Will a full circle of "snakes around the waist" be fatal? Four groups of people are susceptible, it's not too late to see now

Author: Wang Fang and Li Zhen, Chief Physician of Chaoyang District Center for Disease Control and Prevention, Beijing

Reviewer: Jia Bin, deputy chief physician, Chaoyang District Center for Disease Control and Prevention, Beijing

gossip

" Herpes zoster, herpes zoster, crawling all over the body, killing people. " The herpes zoster that is said to be miraculous among the people is actually herpes zoster. It grows on the skin, similar to chickenpox, but it is not large, and looks like a series of red and purple blisters.

So, is it true that this disease is so severe that even gods cannot cure it?

analyze

What exactly is shingles?

What are the symptoms?

Herpes zoster (HZ) is an infectious skin disease caused by the reactivation of varicella- zoster virus (VZV) that has been latent in the dorsal root ganglia of the spinal cord or cranial nerve ganglia for a long time . It often occurs in older people and those who are immunosuppressed or immunodeficient [1].

Clinical features : Typical HZ may have prodromal symptoms such as fatigue, low fever, and loss of appetite. The affected skin may feel burning or neuralgia, and there is obvious pain sensitivity when touched. It may also have rash without prodromal symptoms. The most common sites of rash are the corresponding dermatomes of the intercostal nerves (53%), cervical nerves (20%), trigeminal nerves (15%), and lumbar sacral nerves (11%). The lesions are often arranged in a band along a peripheral nerve area, mostly occurring on one side of the body, and generally not exceeding the midline. Special types such as eye HZ, ear HZ, abortive HZ, rash-free HZ, central nervous system HZ, visceral HZ, generalized herpes, and disseminated HZ can also be seen.

Pain is the most common clinical symptom of HZ , also known as herpes-associated pain (ZAP). Both acute and chronic pain of HZ are severe and may be more severe than labor pain, spinal injury pain, rheumatoid arthritis pain, chronic cancer pain, etc. [2].

The proportion of clinical symptoms from most to least was pain (95.5%), weakness (56.0%), fever (31.1%), headache (30.3%), eye discomfort (27.3%), itching (24.2%) and dizziness (5.3%)[3].

What are the types of shingles?

(1) Herpes zoster ophthalmicus

It is more common in the elderly, manifested by unilateral eyelid swelling, which can also be bilateral; conjunctival congestion, the pain is often more severe, often accompanied by pain in the same side of the head, and can involve the cornea to form ulcerative keratitis.

(2) Herpes zoster oticus

It is caused by the virus invading the facial nerve and the auditory nerve, and manifests as herpes in the external auditory canal and pain in the external auditory canal. When the geniculate ganglion is affected and the facial nerve and the auditory nerve are invaded at the same time, a triad of facial paralysis, ear pain and herpes in the external auditory canal may occur, which is called Ramsay-Hunt syndrome.

(3) Abortive herpes zoster

Only erythema and papules appear without blisters.

(4) Herpes zoster without rash

There is only pain in the skin area but no rash.

(5) Recurrent herpes zoster

Refers to a non-first-time occurrence of herpes zoster, which is rare in people with normal immunity and has a higher recurrence rate in people with immunosuppression. Compared with the first onset, the site of recurrent herpes zoster is uncertain, and the clinical manifestations and pain can be mild or severe.

(6) Central nervous system herpes zoster

When the brain parenchyma and meninges are invaded, viral encephalitis and meningitis occur.

(7) Visceral herpes zoster

When it invades the visceral nerve fibers, it causes acute gastroenteritis and cystitis, manifested as abdominal cramps, difficulty urinating, urinary retention, etc.

(8) Generalized herpes zoster

It refers to the simultaneous involvement of two or more ganglia, with skin lesions occurring in multiple dermatomes on the contralateral or ipsilateral side.

(9) Disseminated herpes zoster

In patients with malignant tumors or extremely low immune function, the virus spreads through the blood, causing widespread varicella-like rash on the skin of the whole body except for the affected dermatomes, often accompanied by systemic poisoning symptoms such as high fever, and may also develop complications such as VZV retinitis, acute retinal necrosis, and chronic progressive encephalitis. About 10% of disseminated herpes zoster cases may be accompanied by visceral involvement, with a mortality rate as high as 55% [4].

What are the causes and pathological mechanisms of herpes zoster?

VZV belongs to the human herpesvirus alpha family and is named human herpesvirus type 3. It is a DNA virus and the smallest human herpesvirus. VZV has only one serotype and humans are the only natural host of VZV.

