Introduction:
Aging is associated with alteration in the immune system. The changes seen in the immune system are responsible for increased susceptibility to infections. As a result, several bacterial and viral infections are common in elderly people. In some cases, viral infections are caused by the reactivation of previous infection. Shingles or varicella-zoster infection is one such infection seen in elderly people.
What Are Shingles?
Infections caused by herpes zoster are known as shingles. It is caused by the reactivation of the varicella-zoster virus.
Varicella-zoster virus (VZV) is responsible for chickenpox. This virus belongs to the herpes virus family and is categorized as human herpes virus 3. This is a neurotropic human herpes virus that belongs to the genus alpha herpesviridiae. It is a DNA virus, and its genome is made up of 125,000 base pairs of linear double-stranded DNA. The virus is usually transmitted through the infected person. Respiratory droplets are the primary mode of transmission. Also, fluid from blisters of the affected persons may cause transmission of infection. However, this infection is not transmitted through sexual contact.
This virus infects human cells like epithelial cells, T lymphocytes, and ganglionic cells of the neurons. The initial incubation period of this infection is seven to ten days. During this period, the viral replication takes place in the respiratory tract. After this, the virus infects the local lymph nodes. Gradually, this leads to viremia and skin lesions. These skin lesions appear as radishes rash over the skin. Eventually, blister formation, along with the formation of raw ulcers and sloughing of skin, is observed. It should be noted that, during pregnancy, this viral infection may spread to the fetus via the placenta. Also, such transmission may cause severe complications. After the primary infection, the virus remains latent in the nerve tissue. This virus usually resides in the dorsal root ganglia, cranial nerve ganglia, and various autonomic ganglia.
During the phase of reactivation, the latent virus replicates and proliferates. After this, the activated virus and the proliferated virus travel through neural pathways. The proliferation damages the structure and functions of peripheral nerves and ganglia, causing pain and numbness. However, there may not be any visible signs of rash at this stage. Inflammation of the skin happens when the virus penetrates the dermis and epidermis of the impacted dermatome. This cycle of nerve damage and skin inflammation progresses from the nerve pathways to the outer dermis and epidermis, leading to the formation of maculopapular lesions.
What Are Shingles in the Elderly?
Shingles in the elderly are nothing but the reactivation of a previous infection. The reactivation seen in elderly people is due to the following conditions:
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The immune system undergoes alterations in elderly individuals, leading to the reactivation of infections. T-cell dysfunction is attributed to DNA damage, while reduced white blood cell production is a result of bone marrow damage. Additionally, hormonal changes contribute to the decreased production of lymphocytes.
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The presence of systemic disorders like diabetes, hypertension, malnutrition, and cardiovascular disorders is responsible for the alteration of the immune status of the body.
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Reactivation of this infection is more common in immunocompromised patients. Patients suffering from HIV or cancer or receiving chemotherapy or radiotherapy may also suffer from such remission.
Among the elderly people, women are commonly affected by this condition. Hormonal changes after menopause are related to such prevalence.
What Are Complications Associated With Shingles in the Elderly?
The complications associated with remission are;
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Initial symptoms of remission are malaise, fever, nausea, vomiting, itching, and difficulty in bright light.
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Patients often complain of tingling sensations in the extremities.
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The initial symptoms persist for three to five days.
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After the initial symptoms, an erythematous maculopapular rash appears in the body. Rashers appear in the chest, face, and extremities.
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These rashes continue to grow for the next seven to ten days. Gradually, the rash will advance to pustules and ulceration, accompanied by crusts, scabbing, or a combination of both, which may last for a maximum of 30 days during the acute stage.
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In severe cases, the seventh cranial nerve is affected, which results in hearing complications. This is known as Ramsay–Hunt syndrome.
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Involvement of the ocular nerve may cause complications like corneal inflammation, swelling of the eyelids, and inflammation of the mucus membrane of the eyelid.
What Are the Treatment Options?
As already discussed, shingles cause complications like skin lesions and fever. Oral antiviral therapy helps reduce the severity of the disorder and the complications associated with it. Also, antiviral therapy may help prevent recurrence of the viral infection. Antiviral drugs like Acyclovir, Valacyclovir, and Famciclovir are usually prescribed in these cases. Acyclovir is usually prescribed for seven to ten days with a dose of 800 millimeters five times. At the same time, both Famciclovir and Valacyclovir are prescribed three times for seven days with a dose of 500 and 1000 milligrams, respectively. Intravenous Acyclovir with a dose of ten milligrams per kilogram of body weight every eight hours is advised for immunocompromised patients. However, it should be kept in mind that antiviral therapy should be started as soon as possible. A delay in starting antiviral therapy may not be as effective.
Chronic pain is a complication associated with shingles. Drugs like opioid analgesics and non-steroidal anti-inflammatory drugs are useful in such cases. Drugs like Gabapentin and Tramadol are opioid analgesics used to treat neuropathic pain or postherpetic neuralgia. The complications associated with drugs are constipation, nausea, and vomiting. Tricyclic antidepressants such as Amitriptyline and Nortriptyline are also effective in curing neuropathic pain. These drugs cause dry mouth, drowsiness, and constipation.
Tropical drugs like Lidocaine, Piroxicam, and Capsaicin are used for topical application. These drugs act as desensitizing agents and provide relief from pain associated with skin lesions.
Varicella zoster is used nowadays to prevent recurrent infections. These vaccines are only prescribed for older individuals who are 60 years or above.
Conclusion:
Shingles in elderly persons are mainly caused by the reactivation of previous infection. Systemic disorders and disorders causing reduced immunity are responsible for such reactivation. Apart from skin problems, pain in the body is the most common symptom of the patient. Neurological damage is the primary cause of such complications. Antiviral drugs can reduce the severity of the disorder. Also, analgesics are useful in reducing nerve pain.
