Ultrasound-Guided Cervical Nerve Root Block for the Treatment of Acute Cervical Herpes Zoster: A Randomized Controlled Clinical Study.

OBJECTIVES: To evaluate the efficacy and safety of ultrasound-guided cervical nerve root block (CRB) on acute pain and its preventive effects on post-herpetic neuralgia (PHN) in patients with cervical herpes zoster (HZ). METHODS: 140 recruited participants were randomized 1:1 to receive ultrasound-guided CRB with either mixed drug liquid (treatment group) or similar looking placebo (placebo group). All patients received a 7-day course of oral antiviral treatment, pregabalin, and analgesics as needed. The primary efficacy was assessed on the basis of HZ burden of illness (HZ-BOI) scores over 30 days (BOI-30AUC ). Secondary outcomes included HZ-BOI scores through 30 to 90 days (BOI-30-90AUC ) and 90 to 180 days (BOI-90-180AUC ), quality of life (QoL) outcomes, concomitant analgesic consumption, and the incidence of PHN. Adverse events were recorded to evaluate safety. RESULTS: The BOI-30AUC values were 92.55 and 112.72 for the treatment and placebo groups, respectively (P < 0.01). Both the BOI-30-90AUC and BOI-90-180AUC in the treatment group were lower than those in the placebo group (P < 0.01). The incidence of PHN at 90 days was significantly less than that at 180 days in the treatment group (P = 0.036). A better improvement in QoL was found in the treatment group (P < 0.05). There was a greater decrease in analgesic use in the treatment group as compared to the placebo group (P < 0.05). No serious adverse events were observed. CONCLUSIONS: Ultrasound-guided CRB represented an early intervention and preventive strategy to reduce the BOI due to acute HZ in the cervical dermatome region, and might be feasible to reduce the incidence of PHN.

Varicella zoster virus infection is an unusual cause of splenic rupture.

A 22-year-old man presented with a 1-day history of severe abdominal pain. He developed a generalised vesicular rash 12 h prior to admission. On examination, he was maximally tender with peritonism in the lower abdomen. Working diagnosis was perforated appendix and a decision to investigate with CT was made, which showed intra-abdominal haemorrhage likely arising from a ruptured spleen. After a period of observation, he subsequently underwent laparotomy and emergency splenectomy. Viral PCR from vesicular fluid was positive for varicella zoster virus. Viral serology was otherwise negative.

Prevalence and clinical consequences of herpes simplex virus type 1 DNA in human cornea tissues.

BACKGROUND: We determined the prevalence and clinical consequences of herpes simplex virus (HSV) type 1 (HSV-1), HSV type 2 (HSV-2), and varicella-zoster virus (VZV) in cornea tissues obtained after penetrating keratoplasty (PKP) was performed. METHODS: The excised corneas of 83 patients with a history of herpetic keratitis (HK; hereafter referred to as "patients with HK") and 367 patients without a history of HK (hereafter referred to "patients without HK") were analyzed by real-time polymerase chain reaction (PCR) and virus culture for the presence of HSV-1, HSV-2, and VZV. In addition, 273 post-PKP donor corneoscleral rims were analyzed. The medical records of the transplant patients were reviewed to determine the risk factors influencing intracorneal viral load and graft survival. RESULTS: HSV-1 was the most prevalent herpesvirus. Both the prevalence of HSV-1 and the HSV-1 DNA load were higher in the corneas of patients with HK than in those of patients without HK. The HSV-1 DNA load in the corneas of patients with HK correlated with age, the recurrence-free interval, cornea neovascularization, steroid treatment before PKP, and disease severity. Herpesvirus DNA was detected in 2 of 273 corneoscleral rims. Graft survival was inversely correlated with the corneal HSV-1 DNA load in patients with HK. CONCLUSIONS: The data presented in this study argue for the implementation of real-time HSV-1 PCR to analyze the excised corneas of patients with HK, to improve post-PKP diagnosis and therapy. Screening of donor corneal tissues for herpesviruses is redundant to prevent newly acquired post-PKP HK.

Relief of post-herpetic neuralgia by surgical removal of painful skin: 5 years later.

Surgical removal of painful skin was first attempted as a treatment for chronic intractable post-herpetic neuralgia (PHN) more than a century ago, but long-term follow-up has rarely been reported. A patient who underwent surgical excision of 294cm(2) of thoracic skin comprising the entire area of pain and allodynia in October 2000 has been followed for 5.5years post-surgery. Our initial report presented evidence of benefit in the form of reduced pain, elimination of allodynia, and reduced medication consumption during the first post-operative year. Unfortunately, pain steadily increased and now exceeds pre-surgery levels despite increased medication use. Pain topography and characteristics are different from pre-surgery and may relate to the pathophysiology of PHN. Skin resection cannot be recommended as a treatment for PHN.

Alivio de la neuralgia posherpética mediante extirpación quirúrgica de piel dolorida / Relief of post-herpetic neuralgia by surgical removal of painful skin

Presentamos un caso de NPH tratado mediante extirpación de piel en la zona más dolorida (11,3 x 26,0 cm2). Esta intervención quirúrgica alivió el dolor, eliminó la alodinia táctil y permitió reducir considerablemente el consumo de medicación durante un periodo de seguimiento de 1 año. Se realizó una evaluación cualitativa de 14 biopsias de sacabocado y 10 tiras de piel (de 10 mm de longitud cada una) extirpadas de la zona con dolor como consecuencia de la NPH. La evaluación se realizó mediante inmunofluorescencia con marcaje doble utilizando anticuerpos contra la proteína producto del gen 9.5 (PGP 9.5), la proteína de los neurofilamentos de 200 kDa (NF), el péptido relacionado con el gen de la calcitonina (CGRP) y el receptor vainilloide 1 (VR-1). Comparado con una biopsia de sacabocado de la piel contralateral, el patrón de inervación cutánea en la piel afectada por la NPH presentó diferencias sistemáticas y considerables. Los resultados pueden explicar la base anatómica de la prueba de respuesta a la capsicina y son importantes para conocer mejor los mecanismos clínicos responsables del dolor en la NPH. © 2002 International Association for the Study of Pain. Publicado por Elsevier Science B.V (AU)

Treatment of postherpetic trigeminal neuralgia with the gamma knife.

