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EBAC - Infectious Disease > Varicella-Zoster Virus Disease > Flashcards

Varicella-Zoster Virus Disease Flashcards

1
Q

What percentage of adults born in the United States have immunity to varicella-zoster virus (VZV)?

A

More than 95%

This immunity is mostly due to primary VZV infection, known as varicella (or chickenpox).

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2
Q

What is the incidence of herpes zoster in the general population?

A

About 3.6 cases per 1,000 person-years

Higher incidence is seen among elderly and immunocompromised individuals.

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3
Q

How does antiretroviral therapy (ART) affect the incidence of herpes zoster in adults with HIV?

A

ART reduces the incidence of herpes zoster but the risk remains threefold higher than in the general population

This is likely due to immune restoration.

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4
Q

What are the common clinical manifestations of varicella rash?

A

Central distribution with lesions evolving through stages: macules, papules, vesicles, pustules, and crusts

Accompanied by pruritus, fever, headache, malaise, and anorexia.

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5
Q

What is the most common site for herpes zoster?

A

Thoracic dermatomes (40% to 50% of cases)

Followed by cranial nerve (20% to 25%), cervical (15% to 20%), lumbar (15%), and sacral (5%) dermatomes.

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6
Q

What is Hutchinson sign in herpes zoster?

A

Vesicles on the tip of the nose indicating nasociliary branch involvement

This can lead to herpes zoster ophthalmicus (HZO).

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7
Q

What are the complications associated with herpes zoster ophthalmicus (HZO)?

A

Keratitis, anterior uveitis, scarring, neovascularization, necrosis, and loss of vision

These complications can be chronic.

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8
Q

What is the recommended treatment for acute retinal necrosis (ARN) and progressive outer retinal necrosis (PORN)?

A

No specific treatment is mentioned; both conditions are associated with high rates of vision loss

ARN can occur in immunocompetent and immunocompromised patients, while PORN occurs almost exclusively in patients with AIDS.

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9
Q

How can varicella be diagnosed clinically?

A

Typically distinctive in appearance; can also be diagnosed by documenting seroconversion

In immunocompromised persons, distinguishing from disseminated herpes zoster may be challenging.

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10
Q

What is the recommended prophylaxis for people with HIV who are susceptible to VZV after exposure?

A

Post-exposure prophylaxis with VariZIG as soon as possible, preferably within 96 hours

Up to 10 days after exposure is acceptable.

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11
Q

What is the live attenuated varicella vaccine recommended for?

A

To prevent primary infection (varicella) in children with HIV who have relatively preserved immune systems (CD4 percentage ≥15%)

It also reduces the risk of subsequent herpes zoster.

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12
Q

What is the FDA-approved vaccine for the prevention of herpes zoster in immunocompetent adults?

A

Recombinant zoster vaccine (RZV) Shingrix

It is administered on a 2-dose schedule.

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13
Q

What is the efficacy of the recombinant zoster vaccine (RZV) against herpes zoster?

A

97.2% overall and 91.3% in those aged ≥70 years

Based on Phase 3 clinical trials involving over 30,000 participants.

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14
Q

What is the recommended interval for varicella vaccination after administering VariZIG?

A

At least 5 months

If post-exposure acyclovir has been administered, an interval of at least 3 days is recommended.

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15
Q

True or False: Long-term prophylaxis with anti-VZV drugs is recommended to prevent varicella.

A

False

Long-term prophylaxis is not routinely recommended.

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16
Q

What is the risk associated with CD4 counts <200 cells/mm3 in relation to herpes zoster?

A

Highest risk of herpes zoster-related complications, including disseminated herpes zoster

The central nervous system is a target organ for herpes zoster dissemination in these patients.

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17
Q

What percentage of vaccine recipients reported Grade 3 local reactions?

A

9.4%

This includes reactions such as redness and swelling.

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18
Q

What percentage of vaccine recipients reported Grade 3 systemic events?

A

10.8%

Systemic events include myalgia, fatigue, headache, fever, and gastrointestinal symptoms.

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19
Q

Which group had more frequent systemic Grade 3 reactions after vaccination?

A

Dose 2 recipients

Systemic Grade 3 reactions were reported more frequently after Dose 2 than after Dose 1.

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20
Q

What is the median age of participants in the Phase 1/2 study of RZV for people with HIV?

A

46 years

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21
Q

What is the schedule for administering the RZV vaccine?

A

0, 2, and 6 months

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22
Q

What were the most common side effects reported in the RZV study?

A
  • Pain at the injection sites (98.6%)*
  • Fatigue (75.3%)*
  • Myalgia (74.0%)*
  • Headache (64.4%)

Grade 3 side effects were also noted for these symptoms.

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23
Q

What is the recommendation for RZV vaccination in people with HIV aged 18 years and older?

A

Administer RZV following the FDA-approved schedule for persons without HIV (IM dose at 0 and 2–6 months) (AIII)

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24
Q

Should RZV be administered during acute episodes of herpes zoster?

A

No

RZV is not a treatment for herpes zoster and should not be given during acute episodes.

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25
Q

What is the preferred treatment for uncomplicated varicella in adults with HIV?

A
  • Valacyclovir (1 g PO three times daily)*
  • Famciclovir (500 mg PO three times daily)

Treatment should be initiated as early as possible after lesion onset.

26
Q

What is the recommended initial treatment for severe or complicated varicella in people with HIV?

A

IV acyclovir (10 mg/kg every 8 hours for 7 to 10 days) (AIII)

27
Q

What should be done if no evidence of visceral involvement with VZV is apparent after IV treatment?

