Viral infections- Exam 2 Flashcards
1
Q
_____ are the smallest of the microbes
A
viruses
2
Q
T/F: Viruses need a host cell to survive and reproduce
A
FALSE, can survive on inanimate objects but need a host cell to reproduce
3
Q
What are the 3 classification of viruses? Where do they each invade?
A
DNA- host cell nucleus
single stranded RNA viruses- host cytoplasm
retroviruses- host RNA
4
Q
_____ use reverse transcription to create a DNA copy of their RNA genome and insert it into the host cell - becomes a part of the host RNA
A
retroviruses
5
Q
Name some instances in which a viral infection can occur
A
Virus attaches to host cell
Viral DNA or RNA then enters the host cell and replicates inside host cell
The host cell typically dies - releasing new viruses that move on to infect other host cells.
6
Q
Where can you interrupt the viral infection process?
A
during each step of viral replication because it involves different enzymes
7
Q
What are some modes of transmission for viral infections?
A
Respiratory secretions (airborne droplets)
Enteric secretions (fecal-oral route)
Sexual contact (direct mucosal contact, semen/body fluids)
Blood (contaminated needles and blood products)
8
Q
What is classic herpes virus lesion presentation?
A
red base with vesicular lesions on top
9
Q
What family of viruses does herpes belong to? How many types can infect humans?
A
Herpesviridae
8 different types
10
Q
T/F: After a herpes infection the virus remains within specific host cells and can reactivate. They usually do not survive long outside the host
A
True
11
Q
Roseola infantum is caused by what herpes strand?
A
HHV 6-7
12
Q
Kaposi sarcoma is commonly found in what patient population? What strand?
A
AIDS patients
HHV8
13
Q
In general, HSV 1 affects the ____ region
HSV 2 affects the ____ region
A
1: oral
2: genital
14
Q
What are the risk factors for contracting HSV?
A
Female
History of STDs
Multiple sexual partners
Contact with sex workers
WSW
15
Q
_____ or ______can trigger an outbreak of lesions
A
immunocompromise
16
Q
How is HSV transmitted?
A
skin to skin contact, fluid from vesicle releases HSV
Can transmit infection without presence of vesicles
17
Q
What is the clinical presentation of HSV 1?
A
Vesicles forming crusts and moist ulcers
Singular or grouped
Lips (upper), nares, mouth
Pain, burning, tingling of skin
Pain with eating (if inside mouth)
Swollen lymph nodes
Low grade fever
18
Q
What is Herpetic Whitlow?
A
herpes on the finger
19
Q
What is the clinical presentation for HSV 2?
A
Multiple vesicles forming crusts and ulcers
Multiple, grouped, painful vesicles
May have pain or itching before appearance of lesions
External genitalia, vaginal canal, perianal
Pain, burning, tingling of skin
Dysuria
Cervicitis
Urinary retention
Swollen lymph nodes
Fever, body ache
20
Q
Severity of symptoms worse and duration typically longer with (first/second) outbreak!
A
initial outbreak
21
Q
What are some conditions that could trigger a HSV flare?
A
Febrile illness
Hormonal changes (pregnancy, menstrual cycle)
Physical or emotional stress
Overexposure to sunlight
22
Q
What is it called when HSV is in the eye?
A
HSV Keratoconjunctivitis
23
Q
Why is HSV Keratoconjunctivitis considered serious?
A
can lead to blindness
24
Q
What are some s/s of HSV Keratoconjunctivitis? How is it transmitted?
A
unilateral
Initially present with blepharitis
Impaired visual acuity
Pain, sensation of something in eye, photophobia
direct inoculation
very common in neonates
25
HSV Keratoconjunctivitis usually follow a _____ nerve spead
trigeminal
26
Name some less common presentations that are usually only seen in immunocompromised patients?
HSV Encephalitis
Disseminated (Pneumonia)
Esophagitis
Proctitis
27
What is the correct procedure to dx HSV?
-clinical appearance
- culture (either the vesicular fluid or scrapings of crust)
-PCR (or CSF if concerned about HSV encephalitis)
-Tzanck smear
28
What will the Tzanck smear of a HSV patient look like?
multinucleated giant cells
Can also be positive with Varicella; does not tell you if HSV 1 or 2
29
What is the process for dx HSV Keratoconjunctivitis?
dendritic lesions on fluorescein stain and slit-lamp examination
IMMEDIATE referral to ophthalmology
30
How long is the initial outbreak of HSV usually last? Recurrences?
