Quiz Om 2

Front 1

Va ricella-Zoster Virus (VZV)

Back 1

• VZV is a DNA virus responsible for two major entirely distinct clinical infections:

• Chickenpox (Varicella) • Shingles (Herpes Zoster [HZ]).

Front 2

• Primary infection with VZV leads to. and the recurrent

infection with the VZV leads to.

Back 2

chickenpox (varicella)

Shingles (Herpes Zoster)

Front 3

• After primary infection, VZV becomes latent in the

Back 3

dorsal root ganglia or ganglia of the cranial nerves and reactivation produces Shingles.

Front 4

Chickenpox

Back 4

A benign illness of children. • It is spread by direct contact with:

• Nasopharyngeal secretions of an infected individual

OR

• Fresh skin lesions.

Front 5

• Incubation period of chickenpox

Back 5

2 to 3 weeks.

Front 6

• Chickenpox:

• Clinical manifestations:

Back 6

• Age peak: 5 to 10 years (most children are infected by the age of

10)

• Prodromal signs: low-grade fever, headache and malaise.

• Cutaneous rashes that manifest as pink, intensely pruritic

maculopapular lesions that later develop into itchy (Dewdrop-like)

vesicles.

• These vesicles become pustular and scab, with the crusts falling off

after 1 to 2 weeks.

• Sites of involvement: scalp, face, chest and back.

• Heal without scarring.

• Recovery: 2-3 weeks.

Front 7

Chickenpox:

• Clinical manifestations oral

Back 7

• Oral lesions might precede the development of

typical skin rashes.

• Lesions present as multiple vesicles that rapidly ruptures leaving small ulcers (often not painful)

surrounded by an area of erythema.

Front 8

Chickenpox:

• Management:

Back 8

• Preventative therapy: Varivax vaccine effective in preventing infection

• Self-limiting in healthy children

• Anti-viral agents: Acyclovir In immunocompromised patients

• <12 years of age: 5mg/kg every 8 hours for 7 days

• >12years of age: 10 mg/kg every 8 hours for 7 days

Front 9

Herpes Zoster

Back 9

It is the recurrent type of VZV resulting from the

activation of the latent virus in response to:

• Trauma • Irradiation • Malignancy • Immunosuppression

Front 10

• The characteristic superficial lesion of herpes zoster

Back 10

is a unilateral vesicular eruption localized to a single dermatome of a single sensory ganglion.

Front 11

• Herpes Zoster might involve:

Back 11

• Sensory branch of the trigeminal nerve (5th Cranial Nerve

(CN)). • Motor and/or sensory branch of the facial nerve (7th CN).

Front 12

• Herpes Zoster:

• Clinical manifestations:

Back 12

• Age: > 50 years of age. • The lifetime risk of HZ in the general population ranges from 20–30% but the risk increases dramatically after 50 years of age with a lifetime risk of HZ reaching 50% at age 85 years.

Front 13

• Herpes Zoster:

• Clinical manifestations:

Back 13

• Prodromal signs: fever, malaise, headache, pain, tenderness, and paresthesia along the course of the affected nerve.

Unilateral severe itching with deep, aching or burning neuralgic pain.

• Constant or intermittent

• Radiating

• Unilateral linear or cluster distributed cutaneous vesicles appear 3 to 5 days later on an inflamed

base along the involved nerve • Vesicula lesions heal within 2 to 4 weeks often with scarring and hypopigmentation.

Front 14

• Herpes Zoster:

• Clinical manifestations:

Back 14

• The ophthalmic division of the 5 th CN (V1) is the cranial nerve most often affected resulting in

Herpes Zoster Ophthalmicus (HZO). • Ocular disease might occur in about 50% of HZO cases and manifestations can include :

• Conjunctivitis • Uveitis • Keratitis • Retinitis

• Corneal involvement may lead to blindness.

• Nearly 15% to 20% of cases of herpes Zoster of the trigeminal nerves affect either the

maxillary division (V2) or mandibular division (V3) causing pain, unilateral lesions, and intraoral lesions along the course of the affected nerve.

Front 15

Herpes Zoster:

• Clinical manifestations:

• Involvement of this nerve leads to lesions on:

Back 15

• Upper eyelid, forehead, and scalp with V1

• Midface and upper lip with V2

• Prodromal pain, burning and tenderness often on the palate unilaterally.

• This is followed several days later by the appearance of painful, clustered 1 to 5 mm ulcers (rarely vesicles, which break down quickly) on the hard palatal mucosa or even buccal gingiva, in a distinctive unilateral distribution

• Lesions heal within 10 to 14 days often with scarring and postherpetic neuralgia is uncommon.

Front 16

Herpes Zoster:

• Clinical manifestations:

Back 16

• Lower face and lower lips with V3

• With the involvement of V3, patients develop ulcers and blisters on the mandibular gingiva and tongue.

