptoms, signs and findings (for review Nagel et al. 28 ). (1) About two-thirds of patients have a history of zoster rash, particularly ophthalmic-distribution zoster or a history of chicken pox. There is a delay between the onset of zoster chicken pox and the onset of stroke averaging 4.1 months (range between same day and 2.5 years). But about one-third of patients with a pathologically and virologically verified disease have no history of zoster rash or chicken pox. (2) Angiographic evidence of narrowing in cerebral arteries may be found in MR angiography. In vascular studies 70 had vasculopathies. Different patterns of vascular lesions have been found. There was pure large artery disease in 13 , pure small artery disease in 37 and a mixed vascular pathology in most patients (50 ). (3) Varicella...

Facial Nerve Paralysis

Evaluation of facial nerve function requires careful attention and comparison between the two sides of the face. The patient should be evaluated at rest and with voluntary movement. The patient should be asked to wrinkle the nose, raise the eyebrows, squeeze the eyes shut, and purse the lips to assess all branches of the facial nerve. The facial skin should be assessed, because a rash can indicate herpes zoster oticus (Ramsay Hunt syndrome). The eyes should be inspected to rule out exposure keratitis from lack of eye closure and dryness. If keratitis is suspected, ophthalmologic consultation should be obtained to prevent loss of vision. A complete neurologic examination must be done. If other neurologic deficits are found, neurology consultation is indicated. Lesions in the auditory canal should raise suspicion of herpes zoster oticus or malignancy of the external auditory canal with facial nerve involvement. Otitis externa and facial weakness can represent malignant otitis externa,...

Kayser Fleischer Ring

Syphilis Penile Lesion Images

Recurrent attacks may be less painful to painless as generalized corneal anesthesia develops. Patients with AIDS or other immunosuppressive conditions are very susceptible to this recurring infection. Figure 10-56 shows a corneal ulceration secondary to HSV infection. Marked blepharospasm is common with corneal ulceration. The most common characteristic finding of HSV-related keratitis is the dendritic ulcer on the cornea. This ulcer is the result of active viral replication in the corneal epithelial cells. Figure 10-57 shows HSV-related keratitis. The eye has been stained with rose bengal. The devitalized, swollen cells laden with the replicating virus stain brightly with this substance. Figure 10-58 shows corneal scarring in another patient as a result of a previous herpes zoster infection. Note the discrete areas of infiltrates in the cornea, as well as the darkening of the skin on the ipsilateral side from the nose to the forehead. Figure 10-58 Corneal scarring secondary to...

Episcleritis Clinical Summary

Episcleritis is a common, benign inflammatory condition of the episclera. It most often affects young adults. Most cases are idiopathic, though up to a third may be associated with systemic conditions, and some cases may also be caused by exogenous irritants or inflammatory stimuli. Associated systemic disorders include gout, systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, and herpes zoster. The symptoms, which include foreign body sensation, mild pain, photophobia, and lacrimation, are generally self-limited. Visual acuity is normal.

Special Clinical Situations

Children who are immunocompromised or infected with HIV usually should not be given live-virus vaccines. However, measles can cause severe disease and death in symptomatic HIV-infected patients. MMR (but not MMRV) is recommended at age 12 months for HIV-infected children with CD4+ T-lymphocyte counts of 15 or greater. The second dose can be given 28 days later to improve the immune response. Children with age-specific low CD4+ counts should not be given measles virus-containing vaccine (AAP Red Book, 2009, 447-455) All HIV-infected children or children of unknown status born to HIV-infected women should receive immune globulin at 0.5 mL kg to a maximum dose of 15 mL, regardless of vaccination status, if exposed to wild-type measles. HIV-infected children are also at increased risk from complications of chickenpox and zoster, and those children with CD4+ counts of at least 15 should receive two doses of varicella vaccine 3 months apart. The MMRV vaccine is not used in this situation...

Acute Disseminated Encephalomyelitis

Parainfectious ADEM usually follows onset of the infectious illness, often during the recovery phase, but because of the latency between pathogen exposure and illness it may precede clinical symptoms of infection or the two may occur simultaneously. The most commonly reported associated illness is a nonspecific upper respiratory tract infection. There have been a vast number of specific infections associated with ADEM, such as virus infections (including rubella, mumps, herpes simplex, varicella-zoster, Epstein-Barr, cytomegalovirus, influenza, and coxsackievirus) and infection with Mycoplasma, Borrelia burgdorferi, and Leptospira. Measles carries the highest risk for ADEM of any infection, occurring in 1 per 400 to 1,000 cases. Although ADEM has been reported in association with measles immunization, the risk is far lower than the risk of acquiring measles and its neurological complications.

