shingles
Introduction
Introduction to herpes zoster Herpeszoster (HZ) is an acute herpetic skin disease caused by varicella-zostervirus (VZV). It is characterized by clustered blister distributed along the peripheral nerves of one side of the body, with banded distribution, accompanied by significant neuralgia and local lymphadenopathy, with little recurrence after healing. Patients with herpes zoster generally receive lifelong immunity to the virus. basic knowledge Sickness ratio: 0.05% Susceptible people: no special people Mode of transmission: blood-borne fluid transmission Complications: nausea and vomiting meningitis viral meningitis coma acute gastroenteritis
Cause
Herpes zoster cause
Varicella-zoster virus infection (35%):
The disease is caused by varicella-zoster virus. The virus enters the human body through the respiratory mucosa, and spreads through the bloodstream. Chickenpox appears on the skin, but most people do not have chickenpox after infection. It is a recessive infection and becomes a virus-bearing person. The virus is neurotropic. After invading the sensory nerve endings of the skin, it can move along the nerve to the ganglia of the posterior root of the spinal cord and lurk there. When the host's cellular immune function is low, such as a cold, fever, system In lupus erythematosus and malignant tumors, the virus is stimulated, causing inflammation and necrosis of the ganglion. At the same time, the reactivated virus can move along the peripheral nerve fibers to the skin to develop herpes. In a few cases, the herpes virus can spread to the front of the spinal cord. Keratinocytes and splanchnic nerve fibers cause motor nerve palsy, such as eye, facial paralysis, and symptoms of the gastrointestinal and urinary tract.
VZV virus infection (25%):
VZV is a herpesvirus, which is a neurotropic virus. The intact VZV is spherical and has a diameter of about 150-200 nm. The nucleic acid is a double-stranded DNA composed of a nucleocapsid of a icosahedron, and the outer layer is formed by a loose lipoprotein. There are virus-encoded glycoproteins, which are only infectious in the outer shell. Varicella and herpes zoster are clinically two different diseases but are caused by the same virus. About 70% of children after VZV primary infection are clinically manifested. For chickenpox, about 30% of people are latent infections, both of which are carriers.
Pathological changes (25%):
VZV enters nerve fibers from the skin mucosa, invades sensitive ganglia, forms latent infections, and does not cause harm to the body. However, once VZV is reactivated, it is infected and the mechanism of VZV reactivation is still unclear. Many factors related to the occurrence of herpes zoster, such as excessive fatigue, trauma, Hodgkin's disease and other malignant tumors, long-term use of immunosuppressive agents and corticosteroids, radiotherapy, major surgery, heavy metal poisoning and other incentives can cause the body The resistance is reduced to the lowest level, VZV can not be controlled, that is, proliferation and proliferation in the ganglion, leading to increased neurological necrosis and inflammation, clinically severe neuropathic pain, VZV reverse transmission to sensitive nerves, causing severe neuritis, and Skin-sensitive nerve endings are extended, where clusters of herpes form, where the cutaneous nerve fibers undergo degeneration on the first day of rash, indicating that infections in sensitive ganglia invade the skin, and ganglion infections can spread to neighbors The part that spreads along the posterior nerve root to the meninges, leading to soft meningitis and segmental myelitis and anterior horn Infection, causing motor nerve paralysis and other complications, with the increase of age, the response of cellular immunity to VZV is also weakened, the elderly cell-mediated immune response to VZV is selective and gradually reduced, so the elderly The incidence, severity and complications of herpes zoster are high. After the disease, lifelong immunity can be obtained and rare recurrence.
Prevention
Herpes zoster prevention
All children aged 1-14 years and some adults should be recommended to receive live attenuated varicella vaccine. Children should only take 1 dose. Adults should take 2 doses at least 2 months apart. Most adults (including those with positive medical history) have all the chickenpox. Immunization, medical and teaching personnel who are exposed to children, foreign tourists, military and postpartum women should be treated with immunity.