OBJECT: Postherpetic neuralgia is a syndrome characterized by intractable pain. Treatment of this pain has not yet been successful. Patients with postherpetic neuralgia will therefore benefit from any progress in the treatment strategy. The authors performed gamma knife radiosurgery (GKS) as a noninvasive treatment for postherpetic trigeminal neuralgia (TN) and evaluated the success rate for pain relief. METHODS: Between 1995 and February 1999, six men and 10 women were treated for postherpetic TN; conservative treatment failed in all of them. The median follow up was 33 months (range 8-34 months). The radiation was focused on the root of the trigeminal nerve in the vicinity of the brainstem (maximal dose 70-80 Gy in one fraction, 4-mm collimator). The patients were divided into five groups according to degree of pain relief after treatment. A successful result (excellent, very good, and good) was reached in seven (44%) patients and radiosurgery failed in nine (56%). Pain relief occurred after a median interval of 1 month (range 10 days-6 months). No radiation-related side effects have been observed in these patients. CONCLUSIONS: These results suggest that GKS for postherpetic TN is a relatively successful and safe method that can be used in patients even if they are in poor condition. In case this method fails, other treatment options including other neurosurgical procedures are not excluded.

Results of DREZ coagulations for pain related to plexus lesions, spinal cord injuries and postherpetic neuralgia.

The results of 58 dorsal root entry zone (DREZ) thermocoagulation procedures in 51 patients are reported. The postoperative analgesic effect was judged by the patients as being good (more than 75% pain reduction), fair (25-75% pain reduction) or poor (less than 25% pain reduction). Of the 14 patients who underwent surgery for pain due to cervical root avulsion, 10 (77%) had permanently good (8) or fair (2) pain relief after a mean follow up period of 76 months, another 2 (15%) experienced recurrence to the preoperative level (initially 1 good, 1 fair) after more than 2 and 4 years, respectively. Twenty two paraplegics were operated upon, 3 of whom twice, for intractable pain. After a mean observation time of 54 months, continuing pain relief was reported by 12 (55%) patients (11 good, 1 fair), and one (initially fair) had recurrent pain after 8 months. All 3 (early) re-operations remain successful for an average period of 75 months. Poor results were seen especially in cases of associated spinal cord cysts (5 out of 7), despite combined drainage, and in patients with diffuse pain distribution (5 out of 6). Continuous marked improvement for longer periods (mean follow up: 52 months) after DREZ lesions was reported only by 2 out of 10 patients with postherpetic neuralgia (12 procedures) and by 1 out of 5 with painful states due to radiation-induced brachial plexopathy (2), previous surgery (2) and malignant tumour infiltration of the brachial plexus (1). Three patients died postoperatively due to acute cardiac failure (2) and pulmonary embolism (1). Major complications, especially permanent gait disturbances were observed in 6 patients (12%) following primary procedures and in 2 out of 7 patients after re-operations, most of them suffering from postherpetic neuralgia. Minor neurological deficits were noted in 9 cases (18%). DREZ lesions revealed to be an effective procedure in patients with pain related to root avulsion and paraplegia. In contrast, it seems to be less successful for painful states due to other plexus lesions or postherpetic neuralgia.

The use of conjunctival flaps in the treatment of herpes keratouveitis.

Conjunctival flaps have been used in the treatment of corneal diseases since the 1800s, although in recent years their use has decreased. In selected cases, however, the placement of a conjunctival flap still may be the treatment of choice. We report our experience with the use of conjunctival flaps in patients with herpes keratouveitis who had persistent corneal epithelial defects. Preoperatively, all patients had chronic or recurrent epithelial defects and intraocular inflammation with or without recurrent live viral infection requiring frequent medicine application and office visits. Postoperatively, all patients had an intact, healthy ocular surface and a noninflamed eye requiring few to no medications and infrequent office visits. No patient has had recurrent live viral activity.

Pathologic findings in the labyrinthine segment of the facial nerve in a case of facial paralysis.

The histopathologic findings for a patient with acute facial paralysis caused by herpes zoster oticus who obtained no return of active facial function after 1 year are presented. All imaging studies were nondiagnostic. Biopsy of the labyrinthine segment was performed. Histopathologic analysis showed a sharp line of demarcation between sclerotic nerve proximal to and necrotic nerve distal to the meatal foramen area of the fallopian canal. This finding is consistent with observations that the lesion producing Bell's palsy and herpes zoster oticus usually is situated at the meatal foramen.

[Treatment of zoster, post-zoster pain and herpes simplex recidivans in loco with laser light]. / Behandlung von Zoster, postzosterischen Schmerzen und Herpes simplex recidivans in loco mit Laser-Licht.

Red light of a krypton laser (lambda = 647 nm) was used for treatment of patients suffering from herpes zoster (n = 4), postherpetic neuralgias (n = 8) and herpes simplex recidivans in loco (n = 13). The afflicted skin was irradiated daily for ten days (laserpower 50 mw, exposure time 90 sec). Improvement was observed in 7 out of the 12 patients suffering from herpes zoster and postherpetic neuralgias respectively, and in 8 out of 13 patients afflicted with recurrent herpes simplex.