10-20 days initial
5-10 days with recurrence
31
What is the treatment for genital HSV?
Antivirals to help shorten the duration and lessen severity
NO CURE!!
Oral acyclovir (Zovirax) 400 mg TID
valacyclovir (Valtrex) 500 - 1000 mg BID
famciclovir (Famvir) 250 mg TID
32
What are some topical anesthetics to recommend for minor symptomatic relief for HSV outbreaks?
dyclonine (Sucrets)
benzocaine (Anbesol)
Rx viscous lidocaine rinse (Magic Mouthwash)
33
What are the HSV antiviral treatments?
acyclovir (Zovirax)
famciclovir (Famvir)
valacyclovir (Valtrex)
34
of the antivirals, _____ comes in oral, liquid, IV and topical forms
acyclovir
35
What is an OTC topical antiviral treatment for HSV?
docosanol (Abreva) - OTC
36
What medication do you give for ophthalmic HSV keratitis?
trifluridine (Viroptic)
oral acyclovir
37
______ MOA Inhibit herpes viral DNA synthesis and replication
antivirals
38
antivirals: _____ and _____ are prodrugs - converted to active form in GI tract
valacyclovir (Valtrex)
famciclovir (Famvir)
39
Which antiviral is metabolized in the liver?
acyclovir
40
antivirals (do/do not) interact with CYP450 system and are primarily _____ excreted
DO NOT
renally excreted
41
What are the MC SE of antivirals?
GI symptoms
HA, dizziness, malaise
Arthralgia
42
What are the more serious SE of antivirals?
Leukopenia, thrombocytopenia
Neurologic manifestations - hallucinations, psychosis, seizures
43
Are antivirals considered safe in pregnancy?
generally yes, category B
44
_____ would be prescribed to a pt if the HSV strain is severely resistant to acyclovir. When is it commonly prescribed?
foscarnet (Foscavir)
M/C use for CMV infections in AIDS patients
45
**What are the BBW for antivirals?
MULTIPLE BLACK BOX WARNINGS:
Seizures
renal impairment causing toxicity
hematologic abnormalities
possible carcinogenic
46
What is the treatment for genital HSV on the initial episode? recurrent episode? When should treatment be initiated? (give both initial and recurrent)
Oral acyclovir (Zovirax) 400 mg TID
valacyclovir (Valtrex) 500 - 1000 mg BID
famciclovir (Famvir) 250 mg TID
for 7-10 days: initial
3-5 days: recurrent
48 hours after onset (no more than 72hrs)
first onset of symptoms (within 24 hours)
47
What is the treatment for oral HSV?
same as genital
plus
Topical 1% hydrocortisone 5% acyclovir cream (Zovirax ointment), penciclovir (Denavir)
48
What is the treatment for recurrent HSV prophylaxis?
acyclovir 400 mg BID daily
valacyclovir 500 mg QD daily
famciclovir 250 mg BID daily
same medication just at a once daily dosing
49
What do you give a patient with Disseminated/Neonatal HSV?
IV acyclovir
50
What are some ways to prevent HSV?
Barrier methods during sexual activity
C-section for women with active genital lesions
Sunscreen can reduce the occurrence of herpes labialis
51
______ is caused by the Varicella zoster virus (VZV) after the initial infection of chickenpox
Herpes Zoster (Shingles)
52
_____ remains dormant, then reactivates causing ______
Varicella zoster virus (VZV)
Herpes Zoster (Shingles)
53
What are 2 risk factors for developing Herpes Zoster (Shingles)?
older than 60
immunocompromised
54
Evolution of macules-papules-vesicles-crusts,
Lesion sits atop an erythematous base "dew drop on rose petal", severe pain commonly precedes rash.
What am I?
Herpes Zoster (Shingles)
55
Herpes Zoster (Shingles) follows a ____ distribution, normally _____, most common on the ___ and ____ regions. _____ nerve involvement
dermatomal
unilateral
thorax and lumbar regions
involves the trigeminal nerve
56
What is the most serious form of Herpes Zoster (Shingles)?
Herpes Zoster Ophthalmicus
57
What are Herpes Zoster (Shingles) lesions in the corner of eye and side of the nose referred to as _______. What can it cause?
