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(C) CM 1B: ID/EENT > Lecture 7: Viral Diseases Part 1 > Flashcards

Lecture 7: Viral Diseases Part 1 Flashcards

1
Q

What are the 3 types of viruses?

A

DNA virus
Single stranded RNA virus
Retrovirus

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2
Q

What is unique about a retrovirus?

A

Their RNA becomes directly integrated with the host’s RNA.

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3
Q

What is the difference in replication of a DNA virus vs a RNA virus?

A

DNA viruses replicate in the NUCLEUS.
RNA viruses replicate in the CYTOPLASM.

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4
Q

Where do we interrupt the viral replication process?

A

Whenever it requires an enzyme to go to the next step.

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5
Q

How many types of herpes viruses are there?

A

8

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6
Q

What is unique about the herpes virus in terms of infection?

A

After you get infected once, it remains latent and can re-activate at a later time.

It can turn normal cells into malignant cells.

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7
Q

What are the 8 herpes viruses?

A

HSV1
HSV2
VZV
EBV
CMV
HHV6 & 7
HHV8

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8
Q

What does HSV1 generally affect? HSV2?

A

HSV1 = oral

HSV2 = genital

1 mouth 2 balls

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9
Q

What is a sex-related risk factor for contracting HSV?

A

WSW

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10
Q

What other way can you contract HSV besides through sexual contact?

A

Fluid from lesions.

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11
Q

What can trigger outbreaks of HSV lesions?

A

Hormonal changes
Immunocompromised state.

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12
Q

What are some signs of HSV1?

A

Mucocutaneous lesions.

Often described as vesicles in the upper lips, nares, and mouth.

Herpetic whitlow (digital vesicular lesions)

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13
Q

What are some signs of HSV2?

A

Multiple vesicles forming crusts and ulcers.
Commonly appear on external genitalia, vaginal canal, and perianal.

May have pain or itching prior.

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14
Q

How does HSV as an oral infection typically present?

A

Pain, burning, tingling of skin
Pain with eating (if inside mouth)
Swollen lymph nodes
Low grade fever

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15
Q

How does HSV severity change with subsequent outbreaks?

A

The initial outbreak is generally the worst, with longer and worse symptoms.

After you get exposed and it flares up again, the symptoms are generally more milder.

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16
Q

How does HSV as a genital infection present?

A

Pain, burning, tingling of skin
Dysuria
Cervicitis
Urinary retention
Swollen lymph nodes
Fever, body aches

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17
Q

What generally causes an IP admission because of HSV?

A

Urinary retention.

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18
Q

How does HSV stay in the body?

A

Remains dormant in NERVE GANGLIA.

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19
Q

What are general triggers for HSV flares?

A

Febrile illness
Hormonal changes (Pregnancy, menstruation)
Physical or emotional stress
Overexposure to sunlight

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20
Q

If a person has HSV lesions near their eye, what am I worried about?

A

HSV Keratoconjuctivitis.

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21
Q

What is HSV keratoconjuctivitis?

A

A dangerous complication of HSV infections that affect the eye.

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22
Q

How does HSV keratoconjuctivitis present?

A

Typically:

unilateral blepharitis with associated impaired visual acuity, eye pain, photophobia, and a sensation that there is something in the eye.

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23
Q

What is the danger of having HSV keratoconjuctivitis?

A

Trigeminal nerve spread. Opthalmology consult is indicated ASAP if suspicious.

Blindness and permanent visual changes.

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24
Q

What are some uncommon presentations of an HSV infection seen usually only in immunocompromised pts?

A

HSV encephalitis
Disseminated (Pneumonia)
Esophagitis
Proctitis

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25
Q

What are some of the diagnostic tests to confirm an HSV infection?

A

Cultures
PCR (CSF for HSV encephalitis)
Tzanck smear (multinucleated giant cells = positive for HSV or VZV in general)

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26
Q

What are the pitfalls of the tzanck smear?

