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Herpes zoster ( shingles, zona ) is a common viral infection of the nervous system occurring at an overall rate of 3 to 5 cases per 1000 persons per year, with higher rates in the elderly Shingles is distinctly rare in childhood It is characterized clinically by radicular pain, a vesicular cutaneous eruption, and, less often, by segmental sensory and delayed motor loss The pathologic changes consist of an acute in ammatory reaction in isolated spinal or cranial sensory ganglia and lesser degrees of reaction in the posterior and anterior roots, the posterior gray matter of the spinal cord, and the adjacent leptomeninges The neurologic implications of the segmental distribution of the rash were recognized by Richard Bright as long ago as 1831 In ammatory changes in the corresponding ganglia and related portions of the spinal nerves were rst described by von Barensprung in 1862 and were later studied extensively The concept that varicella and zoster are caused by the same agent was introduced by von Bokay in 1909 and was subsequently established by Weller and his associates (1954, 1958) The common agent, referred to as varicella or varicella zoster virus (VZV), is a DNA virus that is similar in structure to the virus of herpes simplex These and other historical features of herpes zoster have been reviewed by DennyBrown and Adams and by Weller and their colleagues Pathology and Pathogenesis The pathologic changes in VZV infection are unique and consist of one or more of the following: (1) an in ammatory reaction in several unilateral adjacent sensory ganglia of the spinal or cranial nerves, frequently of such intensity as to cause necrosis of all or part of the ganglion, with or without hemorrhage; (2) an in ammatory reaction in the spinal roots and peripheral nerve contiguous with the involved ganglia; (3) a less common poliomyelitis that closely resembles acute anterior poliomyelitis but is readily distinguished by its unilaterality, segmental localization, and greater involvement of the dorsal horn, root, and ganglion; and (4) a relatively mild leptomeningitis, largely limited to the involved spinal or cranial segments and nerve roots These pathologic changes are the substratum of the neuralgic pains, the pleocytosis, and the local palsies that may attend and follow the VZV infection There may also be a delayed cerebral vasculitis (see further on) As to pathogenesis, herpes zoster represents a spontaneous reactivation of VZV infection, which becomes latent in the neurons of sensory ganglia following a primary infection with chickenpox (Hope-Simpson) This hypothesis is consistent with the differences in the clinical manifestations of chickenpox and herpes zoster, even though both are caused by the same virus Chickenpox is highly contagious by respiratory aerosol, has a well-marked seasonal incidence (winter and spring), and tends to occur in epidemics Zoster, on the other hand, is not communicable (except to a person who has not had chickenpox), occurs sporadically throughout the year, and shows no increase in incidence during epidemics of chickenpox In patients with zoster, there is practically always a past history of chickenpox Such a history may be lacking in rare instances of herpes zoster in infants, but in these cases there has usually been prenatal maternal contact with VZV VZV DNA is localized primarily in trigeminal and thoracic ganglion cells, corresponding to the dermatomes in which chickenpox lesions are maximal and that are most commonly involved by VZV (Mahalingam et al) The supposition is that in both zoster and varicella infections the virus makes its way from the cutaneous.

Acute Cerebellitis (Acute Ataxia of Childhood)

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1 Start Windows 95 as you normally do, and close any running applications and utilities 2 Insert the Windows 98 installation CD In most cases, the Setup utility will start automatically If it doesn t, access the CD using My Computer or Windows Explorer, and double-click the Setup icon 3 The Setup utility will detect the existence of Windows 95 and ask if you want to perform an upgrade Select Yes 4 Follow the on-screen instructions to complete the upgrade, ensuring that you select Yes when prompted to save the system files This will allow you to uninstall Windows 98 and revert to Windows 95 if problems occur When Windows 98 is removed, the Windows 95 system files will be restored The remainder of the installation will proceed as described earlier in the chapter, with the exception of a few steps To begin with, you will not be asked to select an installation type (compact, typical, and the like) Windows 98 will simply migrate existing features when possible or upgrade existing features that cannot be migrated The hardware detection and configuration steps will also be skipped Again, Windows 98 will simply use the existing hardware configurations

A special comment should be made here concerning the dramatic syndrome of acute ataxia that occurs in the context of an infectious illness The syndrome was originally described by Westphal in 1872 following smallpox and typhoid fever in adults, but Batten is credited with drawing attention to the more common ataxic illness that occurs after certain childhood infections such as measles, pertussis, and scarlet fever Currently, acute ataxia of childhood is most often associated with chickenpox (one-quarter of 73 consecutive cases reported by Connolly et al), but it can occur during or after any of the childhood exanthems, as well as in association with infections due to enteroviruses (mainly Coxsackie), EBV, Mycoplasma, CMV, Q fever, vaccinia, a number of vaccinations, rarely with HSV, and also after nondescript respiratory infections (see Weiss and Guberman) The condition is far less frequent in adults, but we encounter a case every 2 years or so in adolescents and individuals in their twenties; besides a late case of varicella, the most common preceding organisms in these individuals have been EBV and Mycoplasma The syndrome, which is essentially a meningocerebellitis, appears relatively abruptly, over a day or so, and consists of limb and gait ataxia and often dysarthria and nystagmus Additional signs include increased limb tone, Babinski signs, or confusion The fever of the original infection may have abated, or it may persist through the early stages of the ataxic illness As a rule, there is a mild pleocytosis; the CSF protein is elevated or may be normal The MRI is normal in the majority of cases but some show enhancement with gadolinium of the cerebellar cortical ribbon Most patients make a slow recovery, but permanent residua are known to follow Because the benign nature of the illness has precluded extensive pathologic study, there is still uncertainty regarding the infectious or postinfectious nature of these ataxic illnesses Some cases have shown an in ammatory pathology most suggestive of a postinfectious process (see Chap 36), but the nding of fragments of VZV and Mycoplasma genomes in the spinal uid by means of DNA ampli cation techniques favors a primary infectious encephalitis, at least in some instances.

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