Basilar Skull Fracture Raccoon Eyes

Raccoon Eyes Medical

Zoster ophthalmicus at different stages of evolution (fresh and crusted vesicles) in the ophthalmic division of the trigeminal nerve. Treatment with antivirals can dramatically reduce the symptoms. Figure 10-27 Herpes zoster ophthalmicus. Figure 10-27 Herpes zoster ophthalmicus. subconjunctival and yet superficial to the underlying sclera. The affected area may be either flat and diffuse or localized and nodular (1 to 4 mm in diameter). Although the cause in most cases is unclear, episcleritis also occurs in patients with inflammatory bowel disease, herpes zoster, collagen vascular disease, gout, syphilis, and rheumatoid arthritis. Figure 10-49 shows the classic features of episcleritis.

Hiv1associated Peripheral Neuropathy Syndromes

Acute demyelinating polyneuropathy, brachial plexopathy, and mononeuritides may occur at the time of acute infection or seroconversion. Acute inflammatory demyelinating polyneuropathy (AIDP) and chronic inflammatory demyelinating neuropathy (CIDP), although rare, are the most common form of peripheral neuropathy during the latent, asymptomatic, or mildly symptomatic stage of HIV- 1 disease when CD4+ cell counts are greater than or equal to 500 cells mm. 3 As immunodeficiency progresses and as CD4+ cell counts decline to the 200 to 500 cells mm3 range, the most frequent neuropathies encountered are mononeuritis multiplex and herpes zoster neuropathy. With HIV-1 disease progression (CD4+ cell counts are less than 200 cells mm 3 ), the occurrence of distal symmetrical polyneuropathy increases, as does the prevalence of other types of neuropathies such as autonomic neuropathy, mononeuritis multiplex, cranial mononeuropathies, mononeuropathies-radiculopathies associated with neoplasms, and...

What is the anatomic basis for EDX as it relates to the assessment of spinal disorders

Metatarsophalangeal Joint

It is possible for the dorsal root ganglion to be situated slightly more proximal in the foramina and be affected by direct compression or indirectly by vascular insult and edema formation. The dorsal root ganglion can also be damaged in diseases such as diabetes mellitus, herpes zoster, and malignancy. In these conditions, the sensory NCS may be abnormal. However, abnormal sensory NCS rarely occur with discogenic radiculopathies.

Epidemiology and Risk Factors HIV1 is transmitted

Clinical and laboratory features at the time of acute primary HIV-1 infection may also portend the subsequent course of disease. y Thrush, persistent fever, diarrhea, weight loss, oral hairy leukoplakia, cutaneous herpes zoster, and age greater than 35 years during this early phase of infection appear to be associated with more rapid disease progression. y Virological markers include infection with SI strain of virus, persistent p24 antigenemia, and high HIV RNA viremia after seroconversion. Immunological features that may have adverse prognostic significance include low p24 antibody titres, high gp120 antibody titres, presence of specific anti-HIV-1 IgM and IgA antibodies after infection, persistent low CD4+ lymphocyte count, high CD38 expression on CD8+ lymphocytes, and an oligoclonal T-cell response. Within 6 months of infection, most infected persons have detectable levels of anti-HIV antibodies. y A stage of clinical latency follows. Signs and symptoms of progressive immune...

Clinical Presentation And Diagnosis Classification of Pain

Neuropathic pain is considered to be a type of chronic nonmalignant pain involving disease of the central and peripheral nervous systems. Neuropathic pain might be broadly categorized as peripheral or central in nature. Examples of neuropathic pain include PHN, which is pain associated with acute herpetic neuralgia or an acute shingles outbreak. Peripheral or polyneuropathic pain is associated with the distal polyneuropathies of diabetes, human immunodeficiency virus (HIV), and chemothera-peutic agents. Types of central pain include central stroke pain, trigeminal neuralgia, and a complex of syndromes known as complex regional pain syndrome (CRPS). CRPS includes both reflex sympathetic dystrophy and causalgia, both of which are neuropathic pain associated with abnormal functioning of the autonomic nervous system. One of the newest categories of neuropathic pain is neuropathic low back pain.