A

Can be positive from varicella. Non-specific between HSV1 and 2.

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27
Q

How is HSV keratoconjuctivitis diagnosed?

A

Dendritic lesions when examined with a slit-lamp and stained with fluorescein.

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28
Q

Why is HSV not screened for?

A

Practically everyone has it.
It is self-limiting in most cases.
No cure.

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29
Q

Why are antivirals used for HSV?

A

Shorten duration
Lessen severity
Prophylaxis for people with recurrent flares.

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30
Q

For HSV in the mouth, what are some things we can recommend to patients?

A

Topical anesthetics:
Dyclonine (sucrets)
Benzocaine (Anbesol, cannot use on babies)
Magic mouthwash

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31
Q

What is the magic mouthwash formula?

A

1/3 lidocaine/xylocaine
1/3 maalox/mylanta
1/3 benadryl

3oz, 2 refills, take TID or QID.

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32
Q

What should I counsel patients on regarding using the magic mouthwash?

A

If you swallow it by accident, you may feel drowsy dt the benadryl.

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33
Q

Why would I recommend topical ABX to a patient with herpetic lesions?

A

Picking of the lesions can lead to a secondary staph/strep SSTI.

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34
Q

What are the 3 main antivirals for HSV? What is the primary one?

A

Acyclovir (Zovirax) - PRIMARY, since cheap and comes in like every formulation.
Famciclovir (Famvir)
Valacylovir (Valtrex)

FAV antivirals

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35
Q

What is the antiviral for an HSV infection in the eye?

A

Trifluridine (Viroptic)

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36
Q

What is an OTC antiviral we can recommend to patients for HSV?

A

Docosanol/abreva

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37
Q

What common antivirals are renally excreted? Liver metabolized?

A

Valtrex and Famvir are RENALLY EXCRETED.

Acyclovir is liver metabolism.

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38
Q

Which common antiviral is not a prodrug?

A

Acyclovir

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39
Q

What should I monitor for a patient on an antiviral?

A

BUN/Cr.

Valcyclovir and famciclovir are dangerous in renal failure.

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40
Q

Are antivirals ok in pregnancy?

A

Generally considered safe, cat B.

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41
Q

When is foscavir indicated for HSV?

A

Resistance to acyclovir, but mainly used in CMV infections for AIDS patients.

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42
Q

What is the only indication for ganciclovir and valganciclovir?

A

CMV infections in AIDS.

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43
Q

What are the BBW of ganciclovir and valganciclovir?

A

Seizures
Renal impairment
Hematologic abnormalities
Possible carcinogen

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44
Q

How long do you treat a patient with an initial outbreak of genital HSV?

A

7-10 days on any of the 3 common antivirals.

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45
Q

When should treatment begin for an genital HSV infection?

A

Within 48 hrs of onset and before 72 hours have passed.

Recurrences should be within 24 hrs.

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46
Q

What are the tx options for Oral HSV?

A

Oral antivirals
Zovirax ointment (hydrocortisone 1% + acyclovir 5%)
Penciclovir (Denavir)
OTC Docosanol (Abreva)

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47
Q

How do I treat HSV prophylactically for recurrent patients?

A

Same 3 antivirals. Dosing is 1 less per day than if you actually had the infection active.

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48
Q

What is the treatment for HSV Keratitis?

A

Trifluridine drops + Oral acyclovir

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49
Q

What is the treatment for Disseminated/neonatal HSV?

A

IV Acyclovir.

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50
Q

What are some prevention methods for HSV?

A

Barrier methods during sex
C-section for women with genital lesions
Sunscreen

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51
Q

What is the etiology of Shingles/Herpes Zoster?

A

Previous infection with VZV (Varicella zoster virus)

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52
Q

What kind of vaccine is the shingles vaccine?

A

Inactivated recombinant vaccine.
Shingrix/RZV

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53
Q

What are the main risk factors for shingles?