VZV can be transmitted through droplets and/or contact, and primary infection mainly causes chickenpox. VZV can retrograde along the sensory nerve axons, or through the fusion of infected T cells and neurons, transfer to the dorsal root ganglia of the spinal cord or cranial nerve ganglia and remain latent. When the body's resistance is reduced, VZV-specific cellular immunity decreases, the latent virus is reactivated, replicates in large quantities, and transfers to the skin through the sensory nerve axons, causing herpes zoster in the corresponding dermatomes [5].

Will a person die if shingles grows all over the body?

The rash of herpes zoster is characterized by erythema and clustered blisters distributed in a band along the unilateral peripheral nerve. The rash generally does not exceed the midline of the body, let alone grow to the opposite side, so clinically, it is almost impossible to see herpes zoster distributed along a circle. With active early and regular antiviral treatment, the skin lesions can be completely cured in about two weeks. A small number of patients will have residual herpes simplex neuralgia, but it is not life-threatening.

It can be seen that herpes zoster is an infectious skin disease, which is not fatal and will not endanger life . However, if it is secondary to a primary disease such as AIDS, it may cause death due to the primary disease.

Who is more likely to get shingles?

HZ is prevalent worldwide, with an overall incidence rate ranging from 0.19/1,000 person-years to 10.4/1,000 person-years. It is more common in people aged 50 years and above, women, people with weakened immune function, and people with chronic underlying diseases.

(1) Age is the most important risk factor for HZ . The older the age, the higher the incidence of HZ. The severity and duration of ZAP also increase with age[6]. Kawai et al. found that the incidence of HZ began to increase significantly after the age of 50, reaching (6-8)/1,000 person-years in people aged ≥60 and (8-12)/1,000 person-years in people aged ≥80. By the age of 85, about half of the people had a history of ≥1 HZ[7].

(2) Survey data from Beijing, China showed that the adjusted HZ incidence rate among women (2.4 per 1,000 person-years) was higher than that among men (1.7 per 1,000 person-years) [8].

(3) Common chronic underlying diseases are risk factors for HZ , and patients with concurrent chronic diseases have more severe and more severe HZ pain. The pain intensity of patients with underlying diseases (such as diabetes, cardiovascular disease, and respiratory disease) during the acute phase of HZ and one month after onset is significantly higher than that of patients without underlying diseases [9].

(4) People with compromised immune function are also more susceptible to diseases , including patients who have undergone bone marrow and stem cell transplantation, HIV infection, autoimmune system diseases, and cancer. Compared with the HZ incidence rate in the general population (4.8 per 1,000 person-years), the HZ incidence rate in people with compromised immune function is 1.67 to 8.96 times higher (8 per 1,000 person-years to 43 per 1,000 person-years) [10].

Do you only get shingles once in your life?

The answer is no.

A review of 130 HZ epidemiological studies in 26 countries showed that the risk of HZ recurrence is 1%-6% [11]. Immunosuppression is a risk factor for HZ recurrence . A cohort study found that the risk of HZ recurrence in immunocompromised individuals is 1.4 times that of the general population [12]. The recurrence rate in individuals with human immunodeficiency virus (HIV) is as high as 13%-26%.

A US cohort study followed up HZ patients from 2007 to 2008 until 2016 and reported a HZ recurrence rate of 10.96 (95% CI: 10.18-11.79) per 1,000 person-years, with a 10-year recurrence risk of 10.26% (95% CI: 9.36%-11.23%) [13]. In a prospective cohort study on HZ recurrence in Japan, 12,000 middle-aged and elderly people aged ≥50 years were followed up for 3 years and found that 401 cases of HZ occurred, of which 341 were primary and 60 were recurrent [14]. A follow-up study in Beijing, China found that the HZ recurrence rate was 11.1% (24/217) [8].

How to relieve pain after being sick?

Pain often persists throughout the course of herpes zoster disease. It is recommended to use different analgesics for different degrees of pain . For mild to moderate pain, acetaminophen, nonsteroidal anti-inflammatory drugs or tramadol can be used; for moderate to severe pain, drugs for treating neuropathic pain can be used, such as calcium channel modulators gabapentin and pregabalin, tricyclic antidepressants such as amitriptyline, specific usage see Table 1, or opioids such as morphine or oxycodone can be selected.

Table 1 First-line drugs for the treatment of postherpetic neuralgia

What are the preventive measures?

The best way to prevent and control the infectiousness of shingles is to get vaccinated. In addition to getting vaccinated, daily habits are also important.

▶ Prevention method 1

In daily life, we can improve our body's immunity by doing appropriate physical exercise ; keep warm , as immunity will decrease after the body is exposed to cold, and we should avoid upper respiratory tract infections;

Improve nutrition , especially for the elderly, who should eat more fresh fruits and vegetables, supplement vitamins, eat more high-protein foods such as meat, eggs and milk, and eat small and frequent meals to avoid increasing the burden on the intestines;

At the same time, we should avoid staying up late, as it can reduce the body's immunity. We should have a regular work and rest schedule and ensure adequate sleep.