The varicella vaccine is extremely safe and effective. Even if it is a breakthrough, the condition is generally mild. Some rashes may occur after vaccination. The vaccine may spread during contact. For those who may be exposed to pregnant women and immune dysfunction, vaccination To remind them to be careful, people with immune dysfunction should not be vaccinated.
The strengthening of medical staff immunity and the increased use of vaccines in the population are expected to reduce the risk of nosocomial infections. However, people who have been exposed to herpes zoster still have problems. Some immunized staff may have chickenpox, which may make it possible. Infecting others, patients with chickenpox, as much as possible in the negative pressure room, strictly isolated, patients who are susceptible to chickenpox but can not be discharged from the hospital should be isolated 10 to 20 days after exposure, for the patient population, screening for susceptibility can be used latex Agglutination test, but the prediction of vaccine protection is not reliable. Some susceptible people, especially those with immune dysfunction, should be passively immunized with varicella-zoster immunoglobulin (VZIG), 7 days after exposure. Acyclovir should be considered for oral administration for 7 days. This will prevent children who have been exposed to the disease from becoming ill.
Immune serum globulin can not prevent chickenpox, it must use a huge amount to receive obvious effects. If it is necessary to prevent the disease or reduce the disease, VZIG is applied. The selected objects are:
1 susceptible person;
2 The risk of comorbid chickenpox is very high;
3 There has been obvious contact. Anyone who has met the first two and has had contact with the home should be prevented from being disposed of. Apart from the situation at home, it is often difficult to determine the intimacy of other types of contacts. For reference, the American Academy of Pediatrics or the Center for Disease Control and Prevention The guidelines are formulated to be helpful.
The situation that should be treated as a high-risk patient is:
1 in an immune dysfunction state due to other diseases or immunosuppressive therapy;
2 babies born to women who develop chickenpox within 5 days of delivery or within 2 days after delivery;
3 some premature babies;
4 bone marrow transplant recipients (regardless of susceptibility);
5 some adults.
The history of varicella is generally reliable in both adults and children. Children with negative medical history are generally susceptible. Adults with negative medical history have serological tests that are practical, but can not delay the application of VZIG. VZIG should be given as soon as possible, because it will be applied after 96 hours, that is, invalid.
The decline of resistance is an important factor in the pathogenesis of herpes zoster. Therefore, in spring, work and rest should pay attention to rest, drink plenty of water, eat more fresh fruits and vegetables, exercise more and improve resistance. This is the key to prevention. Inexplicable skin pain or herpes should be treated as soon as possible in regular hospitals. In the acute period of the first few days of the disease, the nerve cells infected by the virus are directly administered by interventional techniques to block the nerve conduction to the pain sensation. An ideal means of treatment at present.
Complication
Herpes zoster complications Complications nausea and vomiting meningitis viral meningitis coma acute gastroenteritis
If the herpes is damaged, it may cause bacterial infection. If the herpes zoster lesion occurs in a special part, such as the eye, it may cause serious consequences. If the bacterial infection is secondary, it may cause full ocular inflammation and even meningitis. There are sequelae such as decreased vision, blindness, facial paralysis, etc. Head herpes zoster is mostly in the front of the head, the first branch of the trigeminal nerve, which can cause hair loss and permanent scarring.
After the healing of herpes zoster skin damage, the pain can still last for a period of time. In some elderly patients, neuralgia can last for several months or more, which can seriously affect sleep and mood; the pain is heavier, and the longer duration can lead to mental anxiety. Depression and other manifestations.
Herpes zoster can occur in the trigeminal ganglion of the face. There is a nerve fiber in the trigeminal nerve, that is, the ocular nerve fiber. Some nerve fibers are distributed in the cornea of the human eyeball, and the conjunctiva is so as to the entire eyeball. If the nerve fiber in this part is infected with herpes virus Infection, keratitis, corneal ulcer, conjunctivitis can occur, patients can be afraid of light, tears, eye pain, resulting in decreased vision, severe cases of full eye inflammation and blindness.
