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shingles
a) 50%
b) 60%
c) 70%
d) 80%
e) 90%
Source: McCrary, Severson and Tyring, JAAD (1999) 41, 1-14 CME examination
Each of the following is seen with
maternal VZV infection in the first
trimester except:
Source: McCrary, Severson and Tyring, JAAD (1999) 41, 1-14 CME examination
Epidemiology of primary varicella
Vaccination
VZIG as post-exposure prophylaxis in individuals
at high risk
125U/10kg (max 625 U), given IM, NEVER IV
Mothers with varicella 5 days before to 2 days after
delivery
Immunocompromised individuals with no reliable
history
3 weeks duration of protection
Exclude kids from school until sixth day of rash
The efficacy of the VZV vaccine (in terms
of seroconversion) is estimated to be
more than:
a) 50%
b) 60%
c) 70%
d) 80%
e) 90%
Source: McCrary, Severson and Tyring, JAAD (1999) 41, 1-14 CME examination
Ref: White CJ et al., Pediatrics (1991) 87, 604-10. VARIVAX trial of healthy children.
Randomized control trials of VZV
vaccination
Summarized by Skull and Wang (2001) Arch Dis Child 85, 83-90.
Indications for vaccination
Age 12 mos.-13 y.o.
one dose, can be given with MMR
Age 13 y.o.-young adulthood
two doses at 4-8 wk intervals
consider serologic testing first
Contraindications for
vaccination
Congenital immunodeficiency, blood
dyscrasia
Hematologic malignancies
can give to ALL in remission [Gershon AA et al.
(1984) JAMA 252(3):355-62]
Symptomatic HIV
Pregnancy
Intercurrent illness
Contraindications for
vaccination
Corticosteroids of 2 mg/kg/d or
higher for 1 month or longer
exposure to varicella or herpes
zoster within 21 days
neomycin allergy
blood products (including IVIG)
within 5 months
salicylates within 6 wks (relative)
Each of the following is seen with
maternal VZV infection in the first
trimester except:
Source: McCrary, Severson and Tyring, JAAD (1999) 41, 1-14 CME examination
The Zoster Strikes Back?
66 yo F with longstanding history of
photosensitivity and history of actinic
reticuloid and CTCL/erythroderma
presentation
Long-standing prednisone usage dating back
4 years prior to clinic visit
Currently on 30/29 mg/d alternating dose,
with improvement in photosensitivity
The Zoster Strikes Back?
5 months prior, pt was on prednisone at
10/d and noted a painful blistering rash
on the left buttock and left inner leg
Diagnosed as shingles and treated with
acyclovir 800 mg 5x/d
Prednisone dose increased to 15/d
Rash resolved completely according to the
patient
The Zoster Strikes Back?
2 months ago, pt hospitalized with left arm
cellulitis for 4 days
Discharged on prednisone 40/d with taper
Hospitalized again 5 weeks ago for
complications of pseudomembranous colitis
Prednisone increased from 18/d to 30/d, then
increased again to 60/d with taper
Rash that appeared similar to previous shingles
episode reappeared, persisted until this clinic visit
The Zoster Strikes Back?
ROS unremarkable; no constitutional or
prodromal symptoms
Main symptom was itching on leg
FBS of 80-90 in am
ALL: codeine, sulfa
Meds: prednisone (30/29), atenolol,
Zaroxolyn, levoxyl, Mg/K supplements,
Premarin, Prevacid, Starlix
The Zoster Strikes Back?
P = 64, BP = 142/78
On exam, the left inner lower leg had
single and grouped 1-2 mm vesicles on
an erythematous base
Punctate scars were present on left
inner lower leg; the patient said these
scars were from the previous eruption 5
months ago
The Zoster Strikes Back?
FA and viral culture of vesicle on left leg
was POSITIVE for VZV
The incidence of shingles in a person
with a history of varicella is:
a) 10%
b) 20%
c) 30%
d) 40%
e) 50%
Source: McCrary, Severson and Tyring, JAAD (1999) 41, 1-14 CME examination
The percentage of patients with herpes
zoster who experience pain in the
involved dermatome prior to development
of a rash is:
a) 50%
b) 60%
c) 70%
d) 80%
e) 90%
Source: McCrary, Severson and Tyring, JAAD (1999) 41, 1-14 CME examination
Ophthalmic zoster is complicated by
ocular disease in what percentage of
patients:
a) 1%
b) 10-20%
c) 20-70%
d) 30-50%
e) More than 90%
Source: McCrary, Severson and Tyring, JAAD (1999) 41, 1-14 CME examination
A few vesicles can be found remote from
the primarily affected dermatome in what
percentage of immunocompetent pts:
a) 5-10%
b) 10-20%
c) 20-40%
d) 40-60%
e) 60-70%
Source: McCrary, Severson and Tyring, JAAD (1999) 41, 1-14 CME examination
The risk of dissemination in immuno-
compromised patients with herpes
zoster can be estimated at:
a) 10%
b) 20%
c) 40%
d) 60%
e) 80%
Source: McCrary, Severson and Tyring, JAAD (1999) 41, 1-14 CME examination
Recurrent herpes zoster
1900 Head & Campbell report recurrent
zoster in 3 out of 400 patients with zoster
[Head and Campbell (1900) Brain 23,353.]
a) 10%
b) 20%
c) 30%
d) 40%
e) 50%
Source: McCrary, Severson and Tyring, JAAD (1999) 41, 1-14 CME examination
Ref: Hope-Simon RE, Proc R Soc London (1965) 58, 9-20.