A

Age > 60
Immunocompromised

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54
Q

What is the common description of a skin lesion in chickenpox or shingles?

A

Dew drop on a rose petal.

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55
Q

What is a common symptom prior to the rash in shingles?

A

PAIN

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56
Q

How does shingles typically present?

A

Unilateral, dermatomal lesions.

MC in thorax and lumbar.

57
Q

What is the concern with shingles on the face?

A

Trigeminal nerve involvement
Blindness
Herpes Zoster opthalmicus

58
Q

What is Hutchinson’s sign?

A

Lesions in the corner of the eye and side of the nose.

59
Q

What is the main complication of Shingles?

A

Post-herpetic neuralgia, which occurs in 30-40% of patients > 60y.

Causes prolonged, DEBILITATING pain.

60
Q

What are some other complications of shingles?

A

Bacterial secondary skin infections
Vision loss (Herpes zoster opthalmicus)
Bell’s palsy

61
Q

How do we treat shingles?

A

Generally, it is self-limiting.

Our treatment goals are mainly to reduce duration, lessen severity, and reduce the risk of post-herpetic neuralgia.

Antivirals: Zovirax, Famvir, Valtrex within 72 hours of onset.

62
Q

How do we treat herpes zoster opthalmicus?

A

ER admission with IV acyclovir and topical steroids.

63
Q

How do we manage post-herpetic neuralgia?

A

Opioids
TCAs
Gabapentin/Neurontin

64
Q

What is the current Herpes zoster vaccine?

A

RZV or Shingrix.

Previous is Zostavax.

65
Q

Who gets RZV/Shingrix?

A

People => 50y
2 vaccines 2-6 months apart, even if you got zostavax already.

66
Q

How efficacious is RZV/Shingrix?

A

90% reduction in shingles and PHN incidence.

67
Q

What is the primary reason we vaccinate for shingles?

A

To reduce the risk of PHN.

68
Q

What causes Mono?

A

EBV, aka HHV4

69
Q

What are the common symptoms of infectious mononucleosis?

A

Malaise/fatigue, fever, sore throat, tonsillar enlargement, myalgia
Classic triad: sore throat, posterior cervical LAN, fever
Often presents as very exhausted.

70
Q

What are the common signs of infectious mononucleosis?

A

POSTERIOR CERVICAL LAN
Pharyngeal irritation
Splenomegaly (50% of pts)
Palatal petechiae
Maculopapular rash in 20% of pts.

71
Q

Bonus: What increases the rash percentage to 90% in infectious mononucleosis?

A

Erroneous administration of ampicillin when misdiagnosed with strep!

72
Q

Bonus: What throat complaint common presents with ANTERIOR cervical LAN?

A

Strep throat

73
Q

How do we diagnose EBV/Mononucleosis?

A

Monospot: heterophile agglutination test

Blood smear: Atypical large lymphocytes

CBC: leukopenia and lymphocytosis

EBV Antibodies: IgM or IgG

74
Q

Who is a monospot not recommended in?

A

Children < 5

75
Q

What are some complications of EBV?

A

Splenomegaly/splenic rupture.
Hepatitis
CNS involvement

76
Q

What labs should we monitor in mono pts?

A

LFTs and CBCs

77
Q

How do we treat EBV?

A

Fluids and antipyretics

NO antivirals, NO abx

78
Q

How long does it take Mono to resolve typically?

A

10 days for the fever and sore throat.
4 weeks for the LAN and splenomegaly
Fatigue can last for months.

79
Q

What are the associated disorders with EBV?

A

Burkitt lymphoma
B-cell malignancies in immuncomped pts
Nasopharyngeal carcinomas.

80
Q

How prevalent is CMV?

A

60-90% of the population has it asymptomatically.

81
Q

What is unique about CMV transmission?

A

Transplacental is possible!

82
Q

What are the 3 clinical syndromes from CMV?

A

CMV inclusion disease in newborns
Acute viral syndrome in regular people
CMV disease in immunocomped people

83
Q

How does CMV inclusion disease present?

