Viral infections and treatment CIS

Question 1

influenza vs common cold

Answer 1

Flu: abrupt onset, fever, aches, chills, fatigue, chest discomfort, cough, headache
sometimes sneezing, stuffy nose , sore throat

Cold: gradual onset, sneezing stuffy nose sore throat common

Question 2

missed the window for flu treatment (48 hours), what would you do?

Answer 2

just symptomatic treatment

Question 3

how do we treat flu within 48 hours of onset?

Answer 3

oseltamivir

goal being to decrease duration of symptoms

Question 4

most common side effect of osteltamivir?

Answer 4

diarrhea

Question 5

Neuraminidase Inhibitors ADRs

Answer 5

Oseltamivir – nausea, vomiting, abdominal pain (5-10%), headache, fever, diarrhea, neuropsychiatric effects

watch out in kids

Question 6

what do we use as prophylaxis for influenza?

Answer 6

oseltamivir

Question 7

agents that inhibit uncoating of viral RNA

Answer 7

amantidine, rimantidine

Question 8

agents that inhibit release of progeny viruses

Answer 8

neurominidase (oseltamivir)

Question 9

agent that inhibits cell wall synthesis

Answer 9

beta lactam

Question 10

agent that inhibit DNA polymerase

Answer 10

acyclovir, etc.

Question 11

agent that inhibits ergosterol synthesis

Answer 11

-azoles, anti-fungals

Question 12

oseltamivir blocks

Answer 12

release of new influenza A and B virions

Question 13

Neuraminidase Inhibitors MOA and examples

Answer 13

Oseltamivir (PO), zanamivir (INH), peramivir (IV)

MOA: analogs of sialic acid, interferes with release of progeny influenza virus from infected host cell
Active against influenza A and B

Question 14

how do rimantadine and amantadine work?

Answer 14

prevents uncoating of influenza A (not B) viral RNA within host cell

Question 15

M2 Channel Blockers examples and MOA

Answer 15

Amantadine (PO), rimantadine (PO)
MOA: block M2 proton ion channels of virus inhibiting uncoating of viral RNA within host cell
Active against influenza A only

Question 16

Caution should be exercised with administration of which drug in patients with underlying COPD or asthma?

Answer 16

Zanamivir – ADR: cough, bronchospasm, decrease in pulmonary function (reversible), nasal/throat discomfort, not recommended in underlying airway disease

Question 17

Respiratory Syncytial Virus (RSV)- when to suspect, how to diagnose

Answer 17

Suspected:
Age < 12 months
Lower respiratory tract disease
Winter season
Known circulation of RSV

Laboratory diagnosis:
Nasal wash
Bronchoalveolar lavage
Rapid assays (antigen capture technology) can now be performed in < 30 minutes
PCR

Question 18

RSV treatment

Answer 18

Supportive care:
Fluid and respiratory support

Pharmacotherapy:
Bronchodilators (albuterol or epinephrine)
Used if patient wheezing, discontinue if there is not rapid improvement
Hypertonic saline
Has potential to reduce airway edema and mucus plugging but not recommended
Ribavirin
Routine use not recommended, efficacy not clearly proven

Question 19

Ribavirin

Answer 19

Aerosol inhalation

MOA: nucleoside analog, inhibits replication of RNA and DNA viruses; inhibits viral protein synthesis

May be toxic to exposed healthcare workers and variably efficacious –> AAP recommends against routine use

Reserved for life-threatening disease

Question 20

Palivizumab (Synagis)

Answer 20

Monoclonal antibody (IM injection)

Used monthly throughout RSV season
Max of 5 doses per season

MOA: inhibits RSV replication via neutralizing and fusion inhibitory activity

Used for prophylaxis, NOT for treatment

Safety and efficacy established in:
Bronchopulmonary dysplasia (BPD)
History of premature birth (under 35 weeks gestational age)
Hemodynamically significant congenital heart disease (CHD)

Question 21

most likely etiology of retinitis in an HIV + person with CD4 count of 45 is

Answer 21

CMV

can also cause disease throughout the GI tract
Watery diarrhea
Colitis of colon with blood and inflammation

Question 22

Treatment of CMV

Answer 22

Ganciclovir initially if absorption a question with PO medications

Valganciclovir for 3-6 weeks
ART start after CMV retinitis excluded or two weeks after start of CMV treatment

Question 23

Pneumocystis Pneumonia

Answer 23

Ubiquitous fungus

Causes pulmonary disease in immunocompromised hosts

Before TMP-SMX use, incidence of PCP was 70-88% in lung-transplant recipients
With prophylaxis, this risk virtually eliminated

TMP-SMX prophylaxis continued 6 months to 1 year after organ transplant

Question 24

CMV

Answer 24

Most common opportunistic infection following solid organ transplant

Acquired from:
Donated allograft
Blood products transfused from a seropositive donor
Reactivation of endogenous virus

Occurs between 1-4 months after transplant without viral prophylaxis

Those at highest risk of CMV disease:
D+/R-
Those with latent CMV who require antilymphocyte antibodies as part of induction therapy

Question 25

CMV treatment

Answer 25

Historically, treatment was only given once CMV disease occurred Signs and symptoms: fever, leukopenia, or organ involvement (hepatitis, pneumonitis, pancreatitis, colitis, rarely myocarditis) This resulted in overall incidence of 20-60% With prophylaxis, this has fallen to 5% Prophylaxis generally given for 200 days

Question 26

What is the difference between valganciclovir and ganciclovir?

