Chicken pox and shingles

Question 1

chicken pox is is caused by _______________ virus

Answer 1

varicella-zoster virus

Question 2

Up to ______ of susceptible contacts develop the disease

Answer 2

Up to 90% of susceptible contacts develop the disease

Question 3

Transmission is by personal contact or _________, with an incubation period of _______________.

Answer 3

Transmission is by personal contact or droplet spread, with an incubation period of 1–3 weeks.

Question 4

Chickenpox is infectious from _______days before _______ appears

Answer 4

Chickenpox is infectious from 1–2 days before the rash appears.

Question 5

the vesicles are dry or have crusted over, usually about ___________ days after the onset of the rash.

Answer 5

the vesicles are dry or have crusted over, usually about 5 days after the onset of the rash.

Question 6

The virus persists in ______________

Answer 6

sensory nerve ganglia of the dorsal root.

Question 7

Chickenpox is usually a _____________ in healthy children.

Answer 7

self-limiting disease

Question 8

chickenpox Complications include:

______________, is most common in young children.

Answer 8

Bacterial skin infection is most common in young children.

Question 9

chickenpox Complications include:

_____________ is more common in adults.

Answer 9

Lung involvement is more common in adults.

Question 10

chickenpox Complications include:

In pregnancy, _______________ and _____________.

Answer 10

In pregnancy, severe maternal chickenpox and fetal varicella syndrome.

Question 11

chickenpox Complications include:

In later pregnancy, varicella can result in ____________________.

Answer 11

In later pregnancy, varicella can result in neonatal chickenpox infection.

Question 12

chickenpox Complications include:
In immunocompromised people, severe disseminated chickenpox with ___________, ____________, ___________, and ____________.

Answer 12

In immunocompromised people, severe disseminated chickenpox with varicella pneumonia, encephalitis, hepatitis, and hemorrhagic complications.

Question 13

The clinical features of chickenpox include:

Prodromal symptoms such as _______, ________, ________, _______, general malaise, and ____________.

Answer 13

Prodromal symptoms such as nausea, myalgia, anorexia, headache, general malaise, and loss of appetite.

Question 14

The clinical features of chickenpox include:

Small, erythematous macules appear on the ____-, _____, ____, and _______, and progress over ___ hours to papules, clear vesicles (which are intensely itchy), and pustules. Vesicles can also occur on the _____ and _____, and ________, with painful and shallow oral or genital ulcers. Vesicles appear in ________. Crusting occurs usually within 5 days, and crusts fall off after _____ weeks.

Answer 14

Small, erythematous macules appear on the scalp, face, trunk, and proximal limbs, and progress over 12–14 hours to papules, clear vesicles (which are intensely itchy), and pustules. Vesicles can also occur on the palms and soles, and mucous membranes, with painful and shallow oral or genital ulcers. Vesicles appear in crops. Crusting occurs usually within 5 days, and crusts fall off after 1–2 weeks.

Question 15

Antiviral treatment Criteria
neonates less than one month of age should receive __________ to prevent severe disease. In these instances, your patient should be____________.
Children between the ages of 1 month to 12 years - antiviral are ______________, as this is a ________.
Adolescents (14 years or older) and adults - antiviral could be considered to reduce the severity of the condition ONLY IF ______________.
Immunocompromised patients should always be__________________ as antivirals will be required.
Pregnant women - chickenpox can be problematic in pregnancy particularly if the patient has not previously had a chickenpox infection. Patients falling onto this category may require ____________, so should always be referred to their GP or hospital as a matter of urgency.

Answer 15

Antiviral treatment Criteria
neonates less than one month of age should receive antiviral medication to prevent severe disease. In these instances, your patient should be referred to the GP or the Hospital to seek specialist advice.
Children between the ages of 1 month to 12 years - antiviral are not usually required, as this is a self-limiting infection.
Adolescents (14 years or older) and adults - antiviral could be considered to reduce the severity of the condition ONLY IF started within 24 hours of the rash developing.
Immunocompromised patients should always be referred to the GP or hospital to seek specialist advice, as antivirals will be required.
Pregnant women - chickenpox can be problematic in pregnancy particularly if the patient has not previously had a chickenpox infection. Patients falling onto this category may require antiviral therapy, so should always be referred to their GP or hospital as a matter of urgency.

Question 16

Despite having a rash, this little girl really wants to go back to school, so Mum asks if this would be allowed?

Answer 16

When answering this question, the little girl would not be allowed to attend school at the current time because she is still contagious. Once all of her lesions are dry and have crusted over (this is normally around 5 days after the onset of the rash) the patient is no longer infectious and can return to school.

Question 17

Mum is also concerned about the itching, stating that she is finding it hard to stop her little girl itching the vesicles. What advise could you give to this little girls Mum to help elevate her symptoms?

5

Answer 17

Cool baths are often nice to reduce intense itching and these should be encouraged.
Calamine cream/lotion can also help to reduce itching. The lotion does tend to dry out more quickly compared to the cream however it is patient choice as to which they prefer to use.
Oral antihistamines can also be considered to reduce the intense itching.
Analgesics can also be used to reduce any pain, however avoid NSAIDs.
Mum should also be counselled to look out for secondary skin infections, which can often be common due to bacteria entering the skin through the damage caused by intense itching.
Second patient presentation

Question 18

A 60year old hospital administrator
Notices pain on his right side about a week ago
Before it hurts, it had a real odd sensation when he touched the area, sort of pins and needle sensation
Then two days ago, two red spots emerged
No other symptoms at all but he’s been under considerable stress
Got a rash above his belly button going from front of the stomach round to the back

Differential diagnosis- patient is suffering from a viral infection

Should this patient receive treatment?

what is the diagnosis?