When the herpesvirus infects the motor nerve fibers in the facial nerve, facial paralysis occurs. The affected side of the eye cannot be closed, the side of the affected side is dull, the mouth angle is skewed to the healthy side, and the insufflation can not be performed.
Occurred in the auricle, herpes zoster in the ear canal, there will be symptoms of inner ear dysfunction, the patient showed dizziness, nausea, vomiting, hearing impairment, nystagmus and so on.
When the herpesvirus invades the central nervous system, the brain's parenchyma and meninges, from the nerve roots at the spinal cord, viral encephalitis and meningitis occur, manifesting as severe headache, jet-like vomiting, convulsions, limb convulsions, And confusion, coma and life-threatening.
When the herpes virus invades the splanchnic nerve fibers from the nerve roots in the spinal cord, it can cause acute gastroenteritis, cystitis, prostatitis, manifested as abdominal cramps, dysuria, and urinary retention.
Therefore, it is necessary to timely check the patients with herpes zoster to detect and treat the complications of herpes zoster in time.
Symptom
Herpes zoster symptoms Common symptoms Nose or nose appears... Nausea after herpes Herpes, earache, ear ache, blistering, recurrent blisters, herpes zoster-like appearance, deafness, inflammatory lesions
According to the unilateral distribution of vesicular lesions along the peripheral nerve with neuralgia, the diagnosis is not difficult, the disease should be distinguished from herpes simplex, the latter is often distributed at the junction of the skin and mucous membranes, independent of the distribution of external peripheral nerves, easy to relapse , the pain is not obvious, in the herpes zoster prodromal period and herpes simplex, sometimes misdiagnosed as intercostal neuralgia, pleurisy or acute abdomen, etc., should be noted.
The pathogen of the disease is a herpes simplex virus, which is consistent with the varicella virus, also known as varicellazoster virus (VZV).
The lesions of the skin are mainly in the epidermis, and the vesicles are located in the deep layers of the epidermis. Balloon-like epidermal cells with obvious swelling are visible in the blister and at the edges. Eosinophilic nucleus inclusions are seen in the degenerated nucleus, and lesions are also present in the ganglia corresponding to the rash. It is characterized by segmental poliomyelitis of the posterior column of the spinal cord, and a severe inflammatory reaction in the ganglia and the posterior root of the nerve. The sensory nerve fibers in the dermis also show significant degeneration shortly after the appearance of the rash.
Often there are mild prodromal symptoms such as fever, fatigue, general malaise, loss of appetite, localized lymph nodes and burning of the affected area, feeling allergies or neuralgia.
The typical skin lesions are miliary to soy papules that are clustered without fusion on the basis of inflammation. The papules then become blister, the blister fluid is clear, the blister wall is tight, surrounded by redness, and the lesions are distributed along the peripheral nerves, arranged in a belt. Shape, very characteristic, has diagnostic value, the skin between the clusters of vesicles is normal, if there is no secondary infection, after a few days, the blister dry and crusted, leaving a temporary pigmentation, generally no scar, due to immune status The difference is often atypical, but has different names. For those with neuropathic pain and no rash, it is called rash-free herpes zoster; only erythema, papules and no blister are called rash-free herpes zoster; only Red spot, papules do not develop into blisters; blisters are bullous; hemorrhagic is hemorrhagic; necrosis is gangrenous; skin lesions are spread by viral blood sources; Viscera such as the lungs, liver or brain called herpes zoster pneumonia, hepatitis or encephalitis, very few can involve more than two ganglia to produce bilateral or ipsilateral multiple nerve distribution damage.
Neuralgia is one of the characteristics of this disease. It has diagnostic value. It often occurs before or after rash, and can gradually increase. Children have mild or no pain. Older patients are often obvious and paroxysmal. Intensified, unbearable, and can last for months or longer after the lesion has subsided.
