Wait! Is It Chickenpox, Shingles, Zoster, or What??
December 27th, 2006 by The Doc
As we reach the cusp of another annum, let’s skip to the far end of the alphabet today and talk about a bug called “zoster.” Variously known as varicella, VZV (varicella zoster virus), or zoster, this virus is responsible for causing chickenpox in children—though grownups are also occasionally affected—and shingles in adults. It is classified as a Herpesvirus because it shares certain characteristics with those viruses that cause genital herpes and “cold sores” on the lips and face.
VZV is a fascinating entity, from an immunologist’s point of view. When we are first exposed to it, this highly contagious virus touches off a series of events that starts two to three weeks after exposure. Heralded by a cough, runny nose, and high fever, the infection culminates with the eruption of a rash that, until recently, was a part of childhood for most Americans: a collection of blistered, maroon-colored bumps that appear over days, keep us out of school for a week or so, and eventually crust over as the disease wanes. Many of us can find a scar or two to prove we have survived this rite of passage.
Sometimes, complications occur as the result of chickenpox: skin infections (mostly from scratching at the rash), a pneumonia-like syndrome, or encephalitis (brain inflammation). Rarely, people even die from chickenpox.
And that’s not the end of VZV’s legacy. Just like herpes, VZV has the ability to infect special structures in our nervous system—the dorsal root ganglia, which lie like a string of pearls along the base of our brain and down our spinal cord—and there the virus survives, hiding out from our immune system. Then, often years later, it travels down a nerve and sets up housekeeping on the skin in a uniquely painful eruption called “shingles.”
Shingles, or zoster, arises when a lapse in immune coverage allows VZV to awaken from its dormancy. Another viral infection such as a cold, a chronic illness such as diabetes, or the mere process of aging can impair our immunity and allow the virus to temporarily reawaken. What follows is usually several days (often weeks) of severe discomfort, a weeping, crusty, localized rash that is reminiscent of our original encounter with chickenpox, and sometimes—for the unfortunate—a chronic pain syndrome called post-herpetic neuralgia.
For anyone who has suffered through a bout of shingles—usually someone over the age of 50—the mere mention of the word conjures unpleasant memories of lancing pain, sleepless nights, and expensive drugs that, all too often, don’t help much.
Because of its significant impact on people’s health, children have been receiving vaccination for VZV since 1995. While the vaccine is very effective at stimulating an immune response in inoculated individuals, and while there has been a decrease in the number of full-blown cases of childhood chickenpox, it appears the virus still has the ability to cause infections—albeit milder—in vaccinated children; it also appears that immunity in vaccinated individuals decreases over time. So, adolescents—and even adults—who were vaccinated and thus avoided infection as children are seemingly developing chickenpox at a later stage of life…when the infection tends to cause more complications and, hence, is more dangerous. Boosting immunity with additional doses of vaccine is one way to prevent infection later in life, but there seems to be some controversy as to when boosters should be given. Additionally, there is ongoing debate as to the significance of milder infections in vaccinated children.
Since the virus that causes chickenpox is the same one that causes shingles in adults, one would think that vaccinating children against chickenpox would lead to a decrease in the incidence of shingles down the road. The vaccine hasn’t been in use long enough to show if this is the case, however. And, since immunity to VZV in vaccinated individuals does seem to weaken over time, a lifelong vaccination program may be necessary to prevent childhood and adult-onset chickenpox as well as shingles.
With this in mind—and not surprisingly—in addition to the chickenpox vaccine, we now have one for shingles, too. You may have seen it (Zostavax) advertised on TV or in magazines (those marketers are clever, busy people). It reportedly cuts the risk of getting shingles by 50%. Currently it is quite expensive, and it is unclear if insurance companies—including Medicare—will cover its cost. Since anyone who has been infected by VZV can eventually develop shingles, it is difficult to determine who is most “at risk” and needful of vaccination. It may be useful to check the immune status of people considering vaccination, but this incurs a medical expense that, once again, may not be covered by most insurance plans. I suspect we will eventually see blanket recommendations for vaccinating anyone over 55 to 60 years of age who isn’t immunocompromised (people with immune deficiencies cannot safely receive live, attenuated [weakened] viruses in vaccines such as Zostavax).
Time will no doubt iron the wrinkles from the fabric of confusion that surrounds VZV and its prevention. In the meantime, consult your pediatrician, family physician, internist, Ouija board, or crystal ball for appropriate recommendations.