▶ Prevention method 2

Vaccination is the best way to prevent the disease. There are two types of vaccines: herpes zoster live attenuated vaccine (ZVL) and recombinant herpes zoster vaccine (RZV).

In May 2019, my country approved a recombinant shingles vaccine, two doses, and on January 31, 2023, it approved the marketing of a domestically produced live attenuated shingles vaccine, one dose.

Vaccination in China can effectively prevent the occurrence or recurrence of herpes zoster and reduce the severity of herpes zoster and the risk of PHN. The immune protection effect after vaccination lasts for at least 7 years[15]. The protective efficacy for people over 70 years old is as high as 91.3%, and the protective efficacy is still 87.9% 4 years after vaccination; the effectiveness of preventing PHN in people over 70 years old is 88.8%.

in conclusion

"Herpes zoster and herpes zoster are deadly if they spread all over the body." This statement has no scientific basis. First, herpes zoster generally does not extend beyond the midline of the body, and it is almost impossible to see herpes zoster spread all over the body. Second, herpes zoster itself is not a fatal disease and will not endanger life. However, if it is secondary to a primary disease such as AIDS, it may cause death due to the primary disease.

References:

[1] Herpes zoster expert consensus working group of the Dermatology Branch of the Chinese Medical Doctor Association, National Clinical Research Center for Skin and Immunological Diseases. Chinese expert consensus on the diagnosis and treatment of herpes zoster (2022 edition) [J]. Chinese Journal of Dermatology, 2022, 55 (12): 1033-1040.

[2] KATZ J,MELZACK R． Measurement of pain[J].Surg Clin North Am,1999,79(2):231-252．

[3] BABAMAHMOODI F, ALIKHANI A, AHANGAＲKANI F, et al. Clinical manifestations of herpes zoster, its comorbidities, and its complications in north of Iran from 2007 to 2013［J］. Neurol Res Int, 2015, 2015: 896098.

[4] Source: Chinese expert consensus on the diagnosis and treatment of herpes zoster (2022 edition)

[5] GERSHON AA, GERSHON MD, BREUER J, et al. Advances in the understanding of the pathogenesis and epidemiology of herpes zoster［J］． J Clin Virol, 2010, 48 (Suppl 1): S2-7.

[6] SCHMADER KE, LEVIN MJ, GNANN JR JW, et al. Efficacy, safety, and tolerability of herpes zoster vaccine in persons aged 50-59 years［J］． Clin Infect Dis, 2012, 54(7): 922-928．

[7] Xiong Mei, Luo Zhicheng. Progress in epidemiological research on herpes zoster［J］．Journal of Practical Clinical Medicine, 2022, 26(7): 144-148．

[8] LU L, SUO L, LI J, et al. A retrospective survey on herpes zoster disease burden and characteristics in Beijing, China［J］． Hum Vaccin Immunother, 2018, 14(11): 2632-2635.

[9] HARPAZ R, ORTEGA-SANCHEZ IR, SEWARD JF. Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP)［J］． MMWＲＲRecommＲp， 2008，57(ＲＲ－5): 1-30+34

[10] CHEN SY, SUAYA JA, LI Q, et al. Incidence of herpes zoster in patients with altered immune function［J］． Infection, 2014, 42 (2): 325-334.

[11] KIM YJ, LEE CN, LEE MS, et al. Recurrence rate of herpes zoster and its risk factors: a population-based cohort study［J］． J Korean Med Sci, 2018, 34(2): e1.

[12] YAWN BP, GILDEN D. The global epidemiology of herpes zoster［J］． Neurology, 2013, 81(10): 928-930

[13] TSENG HF, BRUXVOORT K, ACKERSON B, et al. The epidemiology of herpes zoster in immunocompetent, unvaccinated adults ≥50 years old: incidence, complications, hospitalization, mortality, and recurrence［J］． J Infect Dis, 2020, 222(5): 798-806．

[14] NAKAMURA Y, MIYAGAWA F, OKAZAKI A, et al. Shozu Herpes Zoster Study Group． Clinical and immunologic features of recurrent herpes zoster (HZ)［J］． J Am Acad Dermatol, 2016, 75(5): 950-956, e1.

[15] Schmader K, Oxman MN, Levin MJ, et al. Persistence of zoster vaccine efficacy. In: Programs and Abstracts of the 48th Annual Interscience Conference on Antimicrobial Agents and Chemotherapy and 46th Annual Infectious Disease Society of America Meeting. Alexandria, VA; 2008.1310-1322, 2009.

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