Varicella Chickenpox Clinical Summary

Chickenpox results from primary infection with varicella zoster virus and is characterized by a generalized pruritic vesicular rash, fever, and mild systemic symptoms. The skin lesions have an abrupt onset, develop in crops, start on the trunk and spread outward, and evolve from erythematous, pruritic macules to papules and vesicles (rarely bullae) that finally crust over within 48 hours. The classic lesions are teardrop vesicles surrounded by an erythematous ring ( dewdrop on a rose petal ). The most common complication of varicella is occasional secondary bacterial infection, usually with Streptococcus pyogenes or Staphylococcus aureus. Other complications from varicella include encephalitis, glomerulonephritis, hepatitis, pneumonia, arthritis, and meningitis. Cerebellitis (manifested clinically as ataxia) may develop and is usually self-limited. Although several illnesses can present with vesiculobullous lesions, the typical case of varicella is seldom confused with other problems....

Sympathetic Blockade For Neuropathic Pain

Sympathetic nerve blocks have been widely used in the treatment of multiple forms of neuropathic pain, and their role has been reviewed extensively by Boas.- Despite its historical role in the treatment of complex regional pain syndromes (CRPS), convincing evidence is lacking to support the use of sympathetic blockade in other neuropathic pain states. For example, although evidence exists that sympathetic blocks can effectively treat acute herpes zoster pain, there are no randomized controlled studies supporting belief by some that they can prevent PHN or effectively treat long-standing PHN pain-

Headaches in Older Adults

Ophthalmic zoster is another type of head pain in the older adult. The pain is described as a burning, constant, piercing, shocklike pain. It follows the distribution of the trigeminal nerve. This is a difficult headache to treat, but it responds well to anticonvulsants, particularly carbamazepine and gabapentin.

Management Of Chronic Nonmalignant Pain

Patients with cancer may also suffer from chronic, nonmalignant pain that may be unrelated to the malignancy. Interpleural analgesia may be a useful adjunct to conventional analgesic therapy consisting of nonopioid and opioid analgesic medications. These pain states may include painful herpes zoster or postherpetic neuralgia in a thoracic dermatomal area, chronic pancreatitis,143 and upper extremity reflex sympathetic dystrophy and causalgia. Chronic administration of interpleural local anesthetic solution can be facilitated by subcutaneous implantation of a reservoir system.

Gram Negative Bacillary Meningitis

Viral encephalitis and meningitis may mimic bacterial meningitis on clinical presentation but often can be differentiated by CSF findings (Table 70-2). The most common viral pathogens are enteroviruses, which cause approximately 85 of cases of viral CNS infections.10 Other viruses that may cause CNS infections include arboviruses, HSV, cytomegalovirus, varicella-zoster virus, rotavirus, coronavirus, influenza viruses A and B, West Nile virus, and Epstein-Barr virus. Viral CNS infections are acquired through hematogenous or neuronal spread.10 Most cases of enteroviral meningitis or encephalitis are self-limiting with supportive treatment.41 However, arbovirus, West

Etiology and Epidemiology

Aseptic meningitis is usually the result of viral infection. Among the many types of viruses that can be involved are mumps, echovirus, poliovirus, coxsackievirus, herpes simplex, herpes zoster, hepatitis, measles, rubella, and several mosquito-borne agents of encephalitis. Fungi, most commonly Cryptococcus, are other possible agents.

Disease Source Material

Smaller nucleated populations that are sedentary or consist of those who practice a mobile settlement strategy are likely to be infected by other types of parasites. The list of potential parasites varies, depending on the degree of mobility, the presence or absence of herd animals or pets, and the size of the population. Both F. Fenner (1980) and F. L. Black (1980) think chronic or latent infections, including chickenpox (Varicella zoster) and Herpes simplex, are probable candidates for persistence in small populations. Zoonotic infections, including yellow fever (arbovirus) and tetanus (Clostridium tetani), that are transferred from animal reservoirs to humans by accidents of proximity are also likely.

Facial Nerve Palsy Clinical Summary

Facial weakness has a better prognosis for full recovery than complete paralysis. Palsies due to herpes zoster have a protracted course, and many do not fully resolve. In comparison, 80 of patients with Bell palsy due to other causes completely recover within 3 months. The recurrence rate is 7 to 10 .