A

Switch from IV to oral antiviral therapy after the patient has defervesced (BIII)

28
Q

What antiviral therapy should be initiated for herpes zoster diagnosed within 1 week of rash onset in people with HIV?

A
  • Oral valacyclovir (AII)*
  • Famciclovir (AII)*
  • Acyclovir (BII)

Treatment should be for 7 to 10 days.

29
Q

Is adjunctive corticosteroid therapy recommended for herpes zoster in people with HIV?

A

No

No data support its benefit in this population (AIII).

30
Q

What is the treatment recommendation for patients with Herpes Zoster Ophthalmicus (HZO)?

A

Topical corticosteroids

Chronic, low-dose therapy may be necessary to maintain suppression of inflammation.

31
Q

What is the recommended treatment for Acute Retinal Necrosis (ARN)?

A
  • High-dose IV acyclovir (10 mg/kg every 8 hours for 10 to 14 days)*
  • Followed by prolonged high-dose oral valacyclovir (1 g three times daily) (AIII)

Intravitreal injections of ganciclovir may also be included.

32
Q

What should be done for patients with suspected or proven acyclovir-resistant VZV infections?

A

Treatment with IV foscarnet is recommended (AII)

33
Q

What is the timing recommendation for starting ART in people with HIV?

A

As soon as possible after diagnosis (AIII)

34
Q

What should be monitored after starting ART in relation to VZV?

A

Increased frequency of VZV reactivation

This peaks around 3 months after ART initiation.

35
Q

What is the risk of herpes zoster after initiating ART?

A

Increased twofold to fourfold between 4 and 16 weeks after initiation

36
Q

What should pregnant women with HIV do if exposed to VZV?

A

Receive VariZIG as soon as possible (within 10 days) (AIII)

37
Q

What is the risk of transmitting VZV to the infant when varicella occurs during pregnancy?

A
  • 0.4% if infection occurs at or before 12 weeks*
  • 2.2% if infection occurs at 13 to 20 weeks*
  • Negligible after 20 weeks
38
Q

What is the recommended treatment for pregnant women with HIV who have uncomplicated varicella?

A

Oral acyclovir or valacyclovir (BIII)

39
Q

What antiviral therapy is recommended for uncomplicated herpes zoster in pregnant women with HIV?

A

Oral acyclovir or valacyclovir (BIII)

40
Q

What is the indication for varicella vaccination in adults and adolescents with HIV?

A

Adults and adolescents with HIV who have CD4 counts ≥200 cells/mm3 and lack documentation of vaccination, history, or diagnosis of varicella or herpes zoster.

41
Q

What should VZV-susceptible household contacts do to prevent transmission to at-risk individuals?

A

They should be vaccinated.

42
Q

What is the recommended administration schedule for primary varicella vaccination in VZV-seronegative persons aged ≥18 years?

A

Two doses (0.5 mL SQ) 3 months apart.

43
Q

What is the recommended treatment if vaccination results in disease due to live-attenuated vaccine virus?

A

Treatment with acyclovir is recommended.

44
Q

How long should one wait before varicella vaccination after receiving post-exposure VariZIG?

A

≥5 months.

45
Q

What is contraindicated for severely immunocompromised individuals with HIV regarding varicella vaccination?

A

Administration of varicella vaccine.

46
Q

What is the preferred prophylaxis for close contacts of individuals with active varicella or herpes zoster?

A

VariZIG 125 IU/10 kg IM, administered as soon as possible and within 10 days after exposure.

47
Q

What alternative prophylaxis can be used 7-10 days after exposure to VZV?

A
  • Acyclovir 800 mg PO 5 times daily for 5 to 7 days
  • Valacyclovir 1 gm PO 3 times daily for 5 to 7 days.
48
Q

What is the only available vaccine for the prevention of shingles in the United States?

A

Recombinant zoster vaccine (RZV, Shingrix).

49
Q

What is the vaccination schedule for RZV in adults with HIV?

A

2-dose series at 0 and then at 2 to 6 months.

50
Q

What is the preferred therapy for uncomplicated primary varicella infection?

A
  • Valacyclovir 1 g PO 3 times a day
  • Famciclovir 500 mg PO 3 times a day.
51
Q

What is the recommended treatment duration for uncomplicated primary varicella infection?

A

5 to 7 days.

52
Q

What is the preferred therapy for severe or complicated primary varicella infection?

A

Acyclovir 10 mg/kg IV every 8 hours for 7 to 10 days.

53
Q

What is the preferred therapy for acute localized herpes zoster?

A
  • Valacyclovir 1,000 mg PO 3 times a day
  • Famciclovir 500 mg PO 3 times a day.
54
Q

What should be done for extensive cutaneous lesions or visceral involvement in herpes zoster?

A

Acyclovir 10 mg/kg IV every 8 hours until clinical improvement.

55
Q

What is the recommended treatment for acute retinal necrosis (ARN)?

A
  • Acyclovir 10 mg/kg IV every 8 hours for 10 to 14 days
  • Followed by valacyclovir 1 g PO 3 times a day for ≥14 weeks.
56
Q

What is strongly recommended for treating progressive outer retinal necrosis (PORN)?

A

Involvement of an experienced ophthalmologist.

57
Q

What should be considered when determining the duration of therapy for PORN?

A

Clinical, virologic, and immunologic responses in consultation with an ophthalmologist.

58
Q

What is the maximum dose of VariZIG for prophylaxis?

59
Q

True or False: Valacyclovir should be given within 72 hours after the last dose of antiviral drug if used as pre-emptive intervention.

60
Q

Fill in the blank: The duration of therapy for herpes zoster is ________.

A

7 to 10 days.

EBAC - Infectious Disease (36 decks)

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