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Photo ID Visual clues to the diagnosis of infectious Disorders in Elderly Persons: Identifying Viral Infections

Noah S. Scheinfeld, MD, JD

[Infect Med. 2007;24:479-481]

Key words: Herpes zoster Varicella-zoster

ge-related changes, such as a Figure 1 – This weakened , thin- , consisting Aning integument, and dimin- of clusters of ished adnexal structures, heighten the vesicles, was identified as risk of skin in elderly patients. herpes zoster. For example, herpes zoster is more often seen in older adults. Although herpes simplex is more common in younger pa- tients, it can result in serious complica- tions in elderly persons. On the following pages, I provide a pictorial guide to the various manifes- tations of herpes zoster and (HSV) infection in older adults.

Herpes zoster (shingles) This infection is caused by reactivation of varicella-zoster virus (VZV), which may remain latent in the dorsal root and cranial nerve ganglia for decades. Reactivation often oc- curs for no apparent reason, although and immu- nosuppression may increase the risk. Herpes zoster may begin with a systemic constellation of mild symptoms that include , anorexia, and lassi- tude. Unilateral dysesthesia and along the site of the future eruption usually precede the rash by 1 to 3 days. The rash consists of clusters of grouped , papulo- vesicles, vesicles (Figure 1), or erosions on an - tous base, or urticaria-like plaques (Figure 2) or erosions (Figure 3). Sometimes the eruption manifests as a plaque of crusted pustules in a (Figure 4). Elderly pa- tients, who are relatively immunosuppressed, may have

Dr Scheinfeld is assistant clinical professor of at Columbia University College of Physicians and Surgeons and assistant attending Figure 2 – Herpes zoster can manifest as urticaria-like plaques, as it physician at St Luke’s–Roosevelt and Beth Israel Hospitals in New York. did in this patient.

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PhotoID continued

Figure 3 – These clude , , direct fluorescent anti- facial erosions were body (DFA) testing, and skin biopsy. DFA testing is more caused by herpes sensitive than conventional viral cultures because of the zoster. lability of VZV. Variations of herpes zoster include scattered vesicles (satellite ) that occur outside 1 or 2 dermatomes. A minority of patients may experience dysesthesia without urticarial plaques or vesicles (zoster sine herpeticum). Treatment consists of a 7-day course of acyclovir, vala- cyclovir, or . Atypical regimen for elderly per- sons is valacyclovir, 1 g tid. Antiviral agents may reduce the duration of postherpetic .1,2 This condition, which leads to chronic pain that is often refractory, is par- ticularly frequent and severe in elderly persons. Thera- peutic options include patches; opiates; and a variety of anticonvulsant, antidepressant, and antipsy- chotic agents. Alive zoster has been approved for prevention of in patients aged 60 years and older. Some subtypes of herpes zoster require intravenous antiviral therapy. Ophthalmic herpes zoster, which in- volves the first division of the fifth cranial nerve, may cause scarring of the cornea and secondary panoph- thalmitis, with subsequent loss of vision. Characteristic a prolonged course of herpes zoster and are more sus- signs include vesicles on the tip of the nose and an ocular ceptible to secondary infections. foreign-body sensation. Herpes zoster remains infectious until all the vesicles Ramsay Hunt syndrome is herpes zoster of the genic- and pustules have evolved into crusted plaques; they re- ulate , which lies at the genu of the seventh solve over the course of 2 to 3 weeks. The differential di- nerve. It is characterized by ipsilateral facial palsy similar agnosis includes insect bites, urticaria, HSV infection, and to Bell palsy and can cause deafness. Vesicles develop in . the external auditory meatus, on the pinna, and some- Diagnostic testing is sometimes useful. Options in- times in the soft . Glossopharyngeal and vagal

Figure 4 – This plaque of crusted pustules in a dermatome was diag- Figure 5 – This patient has disseminated herpes zoster, which involves nosed as herpes zoster. more than 3 dermatomes or more than 20 lesions outside a dermatome.

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Figure 6 – This patient has , an infection caused by Figure 7 – The genital erosion seen on this patient was caused by herpes simplex virus type 1. herpes simplex virus type 2.

zoster affects the jugular and petrosal ganglia, which are vesiculopustules and crusts. The infections are of partic- adjacent and often involved simultaneously, although in- ular concern when they spread to skin whose integrity is dividual ganglial involvement can occur. undermined by xerosis or eczema. A painful vesicular rash typically affects the palate, Bullous also presents with vesicles, but posterior tongue, epiglottis, tonsillar pillars, and occa- they are not grouped, are larger, and do not contain giant sionally, the external . The unilateral distribution helps cells on biopsy or Tzanck test. Darier disease (keratosis distinguish this variation of herpes zoster from HSV in- follicularis) can also manifest with widespread crusted fection and . papules, vesicles, and plaques; culture and biopsy help Disseminated herpes zoster involves more than 3 der- confirm the diagnosis. HSV infections may spread into the matomes or has more than 20 lesions outside a derma- skin of elderly persons affected by , tome; it particularly affects patients with non-Hodgkin Grover disease, or Darier disease. In elderly and debilitat- or HIV infection. It manifests as generalized ed patients, HSV infection can result in refractory flat vesicles, papulovesicles, or erosions (Figure 5). Dissemi- sacral or perioral ulcers with peripheral . O nated herpes zoster may involve internal organs; it pre- sents as , pneumonitis, meningoencephalitis, REFERENCES , or motor . 1. Alper BS, Lewis PR. Does treatment of herpes zoster prevent or short- Ophthalmic herpes zoster, Ramsay Hunt syndrome, en postherpetic neuralgia? J Fam Pract. 2002;49:255-264. 2. Lilie HM, Wassilew S. The role of antivirals in the management of neuro- and disseminated herpes zoster are treated with intra- pathic pain in the older patient with herpes zoster. Drugs Aging. 2003;20: venous acyclovir, 10 mg/kg every 8 hours, with renal 561-570. adjustment of dosing as necessary.

SUGGESTED READING Herpes simplex virus infection • Alper BS, Lewis PR. Treatment of postherpetic neuralgia: a systematic review of the literature. J Pharm Pract. 2002;51:121-128. Infections caused by HSV appear as grouped vesicles on • Gavazzi G, Krause KH. Ageing and infection. Lancet Infect Dis. 2002;2:659-666. an erythematous base and are less common in healthy • Laube S. Skin infections and ageing. Ageing Res Rev. 2004;3:69-89. • Lertzman BH, Gaspari AA. Drug treatment of skin and soft tissue infections in elderly patients than in younger ones. HSV type 1 causes elderly long-term care residents. Drugs Aging. 1996;9:109-121. herpetic , herpes labialis (Figure 6), herpetic ker- • Naesens L, DeClerca E. Recent developments in herpesvirus therapy. Herpes. 2001;8:12-16. atoconjunctivitis, and . HSV type 2 causes • Nagami P. Management of common infections in the elderly outpatient. , genital erosions (Figure 7), and systemic Geriatrics. 1986;41:67-69, 74-77, 80. • Weinberg JM, Scheinfeld NS. Cutaneous infections in the elderly: diagnosis and infections in immunocompromised patients. management. Dermatol Ther. 2003;16:195-205. HSV infections may affect elderly patients with leu- • Weinberg JM, Vafaie J, Scheinfeld NS. Skin infections in the elderly. Dermatol Clin. kemia and lymphoma. These infections, called Kaposi 2004;22:51-61. varicelliform eruptions, appear as large areas covered by

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