Herpes zoster virus is most likely to invade the intercostal nerve. In addition to the thoracic nerve, the intercostal nerve is divided into the thoracic nerve, and the other parts of the spinal nerve are combined with several adjacent spinal nerves to form the neck, arm waist, and iliac crest. The plexus, and then a number of peripheral nerves are distributed from each nerve plexus, which are distributed to the neck, upper, lower limbs and perineal skin. Therefore, after the onset of the thoracic nerve, the intercostal nerve can clearly reflect the segment of the lesion, and the neck Department, after the onset of lumbosacral nerve, only the area of spinal neuropathy can be learned from the lesion.
The cranial nerve has its specific distribution area. The more commonly involved are the trigeminal nerve and the face. The auditory nerve is the most common in the trigeminal nerve. It is more common in the elderly, often accompanied by severe pain. The skin lesions are distributed on one side of the forehead. If there is a rash on the tip of the nose, it is easy to be complicated with ophthalmia, which can lead to blindness. Therefore, special attention should be paid to the cornea when the eye branch is damaged, so as to take appropriate measures early. When the maxillary branch is involved, blisters appear in the uvula and tonsil. When the mandibular branch is involved, blisters appear in the front of the tongue, buccal mucosa, etc., and the auditory nerve is invaded by the virus. Blisters may appear in the external auditory canal or tympanic membrane, and there may be tinnitus, deafness, dizziness, nausea, vomiting, nystagmus, and paralysis of the side. Symptoms such as the disappearance of taste in the front 2/3 of the tongue, also known as herpes zoster, the facial paralysis, earache and herpes simplex of the external ear canal are also known as Ramsey-Hunt syndrome.
If the cranial nerve or the cervical ganglion is invaded by the virus, it may cause herpes zoster encephalitis, which may cause headache, vomiting, convulsions and other symptoms.
In addition, the virus invades the splanchnic nerve fibers of the autonomic nerves from the posterior root ganglia of the spinal cord, and can produce symptoms of the corresponding system, such as gastroenteritis, cystitis, peritonitis, and pleurisy.
The course of the disease is usually about 2 to 3 weeks. Patients with general or recurrence often suggest immunodeficiency, and attention should be paid to the possibility of a potential immunodeficiency disease or malignancy.
Before the appearance of a typical rash, there are often mild itching, stinging, burning sensation, skin sensation or significant neuralgia, individual fever, general malaise and other systemic symptoms, usually appear in the first 2 to 5 days after the prodromal symptoms appear. Red spots of different sizes, clustered miliary papules on the erythema, blisters, herpes, blister wall tension, clear and transparent contents, blister around the blush, blister not blending, blisters can be broken and smashed, number In the future, dry and crusted, the skin will fall off and have color spots. If there is no infection, there will be no scars. The clustered vesicles are distributed along the unilateral peripheral nerves. The damage is light, there are 2 to 3 groups. Up to 10 groups, each group can be fused into a large piece, the rash generally does not exceed the midline, and rarely exceeds the contralateral side of the small branch crossing the contralateral nerve, most patients with local lymphadenopathy Great pain (Figures 1-3)
The disease mostly invades the intercostal nerve, cervical plexus nerve, trigeminal nerve, lumbosacral nerve, etc. The trigeminal nerve is most common in the first eye nerve, accounting for more than half of the eye, often with eye symptoms, and the maxillary branch can cause pharynx Department, sag, tonsil rash; mandibular branch is involved in the anterior part of the tongue, buccal mucosa and rash on the bottom of the mouth, may also involve the third and IV cranial nerves, causing brain stem and other central nervous system involvement, manifested as headache, vomiting, convulsions Such symptoms, if the anterior horn motor neurons are involved, can cause muscle weakness or skin irritation of the corresponding parts, which can last for several weeks to several months, but can recover after recovery. If sympathetic nerves, parasympathetic splanchnic nerve fibers are involved, Causes gastrointestinal and urinary tract symptoms, manifests abdominal pain, frequent urination or difficulty urinating.