Oh. One more point that is a common source of confusion: No, you cannot catch “shingles” from someone who has that condition. However, both shingles and chickenpox are, as you recall, caused by the same highly contagious virus. Anyone who has never had chickenpox can contract chickenpox from someone who has either shingles or chickenpox. Anyone who has an impaired immune system should steer clear of people with active VZV (whether shingles or chickenpox), and pregnant women who aren’t sure of their immune status (a simple blood test can determine this) should also avoid contact with the virus.
Pax vobiscum…
Hi,
I found your blog via google by accident and have to admit that youve a really interesting blog
Just saved your feed in my reader, have a nice day
What I have are many questions?
Can complications, PHN, be the cause of arthritis type pain in hands, shoulders, hips, legs, and feet?
Could a young child exposed to Zoster develop plaques resulting in epilepsy?
Can zoster create plaques in the brain causing alzheimers?
What would plaques in a young child’s brain exposed to zoster look like? Would they appear as bright gray matter on an MRI?
Once the virus has reactivated, how long will it remain active in the body? Can it be active- causing flu like symptoms for a long period of time after the intial breakout of painful shingles has cleared up?
Is there a major publication or research center working on complications from shingles VZV?
Marilyn,
VZV has not been documented to cause chronic arthritis. Secondary infection of skin lesions by bacteria and subsequent bacteremia may eventually lead to bacterial arthritis, but the virus itself doesn’t appear to cause arthritis.
This link will take you to a journal article that cited one case of VZV-concurrent monoarticular arthritis in a child:
(http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=495499)
Neurologic complications of VZV infection (chickenpox) include encephalitis and stroke. Seizures can occur as a result of these complications. Those that occur during the encephalitic phase usually resolve. Stroke can cause longer-lasting problems. To my knowledge, MRI doesn’t reveal classic plaques following central nervous system involvement by VZV. These lesions are more typical of multiple sclerosis. And the neurofibrillary tangles of Alzheimer’s don’t appear as plaques on MRI, either.
Now, since the cause of Alzheimer’s is still unclear, infectious etiologies haven’t been completely ruled out. Alzheimer’s could, indeed, be an autoimmune disease that is triggered by an infectious agent.
The link below outlines some of VZV’s serious neurologic complications; the references cited in this article are interesting, too.
http://www.bioline.org.br/request?gm05040
In immunocompetent individuals, VZV is cleared fairly rapidly after an eruption of shingles. That’s why the rash doesn’t become generalized. However, I’ve seen patients who felt ill for several weeks after a bout of shingles (flu-like symptoms in addition to the discomfort of the rash). I suspect that is due to the regional inflammation secondary to the rash.
Hi Doc,
If a child is vaccinated against chicken pox, does that mean that the child may develop shingles later in life? (Due to the exposure to the chicken pox virus in the vaccine).
Also, my wife (who had chicken pox as a child) is 6 weeks pregnant and her father has in the last week contracted shingles. Should we avoid contact (ie. play it very safe) or not worry about normal social contact at all? When it is said that chicken pox is very contagious does that mean we can catch it off a chair if a person who has shingles sits in it?? I know this may seem a little paranoid but I obviously want to be reassured of the risks involved. As they say, ‘Better safe than sorry’
Hi, John.
Anyone who has had chickenpox or been vaccinated for chickenpox can get shingles later in life.
If your wife is certain that she had chickenpox as a child, there is no risk associated with being around her father. To be certain, her doctor could run a serology to make sure she is immune.
Chickenpox is spread by respiratory droplets. VZV is an enveloped virus (subject to drying), so it won’t survive indefinitely on environmental surfaces. It is conceivable that a person with chickenpox could leave respiratory droplets on the chair, and someone who is not immune could visit the chair, pick up secretions from the infected individual, and inadvertently inoculate their own mucus membranes, but I suspect the threat is more theoretical than real.
I just wrote an article on chickenpox and pregnancy for Suite101. If you’d like to visit, here’s the link:
http://pregnancychildbirth.suite101.com/article.cfm/pregnancy_and_chickenpox
I had chicken pox as a child, in my teens (babysitting), in my thirties and in my late forties exact same symptoms was told it is now shingles. In the past 5 yrs I’ve had it 3 times. I feel awful and get 1-5 pox (very itchy). Now at age 54, I got it again 3 weeks ago and had 2 pox but was so tired and weak missed 4 days of work. I was prescribed acyclovir and z pak for the bronchitis. I finished them 2 weeks ago. I was feeling a little stronger but keep getting new pox every couple of days. Today I feel sick and tired again. Why do I keep getting this? I’ve heard it can be stress related. I just started a new job 1 week before I became ill. Can I be getting it from a person that has no symptoms. I’d like to get the vaccine but I can’t until I am pox free right? Help I can’t stand this.