Front 17

Herpes Zoster:

• Diagnosis:

Back 17

• Often based on characteristic clinical signs and symptoms. • History and Exam:

1. Key diagnostic factors:

1.1Presence of risk factors (>50 years of age, HIV +ve, chronic corticosteroid use, chemotherapy and malignancies)

1.2 Localised pain in a dermatome

The pain is localised, burning, stinging, itching, or tingling and ranges from mild to severe.

Pain, localised to the affected dermatome, can precede the rash by days to weeks. ü The most commonly involved ganglia are the thoracic and trigeminal nerves.

Front 18

Herpes Zoster:

Diagnosis

Back 18

2. Investigations

2.1 Clinical diagnosis (No test or culture are required)

2.2 Investigations to consider:

ü Polymerase Chain Reaction (PCR)

üImmunohistochemistry

üHIV test (It is strongly recommended that patients with HZ should be offered an

HIV test because herpes zoster is an HIV indicator condition)

Front 19

Herpes Zoster: • Diagnosis:

• Differential diagnosis:

Back 19

• HSV

• Pemphigus or pemphigoid

• Acute Necrotizing Periodontitis

Front 20

Herpes Zoster:

• Treatment:

Back 20

• Mild: Analgesic (ibuprofen), 0.2% chlorhexidine mouthwash, Rifampicin, 5% Acyclovir ointment in cutaneous and ocular lesions).

• bSevere:

Antiviral Dose Frequency Duration (d)

therapy (mg) (x/d)

Acyclovir 800 7-10

Valacyclovir 1000 3 /7 Famciclovir 500 3 /7

• Immunocompromised: intravenous acyclovir 10-15mg/kg every 8 hours for 10 days.

Front 21

Herpes Zoster:

• Ramsay Hunt Syndrome:

Back 21

• It is a late uncommon complication of VZV infection, resulting in inflammation of the geniculate ganglion of the 7 th CN.

• Prodrome: fever, headache, malaise, pain localised to ear or radiating to jaws or neck.

• Orally:

• Unilateral localised oral pain in the n=anterior 2/3 of the tongue and soft palate followed by vesicles and ulceration • Facial Bell’s palsy- loss of taste sensation and hyperacusis “perception of sound as excessively loud and irritating”

• Tinnitus vertigo or deafness

Front 22

Herpes Zoster:

• Fate and treatment:

Back 22

• Rapid course with resolution in 7-10 days.

• A common short-term complication of Bell’s palsy is incomplete eyelid closure with resultant dry eye.

• A less common complication is permanent facial weakness with muscle contractures

• Treatment:

Antiviral Dose Duration (d)

therapy (mg)

Acyclovir. 500

Valacyclovir 1000 7-10

Famciclovir. 500

• High-dose corticosteroids are often administered as well, such as prednisone 60 mg daily for 10 days.

Front 23

• Herpes Zoster:

• Post Herpetic Neuralgia (PHN):

Back 23

It is defined as pain which remains for 120 days after the onset of acute rash.

• It is the most debilitating complication of herpes zoster.

• PHN affects up to 20% of patients aged >65 years and up to 30 to 50% of patients aged > 80 years.

• Patients experience pain of sharp, stabbing, burning, or gnawing nature lasting > 1 month.

• Patients might also experience allodynia “perception of light touch or the brush of clothing as painful”.

Front 24

Va ricella-Zoster Virus (VZV)

• Herpes Zoster:

Back 24

• Some unfortunate patients experience pain for years.

• Pain is due to inflammation & fibrosis of the affected nerve.

• It is not uncommon for the pain of PHN to interfere with sleep and recreational

activities and to be associated with clinical depression.

• Predisposing factors include:

ü Older age (Most important)

ü Prodromal pain

ü More severe clinical disease during the acute rash phase

Front 25

Herpes Zoster:

• Post Herpetic Neuralgia (PHN):

• Treatment:

Back 25

• Prevention is better by Acyclovir early in Shingles.

• Preventative therapy: Shingrix to reduce the incidence of PHN.

• 1 st line of treatment

• 5% lidocaine patch: Apply to affected area every 4 to 12 hours as needed.

• 0.8% topical capsaicin: Apply to affected area 3 to 5 times daily.

• Anticonvulsants Varicella-Zoster Virus (VZV)

Front 26

• Herpes Zoster:

• Post Herpetic Neuralgia (PHN):

• Treatment:

• 2 nd line of treatment:

Back 26

• High-dose corticosteroids are often administered as well, such as prednisone 60 mg daily for 10 days.

• Tricyclic antidepressants: Nortriptyline/amitriptyline: start a 10-20mg/d; increase dose in 10 mg increments every 3 to 5 to maximum of 100 mg/d days until satisfactory pain relief is achieved.

• Surgical treatment at level of peripheral nerve.