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A 75-year-old man who presents with a painful vesicular rash on the upper right side of his face is referred to A&E by his GP who suspects shingles.
1. What action do you take?
You immediately move him to an isolation room and request that only staff who have had chickenpox or know they are immune to varicella zoster virus should come into contact with him. You take a sample of vesicle fluid for urgent NAAT to confirm the diagnosis. You enquire about possible immunosuppression and prescribe aciclovir.
2. What is the link between shingles and chickenpox?
Both are caused by varicella zoster virus. Chickenpox is the primary infection, which is usually acquired in childhood. It is a generalized infection with crops of vesicles. Shingles is a reactivation of the virus, which has lain dormant in the dorsal root ganglion, and usually affects a single dermatome.
3. What complication may occur in this case?
Because it is affecting the upper half of the face in the distribution of the trigeminal nerve, it may also affect the cornea. Postherpetic neuralgia is also a risk.
4. Can other patients catch shingles from this patient?
No. Shingles occurs when dormant virus reactivates; however, non-immune contacts may develop chickenpox. The attack rate is >90% for non-immune contacts. Large numbers of virus are shed via the respiratory tract and from vesicles.
5. You learn that a non-immune member of staff spent some time with the patient; what should you do?
The incubation period for chickenpox is 14–21 days, so the member of staff should be excluded from clinical areas from day 14–21 following the exposure. If they are immunosuppressed for any reason, they should be offered zoster immune globulin. A vaccine is available for healthcare workers who are non-immune.
6. The staff member develops fever followed by a florid vesicular rash; how do you manage them?
Chickenpox can be a serious infection in adults with a significant risk of varicella pneumonia. The patient should be isolated and prescribed aciclovir. They should be monitored for respiratory involvement and secondary bacterial infection should be treated if this develops.