Hello, Rose.
First, if you’ve had chickenpox and your immune system is intact, you have at least partial immunity to the virus. Therefore, it’s exceedingly unlikely that you’re catching it from someone else. I assume that your current eruption of pox is following all the rules for someone who is immunocompetent — that is, they are popping up in a belt-like area (called a dermatome) on one side of your body only. If they’re erupting all over the place, something is awry with your immune system and your doc should be chasing that down.
Although most cases of shingles resolve in a week or two, it isn’t unusual for a single episode of shingles to last several weeks, and it isn’t unheard of for someone to get recurrent episodes. Once again, though, frequent recurrences are more likely to occur in a person whose immune system is weakened for some reason (stress, diabetes, certain medications like prednisone, etc.). As you probably know, the vaccine is recommended for people over the age of 60; it is made from a live virus, so a small percentage of people who get the vaccine will develop a mild case of shingles following the injection. As far as I know, having an active case of shingles doesn’t prevent you from getting vaccinated, but most of the time we recommend that the vaccine be withheld until the episode subsides and the symptoms resolve.
Given your age and history, I’d see the physician who prescribed the acyclovir and Zithromax to:
1. Make sure you have shingles
2. Ensure that you don’t have any obvious immune problems (diabetes, etc.)
3. See if you can get vaccinated a bit earlier than the recommended age of 60, since you seem to have a tendency to get shingles.
Hope that all helps. Good luck!! (By the way, I got shingles as a teenager, believe it or not, and I still remember it very clearly)
Hi there, great blog…well done!!
My mother is just over 60 years old. She has this horrid pain from over 1.5 weeks of shingles. She has completed using her anti-viral medicine and her pain killers. The little rash on her back has disappeared but she has excruciating pain all over her body.
She has had severe arthritis in her knees for the past 2 years with both knees having cartilages removed. She is on anti-arthritis medication.
After reading up a bit on this topic, is it correct that anti-arthritis medicine actually increases the incidence of shingles? Will my mum be ok.. I love her so much I am afraid.. because she has been putting up with pain for the past 2 years of arthritis, now shingles…. I am worried…?
How do I get my healthy mum back?
Pls help…
Varicella is a viral infection that causes a dermatological eruption. The rash first appears in face and abdomen, and then it will move towards the entire surface of the body, including the head and genital organs, and even inside the mouth, ear, vagina. The rash elements are at first small vesicles of 5 to 10 millimeters that are red and appear over two or more days in waves.
I have a pain in my right arm after i had a bout of chicken pox, I had pox and a week later was down with high fever and pain in my right arm.The doctor suspected respiratory infection and gave me antibiotics for it, I still have pain in my arms and I have constant pain while doing routine tasks and working(at the computer). I have more pain in right hand and sometimes in left hand as well. When i try to massage or squeeze the area it hurts.
The doctor i am seeing prescribed paracetamol. and it doesnt work.
Please give me an answer.
thanks doc
Did you have chickenpox (a whole-body rash), or did you have shingles (rash limited to a small area on one side of the body)? Post-herpetic pain is common with shingles, and its treatment is fairly straightforward. However, if you had generalized varicella (chickenpox), it’s possible that you have developed a radiculitis, which is an inflammation of the nerve root(s) that lead to your arm. Do you have any problems with your immune system, such as diabetes, long-term prednisone therapy, etc? A compromised immune system can increase your chances of developing radiculitis. And, since you’re apparently an adult, it’s a bit late for you to be getting chickenpox, which makes me wonder about immune deficiency.
Your doctor is the best one to sort this out and recommend appropriate therapy (i.e., corticosteroids, gabapentin, etc.)
Good luck…sounds like you’re pretty uncomfortable.
Varicella and Zoster are the same virus..Why is immunity lacking to Zoster virus when Varicella can never recur?..Is there any antigenic difference between Varicella and Zoster virus?
Ranjith,
You’re right: Varicella and zoster are the same virus; there is no antigenic difference between the two. Once you have had chickenpox (varicella), you are susceptible to shingles (zoster) because the virus retreats to your central nervous system when the chickenpox clears. Your immune system then keeps it sequestered there. When some immune insult (a cold, stress, sleep deprivation, or merely getting older) weakens your immune system, the virus is allowed to temporarily “escape.” It travels down a nerve root and causes a localized infection. However, since your immune system “remembers” the virus, it quickly manages to catch up with the infection before it can spread all over your body. Furthermore, since you already have antibodies and white cells that can rapidly react to the reawakened virus, the immune response can be fairly vigorous; this is what causes the marked inflammation and pain that often accompany shingles.
I hope that helps.
Doc