Trigeminal Neuralgia Tic Douloureux

The diagnosis of tic douloureux can usually be made by history alone, but the disorder must be distinguished from other causes of facial pain syndromes such as glossopharyngeal neuralgia, which can be confused with tic douloureux that involves the third division of CNV. Herpes zoster or post-herpetic neuralgia may also provide some diagnostic confusion. Tumors or vascular lesions of the cerebellopontine angle y or within the trigeminal ganglion itself may induce pain similar to that

Far Distal Peripheral Lesions

Isolated lesions of either the glossopharyngeal or vagus nerves are unusual. As noted earlier, glossopharyngeal nerve abnormalities may be clinically undetectable unless adjacent structures are also involved. Perhaps the most common vagus nerve lesion is that involving the recurrent laryngeal nerve, resulting in ipsilateral vocal cord paresis and hoarseness of voice. The left nerve has a longer course, with its looped recurrence in the chest rather than in the neck, as on the right. The nerve passes around the aorta before returning rostrally to the larynx. The left recurrent laryngeal nerve may be compromised by an expanding aortic arch aneurysm or other intrathoracic processes, such as enlargement of the left atrium of the heart, pulmonary neoplasm, or mediastinal adenopathy. Both right and left superior or recurrent laryngeal nerves may be injured during the course of neck surgery such as thyroidectomy. Vocal cord paralysis has been described with vagal neuropathy attributed to...

Preventive Services for Older Adults

Specific preventive services that are of special interest for older adults include immunizations. The CDC recommends the zoster vaccine for all adults over age 60, pneumococcal vaccine for adults over 65, and influenza vaccine annually for adults over 50 (ACIP, 2009). Other preventive interventions of special importance target common causes of disease and disability and include multifactorial interventions for older adults that improve physical function, maintain independent living, and reduce falls (AGS, 2001 Beswick et al., 2008 Gillespie et al., 2006).


Localized to a single lumbosacral root or peripheral nerve. Pain is a prominent early manifestation when secondary to neoplasm. The differential diagnosis includes idiopathic plexitis, vasculitis, diabetic polyradiculopathy, infection (e.g., with herpes zoster or Schistosoma japonicum) hereditary liability to pressure palsies, hemorrhage, trauma, obstetrical complications, and tumor irradiation.

Viral Infection

Influenza epidemics of 1954, 1957, and 1959 in Australia and Japan have revealed positive associations between gestational exposure to this virus and development of schizophrenia. Reports of viral diseases from 1920 to 1955 in Connecticut and Massachusetts found associations between the development of schizophrenia and gestational exposure to the measles, varicella-zoster, and polio viruses (Torrey et al., 1988). Studies have also found that individuals exposed to rubella in utero, during the 1964 rubella epidemic, had a substantially greater risk of developing nonaffective psychosis than nonexposed subjects (Brown et al., 2000).

Varicella Vaccine

Two SC doses of monovalent varicella (VZV) vaccine or MMRV are indicated in children age 12 months through 12 years. The doses should be separated by at least 3 months, with the second dose routinely recommended at age 4 to 6 years before kindergarten or first grade. Persons 13 years or older who do not have evidence of immunity to varicella should receive 2 doses of VZV vaccine at least 28 days apart because MMRV is not licensed in this age group. A second dose of varicella vaccine should be given to people who previously received only 1 dose. The vaccine is generally contra-indicated in pregnant women, immunodeficient persons, or those receiving high doses of systemic corticosteroids ( 20 mg day of prednisone or equivalent) for 14 days or more. However, VZV vaccine may be considered for HIV-infected patients with a CD4+ T-lymphocyte count of 15 or greater. Vaccine-strain VZV has been rarely transmitted, and vaccinated patients who develop a rash should avoid contact with...


The TCAs alter the amount of certain neurotransmitters (serotonin and norepinephrine), which are the neurotransmitters involved in pain transmission these drugs are particularly useful for pain due to nerve injury but have roles in other pain problems as well, such as headache. In fact, a prescription of an antidepressant (with or without other pain medications, such as the opioids) is the first choice for patients with nerve pain, such as that due to shingles, diabetes, and many postoperative conditions. It is particularly useful for painful skin or hypersensitivity, which patients describe as burning, itching, tingling, shooting, numbing, and other odd qualities. This kind of pain may be facial pain or postsurgical pain, may be due to shingles (herpes zoster), or may result from a tumor pressing near nerves. The tricyclic antidepressants tend to be more effective for relatively constant nerve pain, while the anticonvulsants (see below) are first considered for more intermittent or...

