What Is Internal Shingles?
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Medically reviewed by Amelia MacIntyre, DO
Internal shingles, or zoster sine herpete (ZSH), is a medical condition that occurs due to the reactivation of the varicella-zoster virus (VZV). It's a form of shingles that affects other body systems without external skin symptoms.
The varicella virus is the infectious microbe responsible for causing chickenpox. It can remain dormant in some individuals after the initial infection. This means it's inactive, but still present.
About one million people in the United States get shingles every year. Over 95% of adults in the United States have VZV immunity, mostly from chickenpox. However, internal shingles is uncommon. It's also easy to misdiagnose because it doesn’t present with skin rashes. It can cause symptoms like pain and headaches.
Internal Shingles Symptoms
The herpes zoster virus causes different symptoms depending on the nerves and body systems affected. Possible symptoms include:
Pain (usually more severe than shingles)
A stabbing, burning, or shooting sensation due to damage or irritated nerves (neuralgia)
Headaches
Muscle weakness and fatigue
Fever and chills
Body aches
Lesions at hidden places other than the skin, such as internal organs
Lymph node swelling (often due to your body’s immune system fighting the virus)
What Causes Internal Shingles?
Internal shingles is caused by the activation of the varicella-zoster virus (VZV), which also causes chickenpox. This pathogen is often transmitted through direct contact or by inhaling infected respiratory tract secretions, such as mucus.
After initial infection, the virus can travel to nerve roots, where it might lie dormant for years until it reactivates and multiplies.
The reasons that varicella-zoster virus reactivates in some individuals, as well as the specific mechanism of the activation, are not fully understood. The virus seems to reactivate when your body’s immunity to it decreases. Therefore, factors affecting your immune system might contribute to its reactivation.
Risk Factors for Internal Shingles
Factors that affect immune cell functioning can increase your risk of internal shingles. These factors include:
Genetics
Older age
A weakened immune system (cellular immunodeficiency)
Systemic diseases (diseases that affect your entire body) like diabetes and hypertension (high blood pressure)
Medications and treatments like chemotherapy, which can weaken your immune system
Other viral diseases, like COVID-19
How Is Internal Shingles Diagnosed?
Internal shingles doesn’t present with characteristic shingles skin rashes, so healthcare providers assess other symptoms and perform diagnostic tests. Diagnosis typically includes things like:
Checking medical history: Internal shingles occurs due to reactivation of a formerly dormant varicella-zoster virus, so knowing if you've had the initial infection helps diagnose the condition.
Assessing symptoms: Specific symptoms can point towards internal shingles—for example, pain that travels along a spinal nerve root (radicular pain) and lesions in other body parts.
Enzyme-linked immunosorbent assay (ELISA): People with internal shingles have higher anti-VZV antibodies. which can be detected in their blood serum or cerebrospinal fluid (CSF)—the colorless fluid surrounding your brain and spinal cord. The ELISA technique is a test that can detect these antibodies.
Polymerase chain reaction (PCR): PCR is a lab technique that reproduces VZV DNA. It can be used to test for the presence of VZV DNA in serum, saliva, and CSF samples.
Serology tests: This blood test checks for the presence and concentration of specific antibodies and other substances. It helps determine whether you've been exposed to a particular microorganism.
Treatments for Internal Shingles
There is currently little research on ZSH treatment and no standard guidelines. Healthcare providers use an approach similar to shingles treatment, including antiviral medications. Early diagnosis and treatment are crucial for reducing the risk of more severe complications.
Common medications used to treat internal shingles include:
Antiviral medications: Common antiviral agents include famciclovir (Famvir), aciclovir (Zovirax), and valaciclovir (Valtrex).
Corticosteroids: Corticosteroids like hydrocortisone and prednisone can reduce inflammation, nerve injury, and pain.
Non-steroidal anti-inflammatory drugs (NSAIDs) and nerve blocks: NSAIDs such as Advil (ibuprofen), Aleve (naproxen), and anesthetic (numbing) injections might relieve pain.