The percentage of patients with herpes
zoster who experience pain in the
involved dermatome prior to development
of a rash is:
a) 50%
b) 60%
c) 70%
d) 80%
e) 90%
Source: McCrary, Severson and Tyring, JAAD (1999) 41, 1-14 CME examination
Ophthalmic zoster is complicated by
ocular disease in what percentage of
patients:
a) 1%
b) 10-20%
c) 20-70%
d) 30-50%
e) More than 90%
Source: McCrary, Severson and Tyring, JAAD (1999) 41, 1-14 CME examination
Ref: Ragozzino et al., Medicine-Baltimore (1982) 61, 310-6.
A few vesicles can be found remote from
the primarily affected dermatome in what
percentage of immunocompetent pts:
a) 5-10%
b) 10-20%
c) 20-40%
d) 40-60%
e) 60-70%
Source: McCrary, Severson and Tyring, JAAD (1999) 41, 1-14 CME examination
Ref: Oberg and Svedmyr, Scand J Infect Dis (1969) 1, 47-49.
The risk of dissemination in immuno-
compromised patients with herpes
zoster can be estimated at:
a) 10%
b) 20%
c) 40%
d) 60%
e) 80%
Source: McCrary, Severson and Tyring, JAAD (1999) 41, 1-14 CME examination
Ref: Weber and Pekllecchia, JAMA (1965) 192, 572-7.
The Phantom Menace
airborne VZV in the setting of
herpes zoster
Detection of VZV DNA in air samples from
hospital rooms
Sawyer MH et al. (1994) J Infect Dis 169, 91-4.
PCR assay of air filter samples from
patients with varicella and herpes zoster
VZV DNA found in 64/78 (82%) of room
samples with varicella patients
VZV DNA found in 9/13 (70%) of room
samples with herpes zoster patients
VZV detected 1.2-5.5m from patient beds
for 1-6 days
Rapid contamination of the environment with
VZV DNA from a patient with herpes zoster
Yoshikawa T et al. (2001) J Med Virol 63,64-66.
Days Serum PBMCs hands throat chair door table filter
3 ND ND -- -- -- -- -- --
4 yes yes -- -- yes -- yes --
5 -- yes -- -- yes -- -- --
6 yes yes yes yes -- -- -- --
7 yes yes -- -- yes yes -- yes
8 ND ND -- yes yes yes yes yes
14 ND ND yes -- yes yes -- yes
21 ND ND yes -- yes -- -- --
37 -- -- -- -- -- -- -- yes
ND=not done
100
Skin
Throat
PCR positivity
75
Air filters
PBMCs
50
25
0
0 2 4 6 8 10 12
Days of illness
A New Hope - brivudin
For strains of VZV found to be resistant
to acyclovir, the most appropriate
therapy is:
a) foscarnet
b) valaciclovir
c) famciclovir
d) vidarabine
e) idoxuridine
Source: McCrary, Severson and Tyring, JAAD (1999) 41, 1-14 CME examination
Brivudin
[(E)-e-(2-bromovinyl)-2-deoxyuridine]
nucleoside analog, highly selective for
HSV and VZV (competitive polymerase
inhibitor like sorivudine)
Requires thymidine kinase
MIC of 0.0033 uM; more potent in culture
than acyclovir (MIC 0.93 uM) or penciclovir
(3.6 uM) against VZV
Brivudin
dosed once daily 125 mg
licensed for treatment of herpes zoster in
Austria, Belgium, Germany, Greece, Italy,
Luxemborg, Portugal, Spain
Similar results in two large multi-center
phase III double-blind RCTs
Brivudin 125 qd vs acyclovir 800 5x/d
Brivudin 125 qd vs famvir 250 tid
Oral brivudin in comparison with acyclovir for
improved therapy of herpes zoster in
immunocompetent patients: results of a
randomized, double-blind multicentered study
Sawko WW and the Brivudin Herpes Zoster Study
Group (2003) Antiviral Res 59, 49-56.
Nausea 16 13
Headache 6 7
Abd pain 5 4
Dizziness 4 1
Vomiting 3 7
elevated GGT 1 4
For strains of VZV found to be resistant
to acyclovir, the most appropriate
therapy is:
a) foscarnet
b) valaciclovir
c) famciclovir
d) vidarabine
e) idoxuridine
Source: McCrary, Severson and Tyring, JAAD (1999) 41, 1-14 CME examination
Foscarnet
a.k.a. trisodium phosphonoformic acid
exhibits in vitro activity against all herpes
viruses
Noncompetitive inhibitor of viral DNA
polymerase
not dependent on phosphorylation by
thymidine kinase
thymidine kinase-negative strains seen
increasingly in HIV population
Foscarnet
Not orally available; given IV
Renal toxicity
Seizures, anemia, neuropathy, penile
ulcers
The Clone Wars -
pityriasis lichenoides as yet
another manifestation of VZV?
Is VZV involved in the etiopathogeny of
pityriasis lichenoides
Boralevi F et al. (2003) JID
13 pts with clinical and histological PL (9
PLC, 4 PLEVA) and 22 normal controls
mean delay in dx for PL group = 6 mo (7d-
30mo)
PCR performed blind on skin biopsies
all PL patients given option for trial of
acyclovir for two weeks
Is VZV involved in the etiopathogeny of
pityriasis lichenoides?
Boralevi F et al. (2003) JID
PCR+ for VZV DNA in 8/13 PL patients (6
PLC, 2 PLEVA)
no positive PCR from 22 controls
10/12 patients with improvement on ACV;
2 resolved, 6 with >50% improvement by
dermatologist assessment