Chemotherapy agents

Dysfunction may be caused by aging, systemic inflammatory diseases, a decrease in androgen hormones, surgery, ocular surface diseases (such as herpes zoster), systemic diseases, or medications that affect the efferent cholinergic nerves. Decreased tear secretion produces an inflammatory response on the ocular surface called keratoconjunctivitis sicca. This inflammation is a target for new medications that treat dry eye.32,33

Why Cancer Hurts

Pain is caused either by the effects of the cancer treatments (such as chemotherapy, surgical scarring, and radiation), the effects of the tumor's growth (intruding on neighboring tissues or invading other tissues distant from the tumor's primary site), other conditions that occur along with the cancer (such as herpes zoster, commonly known as shingles, a condition that chemotherapy patients are more susceptible to, or back pain from prolonged bed rest), or side effects from therapies and medications (such as getting on and off the radiation table, constipation, or nausea). In addition, of course, many patients with cancer may have long-standing chronic pain due to an unrelated condition such as arthritis or an old back injury. Since chronic pain is so often undertreated, many cancer patients are surprised and pleased to learn that these old pains they have been told to live with can in fact also be relieved. Many patients with nerve pain also experience...

Neuromyelitis Optica

An occasional patient may need prone and supine myelography to exclude a spinal dural-based AVM. Laboratory investigations reveal an elevated erythrocyte sedimentation rate in one third, positive antinuclear antibodies in nearly one half, and occasionally other autoantibodies. y It is reasonable to exclude syphilis, Lyme disease, and human immunodeficiency virus by laboratory testing. A chest radiograph helps to exclude pulmonary tuberculosis and sarcoidosis. CSF examination is an essential part of the evaluation for Devic's syndrome, and repeated studies are sometimes necessary to ensure that there is no infection in that the CSF findings are sometimes atypical for inflammatory demyelination. In contrast to MS, a minority of patients with Devic's syndrome (17 percent) have a normocellular CSF during the acute phase. A marked pleocytosis is often present, sometimes exceeding 100 cells. Moreover, neutrophils are commonly seen in CSF and may predominate, a...

Bullous Myringitis

It is important to distinguish bullous myringitis from acute otitis externa, which requires topical treatment, and from herpes zoster oticus, which can lead to cranial neuropathy and requires antiviral treatment. Neither of these conditions is usually limited to only tympanic membrane involvement.

Reyes Syndrome

A growing body of evidence suggests that Reye's syndrome may be a multiorgan disease due to diffuse mitochondrial injury of unknown origin.y , y Mitochondria in hepatocytes, brain capillary endothelial cells, neurons, cardiac and skeletal muscle fibers, and pancreatic cells show histological damage. Liver mitochondrial enzyme activity is low. y In one study, several depressed electron transport enzymes and lowered ATP adenosine diphosphate (ADP) ratios were documented.y Epidemiological studies strongly associate three virus infections (influenza B, influenza A, and varicella-zoster (see Chapte.r 4.1 ) with Reye's syndrome, although the mechanism of their involvement with the pathogenesis of the condition is unclear. There is no evidence of full viral replication in the two primary organs of damage liver and brain. It has been suggested that viral proteins are toxic, that the infection causes release of toxins, or that the viral infection plus...

Aseptic Meningitis

The differential diagnosis of this clinical presentation includes other causes of aseptic meningitis (enteroviruses, varicella zoster), bacterial meningitis, intracranial mass (abscess), subarachnoid hemorrhage, and other causes of headache (migraine). In HIV-related aseptic meningitis, the CSF will reveal a mononuclear pleocytosis ranging from 20 to a few hundred cell mm3 in the association of an elevated protein. The diagnosis will be made by the demonstration of HIV-1 infection, which may require repeat testing after the resolution of the acute presentation.

Subject Index

In varicella-zoster virus disease, 359 viral, 231 Conn's syndrome, 170 consumption, 339. See also tuberculosis contagious abortion, 59 continued fever, 350 convulsions, 120, 185, 215, 329-30, 360 convulsive ergotism, 120 coolie itch, 165 corneal herpes, 161 coronary artery disease, 101, 157 coronary disease, 159 coronary heart disease, 157, 159-60 cor pulmonale, 101 dwarf tapeworm, 320 dysentery, 105. See also diarrhea amebic, 19-21 bacillary, 21, 43-44 characteristics, 105 diarrheal diseases, 92-94 enteric diarrhea and, 340 dysmimia, 226 dyspepsia, 105-7, 166 dysphagia, 108, 226-27 dysphonia, 226 dyspnea in brown lung, 53 in croup, 82 dropsy and, 101-2 in histoplasmosis, 163 in myasthenia gravis, 226 in pneumonia, 256 in varicella-zoster virus disease, 359 dysuria, 161, 291 encephalitis Japanese, 36, 38, 115, 181-82, 366 lethargica, 114-16, 179, 24 0-41 Lyme disease and, 202 measles and, 212 meningitis and, 214 mumps and, 223 rabies and, 115 rubella and, 287 scrub typhus and, 356...

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