Herpes Zoster: Query and Concern–Reply–I

Abstract

Dr Homler is correct in that transmission of varicella virus from persons with localized herpes zoster (HZ) most commonly results from direct contact with skin lesions. However, studies have shown that patients with HZ shed virus into the environment even when the lesions are covered, and aerosolized viral DNA has been detected in rooms of patients with localized HZ.1Suzuki K Yoshikawa T Tomitaka A Matsunaga K Asano Y Detection of aerosolized varicella-zoster virus DNA in patients with localized herpes zoster.J Infect Dis. 2004; 189 (Epub 2004 Feb 27.): 1009-1012Crossref PubMed Scopus (41) Google Scholar A recent report describing an outbreak of varicella in a nursing home that was traced to an elderly patient with localized HZ further supports airborne transmission.2Lopez AS Burnett-Hartman A Nambiar R et al.Transmission of a newly characterized strain of varicella-zoster virus from a patient with herpes zoster in a long-term-care facility, West Virginia, 2004.J Infect Dis. 2008; 197: 646-653Crossref PubMed Scopus (69) Google Scholar None of the persons with varicella had direct contact with the index case of zoster. On the basis of genotypic analysis, all the cases were shown to have the identical virus, and viral DNA was isolated from the environment of the index case, making a strong case for airborne transmission of the virus. Dr Homler raises concerns about the potential for serotonin syndrome with the drug combinations recommended for treatment of postherpetic neuralgia. Potential drug-drug interactions abound in daily clinical practice, and the clinician must be ever vigilant. A striking number of drugs and drug combinations have been associated with the serotonin syndrome. Dr Homler is correct in pointing out the potential interaction between serotonin-norepinephrine reuptake inhibitors and tramadol. However, when introduced sequentially and in low incremental doses, as recommended in our article, we do not think the risk for problems is high. One estimate in the literature suggests that the risk is on the order of 0.6 cases per 1000 persons.3Boyer EW Shannon M The serotonin syndrome.N Engl J Med. 2005; 352: 1112-1120Crossref PubMed Scopus (1384) Google Scholar Herpes Zoster: Query and ConcernMayo Clinic ProceedingsVol. 84Issue 7PreviewTo the Editor: The review by Sampathkumar et al1 on shingles and postherpetic neuralgia raised 1 question and 1 concern. The authors mentioned the risk of contagion via contact and by the airborne route, but the reference provided discussed only varicella, rather than specifying shingles or the route of transmission. I understand direct contact as a mode, but is there good evidence for airborne transmission of shingles? My concern about the recommendation for combinations of low doses of medications for treating the pain associated with shingles or postherpetic neuralgia is that tramadol, one of the agents suggested, has a risk of serotonin syndrome when combined with several of the other agents, such as serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants. Full-Text PDF