Correspondence

Herpes Zoster

N Engl J Med 2003; 348:2044-2045May 15, 2003

Article

To the Editor:

Gnann and Whitley (Aug. 1 issue)1 state that serologic testing for the human immunodeficiency virus (HIV) may be appropriate for healthy persons with herpes zoster who are younger than 50 years of age. Herpes zoster develops in more than 20,000 apparently healthy children each year in the United States. Children with a history of chickenpox at less than one year of age are at increased risk.2-5 Studies of herpes zoster in normal children6 have not shown occult underlying problems and have led to the conclusion that laboratory studies in healthy children with herpes zoster are not helpful. It should be noted that in Africa, where HIV infection is epidemic, herpes zoster may be the harbinger of the infection, but this relation has not been reported in the United States. Herpes zoster in children requires a thorough history taking and physical examination, as well as careful follow-up. For most children, herpes zoster is an unlucky and miserable event that should not be compounded by serologic testing for HIV or other laboratory tests.

Henry M. Feder, Jr., M.D.
University of Connecticut Health Center, Farmington, CT 06030-2918
feder@nso2.uchc.edu

6 References

1. 1

   Gnann JW Jr, Whitley RJ. Herpes zoster. N Engl J Med 2002;347:340-346
   Full Text | Web of Science | Medline

2. 2

   Guess HA, Broughton DD, Melton LJ III, Kurland LT. Epidemiology of herpes zoster in children and adolescents: a population-based study. Pediatrics 1985;76:512-517
   Web of Science | Medline

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   Donahue JG, Choo PW, Manson JE, Platt R. The incidence of herpes zoster. Arch Intern Med 1995;155:1605-1609
   CrossRef | Web of Science | Medline

4. 4

   Baba K, Yabuuchi H, Takahashi M, Ogra PL. Increased incidence of herpes zoster in normal children infected with varicella zoster virus during infancy: community-based follow-up study. J Pediatr 1986;108:372-377
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   Liang MG, Heidelberg KA, Jacobson RM, McEvoy MT. Herpes zoster after varicella immunization. J Am Acad Dermatol 1998;38:761-763
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   Smith CG, Glaser DA. Herpes zoster in childhood: case report and review of the literature. Pediatr Dermatol 1996;13:226-229
   CrossRef | Web of Science | Medline

To the Editor:

Would Drs. Gnann and Whitley comment on whether or not isolation procedures are necessary when latent activation occurs in a setting such as an assisted-living facility or a nursing home?

E. Ford Crider, M.D.
2664 Drummond Rd., Toledo, OH 43606

Author/Editor Response

Although our recommendation regarding serologic testing for HIV was directed primarily at adults younger than 50 years of age with herpes zoster, Dr. Feder raises an interesting question regarding such testing in children with shingles. Herpes zoster certainly occurs in pediatric populations, although the incidence is much lower than that among older adults1; the frequency will most likely continue to decrease with the increasingly widespread use of the varicella vaccine. Herpes zoster occurs at a dramatically higher frequency among HIV-infected persons, including children.2 In a population of 480 HIV-infected children, 117 episodes of varicella–zoster virus (VZV) infection were identified in 73 patients, of whom 38 (52 percent) had recurrent VZV infections.3 Most children (and adults) who present with herpes zoster are not infected with HIV. However, we think that it is reasonable for a physician to at least consider the possibility of undocumented HIV infection in a young child in whom herpes zoster develops shortly after an episode of varicella, especially if the HIV serologic status of the mother is unknown.

Dr. Crider asks about isolation procedures for patients with herpes zoster. VZV is shed from the cutaneous lesions of herpes zoster and can cause varicella in seronegative persons; susceptible persons should therefore avoid close contact with patients with herpes zoster until the cutaneous lesions are crusted. However, seropositive persons (who have previously had chickenpox or received the varicella vaccine) are not at risk for acquiring VZV infection from a patient with herpes zoster. The risk of transmission of VZV is much lower from a patient with herpes zoster than from a patient with varicella. A combination of respiratory and contact isolation is recommended for hospitalized patients with herpes zoster, primarily to minimize the risk of transmission to immunocompromised patients.4,5 Health care personnel who have had varicella or herpes zoster or have received the varicella vaccine are considered to be immune and can safely provide care for a patient with herpes zoster. Decisions regarding isolation precautions in a nursing home or assisted-living setting will depend on the population in the facility. Patients with acute herpes zoster should remain isolated from persons with impaired cell-mediated immunity (e.g., those with HIV infection or lymphoproliferative cancers or those receiving immunosuppressive drugs) who are known to be seronegative for VZV or whose serologic status is unknown. In a group of immunocompetent older adults known to have had chickenpox, isolation is not mandatory.

John W. Gnann, Jr., M.D.
Richard J. Whitley, M.D.
University of Alabama at Birmingham, Birmingham, AL 35294

5 References

1. 1

   Donahue JG, Choo PW, Manson JE, Platt R. The incidence of herpes zoster. Arch Intern Med 1995;155:1605-1609
   CrossRef | Web of Science | Medline

2. 2

   Gershon AA, Mervish N, LaRussa P, et al. Varicella-zoster virus infection in children with underlying human immunodeficiency virus infection. J Infect Dis 1997;176:1496-1500
   CrossRef | Web of Science | Medline

3. 3

   von Seidlein L, Gillette SG, Bryson Y, et al. Frequent recurrence and persistence of varicella-zoster virus infections in children infected with human immunodeficiency virus type 1. J Pediatr 1996;128:52-57
   CrossRef | Web of Science | Medline

4. 4

   Garner JS. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol 1996;17:53-80[Erratum, Infect Control Hosp Epidemiol 1996;17:214.]
   CrossRef | Medline

5. 5

   Saiman L, Weber DJ. Prevention of nosocomial transmission. In: Arvin AM, Gershon AA, eds. Varicella–zoster virus: virology and clinical management. New York: Cambridge University Press, 2000:477-99.
   

Citing Articles (4)

Citing Articles

1. 1

   E W Chan, S Sanjay. (2009) Herpes zoster ophthalmicus complicated by incomplete ophthalmoplegia and a neurotrophic ulcer. Eye 23:4, 994-994
   CrossRef

2. 2

   Richard A. Harrigan, Michael A. DeAngelis. 2007. Evaluation and Management of Patients with Chest Syndromes. , 1-16.
   CrossRef

3. 3

   Ralph P. Insinga, Robbin F. Itzler, James M. Pellissier, Patricia Saddier, Alexander A. Nikas. (2005) The Incidence of Herpes Zoster in a United States Administrative Database. Journal of General Internal Medicine 20:8, 748-753
   CrossRef

4. 4

   Henry M. Feder, Diane M. Hoss. (2004) Herpes Zoster in Otherwise Healthy Children. The Pediatric Infectious Disease Journal 23:5, 451-457
   CrossRef