Answer 18

Yes

shingles.

Question 19

antiviral treatment of Shingles differs from that discussed for the treatment of Chickenpox. An oral antiviral drug should be started within ______ hours of rash onset, to reduce pain and severity for:
Anyone aged _______ years and over.
People aged less than 50 years should receive treatment if their infection is associated with any of the following criteria:

Patients presenting with _________involvement should seek immediate specialist advice, as a pharmacist you should __________ immediately.
Immunocompromised patients are at risk of severe infections, again these patients should be __________.
Non-truncal involvement (such as shingles affecting the neck, limbs, or perineum).
Patients suffering _____________ may well benefit from treatment.
Patient suffering from a____________, would also benefit from treatment.

Answer 19

antiviral treatment of Shingles differs from that discussed for the treatment of Chicken pox. An oral antiviral drug should be started within 72 hours of rash onset, to reduce pain and severity for:
Anyone aged 50 years and over.
People aged less than 50 years should receive treatment if their infection is associated with any of the following criteria:

Patients presenting with ophthalmic involvement should seek immediate specialist advice, as a pharmacist you should refer these patients immediately.
Immunocompromised patients are at risk of severe infections, again these patients should be referred to a GP or the hospital for specialist advice.
Non-truncal involvement (such as shingles affecting the neck, limbs, or perineum).
Patients suffering moderate or severe pain may well benefit from treatment.
Patient suffering from a moderate or severe rash, would also benefit from treatment.

Question 20

If you are not able to start treatment within 72 hours of rash onset you can also consider:
Starting an antiviral drug up to one week after rash onset particularly if the person is at higher risk of _______________.
For immunocompetent children suffering from shingles, antiviral treatment is not usually recommended, as this is a self-limiting infection.
Supportive treatment for this patient
this patient reports that the rash is painful. They would benefit from either______, _________, or even ________ don’t forget to consider the dose!!

Answer 20

If you are not able to start treatment within 72 hours of rash onset you can also consider:
Starting an antiviral drug up to one week after rash onset particularly if the person is at higher risk of severe shingles or complications (for example continued vesicle formation, older age, immunocompromised, or in severe pain).
For immunocompetent children suffering from shingles, antiviral treatment is not usually recommended, as this is a self-limiting infection.
Supportive treatment for this patient
this patient reports that the rash is painful. They would benefit from either paracetamol, ibuprofen, or even co-codamol - don’t forget to consider the dose!!

Question 21

Post-herpetic neuralgia can occur due to nerve damage cause by the varicella-zoster virus. This does not happen to all patients however it is something you need to keep in mind when dealing with patients suffering from shingles.
The symptoms include:

Answer 21

Post-herpetic neuralgia can occur due to nerve damage cause by the varicella-zoster virus.  This does not happen to all patients however it is something you need to keep in mind when dealing with patients suffering from shingles.
The symptoms include:
Burning
Aching
Itching
Electric shock sensation

Question 22

These symptoms normally reside in around four weeks however a proportion of patients may experience post-herpetic neuralgia for up to ___________.

Answer 22

These symptoms normally reside in around four weeks however a proportion of patients may experience post-herpetic neuralgia for up to 24 months.

Question 23

Treatment options for post-herpetic neuralgia include

Answer 23

Paracetamol +/- codeine to help with the pain.
Amitriptyline (off-label), duloxetine (off-label), often prescribed for chronic pain.
Anticonvulsants e.g., pregabalin, gabapentin, often prescribed to relieve the chronic neuropathic pain.
Counter-irritants e.g., capsaicin cream, often also prescribed to relieve the neuropathic pain.
Oral corticosteroids such as prednisone (with antiviral medication) are often prescribed to reduce the duration of acute neuralgia.

Question 24

Varicella-zoster Vaccination

There are now vaccines available to prevent Varicella-zoster infections, particularly in those within at-risk groups.

The vaccines now available include:

______ and ________

Active immunization against varicella in patients who have been found to be seronegative with respect to the varicella-zoster virus.
Although not offered as part of the routine vaccination schedule, these can be used to protect adults who have not suffered a Varicella-zoster infection in the past.

Zostavax
This can be used for the prevention of shingles and post-herpetic neuralgia.
It is also indicated for immunization of some ___________-year-olds on the NHS!

Answer 24

Varicella-zoster Vaccination

There are now vaccines available to prevent Varicella-zoster infections, particularly in those within at-risk groups.

The vaccines now available include:

Varilrix and Varivax

Active immunization against varicella in patients who have been found to be seronegative with respect to the varicella-zoster virus.
Although not offered as part of the routine vaccination schedule, these can be used to protect adults who have not suffered a Varicella-zoster infection in the past.

Zostavax
This can be used for the prevention of shingles and post-herpetic neuralgia.
It is also indicated for immunization of some 70 – 80-year-olds on the NHS!