Answer 26

Valganciclovir is the L-valyl ester prodrug of ganciclovir. | Ester prodrug improves oral bioavailability from about 7  70%

Question 27

How is chicken pox spread?

Answer 27

respiratory droplets

Question 28

How is Varicella-zoster virus (VZV) prevented in adults?

Answer 28

Varicella Zoster Vaccine – Live attenuated vaccine

Question 29

What are the contraindications for Varicella-zoster Vaccine?

Answer 29

Vaccine contraindicated in hematologic malignant neoplasms, AIDS, HIV infection with CD4 count of 200/mm3 or lower, and in persons receiving high dose immunosuppressive therapy, or anti-tumor necrosis factor–α therapy.

Question 30

You would like to prescribe acyclovir for your patient. Why is acyclovir virus specific?

Answer 30

Initial phosphorylation step via virus specific thymidine kinase.

Question 31

What is a major limitation of acyclovir?

Answer 31

Very low oral bioavailability – must be given up to 5 times a day

Question 32

VZV treatment effectiveness

Answer 32

Treatment most effective when started within 72 hours of onset of rash Antivirals decrease the duration of herpes zoster rash and severity of pain Moderate reductions in development of postherpetic neuralgia  variable results in clinical trials

Question 33

Rubeola

Answer 33

Measles spread by large respiratory droplets Cough, coryza, and conjunctivitis How long is the child infectious? 4 days prior to rash, until 4 days after rash appears

Question 34

What are some of the major complications of measles?

Answer 34

Pneumonia Post-infectious encephalomyelitis Subacute sclerosing panencephalitis

Question 35

prevention of measles?

Answer 35

MMR – live attenuated vaccine | Given at 12-15 months and 4-6 years

Question 36

mumps transmission and prevention

Answer 36

How is mumps transmitted? Respiratory droplets How is mumps prevented? MMR vaccination

Question 37

Ebola

Answer 37

Non-segmented, negative-sense, single stranded RNA virus Hemorrhagic fever virus - Coagulation defects - Capillary leak syndrome - Shock Transmission - Ingestion - Inhalation - Breaks in skin - Contact with infectious body fluids (blood, feces, vomit, urine, saliva, tears) - Droplet inoculation of virus into mouth or eyes in nonhuman primates Abrupt onset of symptoms 8-12 days after exposure (range 2-21 days) S/S: nonspecific flu-like illness, rash, watery diarrhea, nausea, vomiting, hemorrhage (petechiae, ecchymosis, oozing from puncture sites, mucosal hemorrhage

Question 38

Ebola treatment

Answer 38

Supportive care: Intravenous fluid repletion (up to 5-10 L per day) Correction of electrolyte abnormalities (Na+, K+, Ca2+) Nutrition support Intensive nursing care (rapidly changing clinical picture) Experimental therapy: ZMapp: three monoclonal antibodies directed against Ebola viral glycoprotein TKM-Ebola, RNA interference agent suppresses production of viral proteins, Phase I started Jan 2014

Question 39

Enterovirus D68

Answer 39

Transmitted from person to person through fecal-oral contact Poliovirus is a prototypical enterovirus Can cause bronchiolitis and pneumonia which can be severe and lead to mechanical ventilation Low grade fever, wheezing, dyspnea, hypoxia, and perihilar infiltrates primarily in children with a history of asthma

Question 40

Enterovirus D68 Neurologic Manifestations

Answer 40

Children with acute limb weakness and/or cranial nerve dysfunction Moderate lymphocytic pleocytosis in the CSF Nonenhancing grey matter spinal cord lesion on MRI similar to polio Enterovirus D68 was identified in nasopharyngeal specimens from a subset of these patients, but not from the CSF

Question 41

Dengue Fever

Answer 41

Mosquito Vector Fevers, muscle pains, headache, and possible hemorrhage No conjunctivitis

Question 42

Chikungunya

Answer 42

Mosquito Vector High Fever, intense joint pains affecting hands, feet, knees, and back Patients are in such severe pain that they can’t stand straight or walk No conjunctivitis

Question 43

Parvovirus

Answer 43

Symmetric arthritis of hands, wrists, knees, and feet | Rash may or may not be present

Question 44

Rubella

Answer 44

Fever and coryza | Macular rash may or may not be present

Question 45

Zika Virus

Answer 45

Mosquito-borne flavivirus – Aedes mosquito Africa, Southeast Asia, Pacific Islands, and Americas ``` Clinical Manifestations Acute onset of low grade fever Maculopapular pruritic rash Arthralgias(hands and feet) Conjunctivitis ``` Serious Clinical Manifestations Congenital microcephaly Fetal Loss Guillain-Barre syndrome Incubation 2-14 days No specific treatment ``` Prevention Protective measures to avoid mosquitos Disease can be sexually transmitted Men may carry disease for 6 months Women may carry disease for 2 months ```