This young lady shows up to your ED with 1 week of rash over her abdomen. The rash was preceded by pain to the area, which improved but still bothers her, and much to her chagrin, the rash still has not resolved. She has no medical problems, vitals are within normal limits, but she wants to know if she can go back to work as a waitress.

What isolation precautions should we use for shingles?

ANSWER:

Airborne isolation (negative pressure room) if disseminated; standard precautions (and cover rash entirely) if localized lesion before crusting of the vesicles. So the young lady above may return to work so long as her rash is covered and she follows expected sanitation precautions (hand washing) at work.

Herpes zoster (shingles) shown in this patient occurs from reactivation of the varicella zoster virus (which causes both chicken pox and shingles) that has been dormant in a dorsal root nerve ganglion since an episode of chicken pox. Elderly and immunocompromised patients are most at risk for such reactivation. Prior to the onset of rash, patients experience tingling or hyperesthesia in the dermatome. Painful, vesicular lesions then appear on the skin along the distribution of the dermatome. Patients are considered infectious from 5 days before the appearance of the rash until 5 days after the appearance of the vesicles or until the vesicles are crusted over. According to the CDC, “infection-control measures depend on whether the patient with herpes zoster is immunocompetent or immunocompromised and on whether the rash is localized or disseminated (defined as appearance of lesions outside the primary or adjacent dermatomes). In all cases, standard infection-control precautions should be followed.”

If the patient is immunocompetent with

  • localized herpes zoster, then standard precautions should be followed and lesions should be completely covered.
  • disseminated herpes zoster, then standard precautions plus airborne and contact precautions should be followed until lesions are dry and crusted.

If the patient is immunocompromised with

  • localized herpes zoster, then standard precautions plus airborne and contact precautions should be followed until disseminated infection is ruled out. Then standard precautions should be followed until lesions are dry and crusted.
  • disseminated herpes zoster, then standard precautions plus airborne and contact precautions should be followed until lesions are dry and crusted.

 

 

References:

CDC website: http://www.cdc.gov/shingles/hcp/hc-settings.html

Haile-Mariam T, May L: Viral Illnesses, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2013, (Ch) 130: pp 1727-1729.