How To Prevent Internal Shingles
The zoster vaccine is one of the most effective ways to prevent internal shingles. Shingrix (recombinant zoster vaccine) is recommended for adults 50 years and older as well as adults 19 years and older with weakened immune systems. This vaccine is up to 90% effective depending on the strength of your immune system. You'll get two doses, 2-6 months apart.
Pregnant people and people who currently have shingles should not get Shingrix. If you're sick, get the vaccine after you recover.
Other things that may help reduce the risk of developing internal shingles include:
Getting enough sleep and rest
Prioritizing nutrient-rich foods
Working with your healthcare provider to manage medical conditions, including those that compromise your immune system
Keeping up to date with medical appointments to continually monitor your immune system
Taking shingles medications as prescribed if you have been diagnosed with shingles
Complications
The virus that causes internal shingles can spread to different parts of the body, affecting organs like the eyes, brain, and ears. Complications include neurological conditions and brain inflammation.
Postherpetic Neuralgia (PHN)
Postherpetic neuralgia (PHN) is one of the most common neurological complications of internal shingles. It's characterized by persistent, more intense, localized pain and tingling due to inflammation of your nerve fibers where the virus has stayed dormant.
Possible symptoms include:
Increased or decreased sensitivity in the affected areas
Allodynia (pain with light touch)
Excessive sweating in the affected area
Ramsay Hunt Syndrome
Ramsay Hunt syndrome is also called herpes zoster oticus. It occurs when the varicella-zoster virus reactivates along your facial nerve pathway. Symptoms include:
Painful rash in or on the ear, on the tongue, or in the mouth
Loss of hearing in the affected ear
Vertigo (dizziness or spinning sensation)
Facial weakness or paralysis
Up to 30% of Ramsay Hunt syndrome cases are linked to internal shingles. It can occur with or without rashes.
Meningitis and Encephalitis
If zoster sine herpete goes undiagnosed or misdiagnosed, the varicella-zoster virus can spread to the brain, spinal cord, and meninges. The meninges are three layers of membranes that protect your brain and spinal cord.
Brain inflammation from an infection is called encephalitis. Inflammation of the meninges is called meningitis. Both conditions can be severe and fatal, especially if untreated. Possible symptoms of both conditions include:
Neck stiffness
Nausea
Headache
Photophobia (light sensitivity)
VZV Vasculopathy
A complication of VZV reactivation can occur when the virus affects both large and small arteries in the cerebral part of your brain. This can cause things like:
Blood vessel rupture and bleeding into your brain (hemorrhagic stroke)
A stroke within your spinal cord
The formation of blood clots
Poor blood flow in other parts of your body
Quick Review
Internal shingles can develop in people who have previously had a varicella-zoster infection—the virus that causes chickenpox. There are treatments for people with an active infection, but there's no definite cure for the virus. As a result, the virus can reactivate after being dormant (inactive), causing another episode of shingles.
Until typical shingles, internal shingles doesn't include skin rashes. This can make it difficult to diagnose. Diagnosis and treatment of internal shingles are essential for reducing the risk of complications.
The vaccine is the most effective prevention strategy. It's particularly valuable for high-risk individuals, such as those with a compromised immune system and those who have had chickenpox.
Frequently Asked Questions
What kind of doctor treats internal shingles?
Different healthcare providers may be involved in diagnosing and treating shingles, including primary care physicians, neurologists, ophthalmologists, and doctors who specialize in treating chronic pain. It will depend in part on your symptoms and complications of the condition.
Can stress cause internal shingles?
Stress does not directly cause internal shingles. However, chronic (long-term) stress can contribute to the weakening of the immune system, increasing the risk of varicella-zoster reactivation and the occurrence of internal shingles.
When is it too late to take antiviral medications for internal shingles?
Early treatment is important to prevent severe complications from internal shingles. Treatment is most effective for typical shingles within 72 hours of symptom onset. However, estimating the onset duration of internal shingles is often difficult since it doesn’t present with the characteristic rashes.
Seek immediate medical attention as soon as you notice abnormal symptoms like pain, muscle weakness, fatigue, and body aches.
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