Significant neuralgia is a characteristic symptom of this disease. It usually occurs before the rash or at the same time as the rash. The greater the age, the more severe the pain. Most elderly patients often have stubborn neuralgia due to fibrosis caused by ganglion inflammation. For months to years, severe neurological paralysis can be left for a long time.
The course of the disease, children and young people about 2 to 3 weeks, the elderly about 3 to 4 weeks, very few recurrence after the recovery, severe cases, especially rash outbreaks often suggest immune function defects and potential malignant tumors, should be checked early Find.
Clinical manifestations of herpes zoster:
1. Incomplete herpes zoster (stunned type) There is no local rash or only erythema or papules, no typical blisters, and quickly resolves.
2. Bullous herpes zoster can appear as bullae with a diameter greater than 0.5 cm, such as the size of a cherry.
3. Hemorrhagic herpes zoster blister content is bloody or bloody.
4. The center of gangrenous herpes zoster rash can be necrotic, dark brown suede, not easy to peel, healing can leave scars, more common in the elderly and malnourished patients.
5. Pan-type (distributed) herpes zoster is serious, there are reports of death, this type is rare, local rash to spread the body for about 1 to 10 days, vesicles cluster, there is a tendency to fusion, can affect the lungs, brain Such organs, often accompanied by high fever, headache and other symptoms of central nervous system involvement, more common in debilitated elderly and patients with malignant lymphoma.
6. Eye herpes zoster (trigeminal nerve branch) More common in the elderly, severe pain, can involve the cornea, conjunctiva, iris ciliary body, sclera and other inflammation, and even full ocular inflammation, resulting in blindness, ascending infection can cause meningitis And cause death.
7. Herpes zoster (Ramsay hunt syndrome) is facial hernia, deafness, external ear canal herpes triad, VZV invades the posterior root of the genic ganglia, causing facial nerve, auditory nerve involvement, manifested as unilateral hernia, external ear canal herpes, tympanic herpes With ear pain, tinnitus, deafness, mastoid tenderness, 1/3 of the tongue in front of the taste disorder, often accompanied by dizziness, nausea, vomiting, nystagmus and other symptoms.
8. Visceral herpes zoster is rare. VZV invades the posterior root ganglia of the spinal nerve and causes sympathetic and parasympathetic visceral nerve fiber innervation area rash, gastrointestinal and urinary tract symptoms, segmental gastroenteritis, cystitis; If the chest and peritoneum are invaded, it may cause chest, peritoneal inflammation or effusion.
TCM pathogenesis and treatment
Herpes zoster is equivalent to the "waisted fire Dan" of the Chinese medicine, "snake sore", "spider sore", such as "medical medicinal Jin Jian · surgical heart disease to blame the vernacular solution" wrapped around the waist Dan Dan records: "This disease is a common name snake String sores, there are different wet and dry, red and yellow, are like a lot of beads, dry red and red, shaped like a cloud, on the wind millet, itchy heat; wet yellow and white, blister size, The rotten water is more painful than the dry ones, and the "Surgical Qi Xuan" spider sore records: "This sore is born in the skin and is similar to the leeches, reddish and painful, 5, 7 piles, can also be scattered" Some people call it the "waisted dragon".
TCM pathogenesis: This disease has many factors, such as liver qi stagnation, stagnation and heat, or due to unhealthy diet, spleen loss of health, dampness and heat, and toxic and evil.
Dialectical classification:
Hepatobiliary heat type: local skin lesions are bright red, edema, blister wall tension, burning sting, conscious mouth bitter throat, thirst, irritability, poor appetite, dry or uncomfortable stool, short red urine, red tongue, The moss is thin yellow or yellow thick, and the pulse string slides slightly.