A

Hepatitis, mental retardation, hearing loss
Stillbirth

84
Q

How does acute viral syndrome due to CMV present?

A

Fever, malaise, arthralgia (Like mono without the pharyngitis)

85
Q

How does CMV disease in immunocompromised pts present?

A

CMV retinitis + GI irritation + pneumitis + Encephalitis

86
Q

How is CMV diagnosed?

A

Serologic testing

87
Q

When is CMV treated and how?

A

Only for severe presentiations such as CMV retinitis, encephalitis, or CMV inclusion disease

Ganciclovir (newborns use this one specifically) or valganciclovir
Foscarnet (Foscavir)

88
Q

How is HPV transmitted?

A

Sexual contact only.

89
Q

How many strains of HPV exist?

A

100+, but we most only care about 4! :)

90
Q

What are the important strains of HPV and what do they cause?

A

HPV 6 & 11 do genital warts (condyloma acuminatum)
HPV 16 & 18 do 70% of cervical cancers and are the #1 cause of cervical cancer.

16 is the primary cause.

91
Q

What does HPV infect?

A

Epithelial tissue

92
Q

What is a unique way HPV can be transmitted?

A

Birth canal, so newborns can get it.

93
Q

What gender commonly gets condyloma acuminata more?

A

Women

94
Q

What is the main concern of condyloma acuminata?

A

Increased risk of malignancy.

95
Q

How does condyloma acuminata present?

A

Scaly, raised, skin colored to pearly lesions
Often occur in clusters and may be pedunculated.

Occurs anywhere in genital, perineal, or anal region.

Associated pruritis, burning, bleeding, or pain

96
Q

How do we diagnose condyloma acuminata?

A

Clinical diagnosis
Anoscopy, speculum exam, Colposcopy to assess extent of involvement to guide treatment

97
Q

How do we treat condyloma acuminata?

A

Chemical Destruction: Podophyllin/podofilox

Cryotherapy in the office
Systemic treatment (interferon)
Laser surgery/Surgical excision
Aldara cream/topical

98
Q

How is podophyllin/podofilox used?

A

Spread it around the base of lesion

99
Q

What should we counsel pts on regarding HPV and cervical cancer?

A

Potential of malignancy

Cervical, oropharyngeal, vulvar, and penile cancer

100
Q

How is HPV typically found?

A

Pap smear and routine screenings

101
Q

How do we treat cervical cancer?

A

Laser ablation
Cone biopsy/LEEP
Surgery

102
Q

How is HPV prevented?

A

HPV Vaccine Gardasil!!!

Cover strains: 6,11,16,18 (primary 4), and 31,33,45,52,58

AKA Gardasil 9

103
Q

Who can get Gardasil? When should you get it?

A

As young as 9

Best to be given prior before becoming sexually active

104
Q

What are the two primary causes of seasonal influenza?

A

Influenza A or B

105
Q

How do influenza viruses mutate?

A

Antigenic drift (slow changes, like they’re drifting in the wind)
Antigen shift (Sudden change, sudden shift)

106
Q

What kind of mutation can we predict in influenza virus? Why is it significant?

A

Antigenic drift.

We cannot predict antigenic shift, which is when pandemics occur.

107
Q

What are some pandemic-level influenza strains in the past?

A

H1N1 2009 (swine)
H3N2v 2012 (swine)

H5N1 (bird flu, highly pathogenic), began in 2003
H7N9 (china only)

108
Q

How does influenza typically present?

A

Sudden onset of fever, chills, HA, myalgia, and prostration/malaise.

Non-productive cough, sore throat, nasal discharge

PE is typically unremarkable

109
Q

What kind of CXR would I see on influenza?

A

Clear. Similar to atypical pneumonia.

110
Q

What are the complications of influenza?

A

Secondary bacterial infections like pneumonia or sinusitis.