Spleen and damp lung heat type: local skin lesions are lighter in color, more blisters, looser walls, slightly lighter pain, no thirst or thirst for drinking, no diet, bloating after eating, sticky stools, and yellow urine. Female vaginal discharge increased, pale red body fat, thick white or greasy fur, slow or slippery pulse.
Qi stagnation and blood stasis type: After the rash subsides, the local pain is still more than the tongue, the tongue is dark, the fur is white, and the pulse string is fine.
Examine
Herpes zoster examination
Like the blood of patients with chickenpox, the total number of granulocytes and the proportion of neutrophils in normal herpes zoster patients are normal.
The main changes in histopathology are found in the nerves and skin. Like herpes simplex, cell degeneration is the main cause. The neurological damage of this disease begins in one or several adjacent dorsal root ganglia or cerebral ganglia and is initiated by severe inflammatory infiltration. Corresponding sensory spinal nerves or cranial nerves, inflammation leads to the destruction of nerve cells in the ganglion. In this disease, the affected ganglia are examined by light microscopy and electron microscopy or cultured with monkey kidney cells to prove that they contain intranuclear eosin. Body, degeneration can be extended from the affected ganglia along the sensory nerve to the skin. Chickenpox is located deep in the epidermis, which is multi-atrial, contains a transparent serum, and the old ones have red blood cells and neutrophils, in the chickenpox and its edges. Expanded balloon-like cells can be found. Due to the degeneration of the spine cells, the edema around the blisters is obvious, the dermal papilla is swollen, the capillaries are dilated, and there are polymorphonuclear leukocytes, lymphocytes or plasma cells infiltrating around the blood vessels, hair follicles and nerves. Eosinophilic intranuclear inclusions (Lipchuetz bodies) can be found in vesicular epithelial cells or denatured nuclei, especially in qi Like the nucleus more common.
In systemic varicella or herpes zoster, focal necrotic areas containing nucleus eosin inclusion bodies can be found in different organs, especially in the liver, kidney, lung and adrenal glands, and nuclear nucleus seen in the vascular endothelium. Eosin inclusions can be used as evidence of hematogenous dissemination. Varicella is different from this disease in that there is no nuclear eosin inclusion in the dorsal root ganglia. In the case of herpes zoster pneumonia, the autopsy is in the epithelium of the bronchi. Inclusion bodies of intranuclear eosin are shown in cells and alveolar cells.
Staining with acetylcholinesterase demonstrated that the dermal neural network appeared to be significantly reduced in the skin stage of herpes zoster infection, which can be considered to be due to the presence of the virus, because in the dermis under the blister, small nerves Inclusion bodies of eosinophils have been confirmed in neuromembrane cells; in addition, electron-microscopic examination of viral mature particles and severe destruction of unmyelinated nerve fibers have been observed in axons of unmyelinated dermal nerves.
Diagnosis
Diagnosis of herpes zoster
It is generally not difficult to diagnose a detailed medical history with a detailed medical history.
In the prolapse of herpes zoster and herpes zoster, sometimes misdiagnosed as intercostal neuralgia, pleurisy or acute abdomen, should be noted.
The disease sometimes needs to be differentiated from herpes simplex, the latter occurs at the junction of the skin and mucous membranes, the distribution is not regular, the blister is small and easy to break, the pain is not, more common in the process of fever (especially high fever), often easy to relapse .
Occasionally, it is confused with contact dermatitis, but the latter has a history of exposure. The rash has nothing to do with nerve distribution, consciously burns, itchy, and has no neuralgia.
In the prodromal period of herpes zoster and rash-free herpes zoster, patients with neuropathic pain are easily misdiagnosed as intercostal neuralgia, pleurisy and acute appendicitis. It is necessary to pay attention. Herpes simplex is usually in the same area. A history of multiple recurrences, but not in patients with herpes zoster with no obvious immunodeficiency, is the only reliable method for the differential diagnosis of virus isolation or detection of VZV from blister fluids.