Rhabdomyolysis, myositis

Encephalitis, aseptic meningitis

Cardiac complications

111
Q

How do we diagnose influenza?

A

RIDT (rapid influenza diagnostic test)
NP swabs, nasal aspirate
HIGH FALSE NEGATIVE RATE

Viral cultures

112
Q

When do we order viral cultures for influenza suspicion?

A

All hospitalized patients or a different strain of influenza is suspected.
Takes much longer.

113
Q

What are the general treatment options for influenza?

A

Antipyretics
Fluids
Analgesics
Antivirals

114
Q

What two drug classes are indicated for Influenza?

A

Neuraminidase inhibitors (A and B)

NMDA Receptor Antagonists (A only)

115
Q

What are the neuraminidase inhibitors?

A

Oseltamivir (Tamiflu) Oral
Zanamivir (Relenza) Inhalation
Peramivir (Rapivab) IV

116
Q

What are the NMDA receptor antagonists?

A

Amantadine (mainly for parkinson’s)
Rimantadine

117
Q

What is the concern with NMDA receptor antagonists?

A

Growing resistance in strain A.

118
Q

Which antivirals can be used prophylactically for influenza also?

A

Tamiflu and Zanamivir (Relenza)

119
Q

What is the dosing for tamiflu?

A

75mg PO BID x 5 days

120
Q

When are neuraminidase inhibitors supposed to be started?

A

Within 48 hours of onset.

121
Q

What is Relenza CId in?

A

People with lung disorders

122
Q

What should we counsel patients in regards to neuraminidase inhibitors?

A

GI SE (sometimes very strong and people prefer the flu over treating it)
Bronchospasms with Relenza
Rare Behavioral disturbances

123
Q

How is tamiflu excreted?

A

Renally. Must adjust for renal failure.

124
Q

When can you start getting the flu vaccine?

A

October generally.

Starting at 6mo and older.

125
Q

What are the two types of common flu vaccines?

A

Inactivated influenza vaccine (flu shot)
Live attenuated influenza vaccine (IN administration)
Flumist (CId in lung disorders)

126
Q

What are the primary causes of viral pneumonia in adults?

A

Influenza virus
RSV (Also causes pneumonia and bronchiolitis in children)
Parainfluenza (Also causes croup in kids)
Adenovirus (also the common cold)
Coronaviruses

127
Q

How does viral pneumonia often present?

A

Fever, chills, myalgia
NON-PRODUCTIVE cough
Possible bilateral rhonchi
Non-diagnostic CXR

128
Q

What is the treatment for viral pneumonia?

A

Antipyretics and fluids.

129
Q

What does adenovirus do in general?

A

Affects every mucuous membrane in the body.

130
Q

What can adenovirus do to urine?

A

Sterile pyuria

131
Q

What are two other viruses that cause minor respiratory diseases?

A

Rhinovirus (common cold)
Adenovirus

132
Q

What animals are reservoirs of Rabies?

A

Bats
Raccoons
Skunks
Foxes
Woodchucks
Coyotes

133
Q

How is rabies almost always transmitted?

A

BITE of an infected animal.

134
Q

What does rabies eventually cause?

A

Encephalitis.

135
Q

Why is rabies so dangerous?

A

Irreversible binding, so it must be treated ASAP.

136
Q

What is the survival rate of someone who is exhibiting neurological symptoms from rabies?

A

Extremely rare.

10 cases have survived per the CDC.

137
Q

What are some neurologic symptoms from rabies?

A

Initially: Anxiety, confusion, agitation

Progresses: Delirium, abnormal behavior, hallucinations, insomnia.

Seizures + hydrophobia

138
Q

How do we treat Rabies?

A

Immediately wash the wound and go to the ER!!

Requires 1 dose of immune globulin and 4 doses of a rabies vaccine over a 2 week period. 1,3,7,14 (aka the day doubles + 1 pretty much)

(C) CM 1B: ID/EENT (27 decks)

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