Hutchinson's sign
blindness with severe eye involvement
58
What are common Herpes Zoster (Shingles) complications?
Post-herpetic neuralgia (Occurs in 30-40% of patients > 60 years of age)
Bacterial secondary skin infections
Vision loss (Herpes Zoster Ophthalmicus)
Bell's palsy
59
What are the treatment goals of Herpes Zoster (Shingles)?
Reduce duration
Lessen severity of symptoms
Reduce risk of post-herpetic neuralgia
60
What medications do you use to treat Herpes Zoster (Shingles)? When should treatment be initiated?
acyclovir (Zovirax), valacyclovir (Valtrex), famciclovir (Famvir)
Treatment should be started within 72 hours of onset of symptoms
61
What is the treatment for Herpes Zoster Ophthalmicus?
Considered an EMERGENCY!!
Admit for IV acyclovir
Topical steroids
62
What is the treatment for Post-Herpetic Neuralgia?
Opioids
TCA's
gabapentin (Neurontin)
63
What is the best way to prevent Shingles? Who qualifies for the prevention? What is the schedule?
zoster vaccine (RZV or Shingrix)
50 years and older
2 vaccines required 2-6 months apart whether or not they received Zostavax
64
What is the Shingles
prevention recommendation for pt who are immunocompromised?
19 years of age and older should receive 2 doses of RZV
think pts starting chemo
65
What is the best motivator to get the Shingles vaccine?
to avoid the extremely painful post-herpetic neuralgia
66
What strand of HSV is Epstein-Barr virus caused by? It is the causative agent for _____
human herpesvirus 4
Infectious Mononucleosis
67
How is Epstein-Barr Virus transmitted?
saliva or blood products
68
Malaise/fatigue, fever, sore throat, tonsillar enlargement, myalgia, posterior cervical lymphadenopathy, pharyngeal irritation
Splenomegaly (50% of patients)
Palatal petechiae
Maculopapular rash (20% of patients)
Epstein-Barr Virus
69
Maculopapular rash is common in 20% of patients who have Epstein-Barr Virus, the percentage jumps up to 90% in patient who have received _____
ampicillin
70
Concerned about Epstein-Barr Virus, what PE should you absolutely perform?
abdominal exam to check for Splenomegaly
71
super horrible sore throats are usually _____
viral
72
What are some common lab findings in mono?
low WBC
atypical large lymphocytes
elevated LFTs
73
Low WBC count, should be thinking _____
viral infection
74
What tests should you order to help confirm a EBV diagnosis?
Monospot
Heterophile agglutination (HA) antibody test
Blood smear
CBC
EBV antibodies
75
What will a blood smear look like on a pt with EBV?
atypical large lymphocytes
76
What will a CBC look like on a EBV pt?
Leukopenia, lymphocytosis
77
EBV antibodies: IgM will (rise/fall) with an acute infection
rise in acute infection
78
T/F: EBV antibodies: IgG will only be present during an acute infection
FALSE, IgG antibodies to EBV persist for life
79
What are some EBV complications you need to be mindful of? What education points should you tell your patients?
Splenomegaly/splenic rupture -> Avoid strenuous activity / contact sports
Hepatitis -> Watch for s/sx: jaundice, N/V, Monitor LFTs
80
What is the treatment for EBV?
supportive treatment only!!!
antivirals are NOT indicated
antibiotics are NOT indicated
81
EBV, which abx specially would you have to avoid?
Avoid all abx but amoxicillin especially!!
82
What is the prognosis for EBV?
Fever, sore throat - resolves in 10 days
LAN, splenomegaly - resolves in 4 weeks
Fatigue - can linger for months
Can rarely have a chronic EBV syndrome
Bells Palsy: usually last 2 weeks
83
What are the associated EBV disorders?
Burkitt Lymphoma
B-cell malignancies in immunocompromised persons
Nasopharyngeal carcinomas
84
____ of the population has cytomegalovirus, most are asymptomatic. What pt population might have symptoms?
60-90%
immunocompromised persons
85
How is CMV transmitted?
Transmitted via blood, body fluids, and transplacentally
86
What are the three clinical CMV syndromes?
CMV inclusion disease - newborns
Acute viral syndrome - immunocompetent persons
CMV disease - immunocompromised persons (HIV)
87
What are some s/s of CMV inclusion disease - newborns?
Hepatitis, mental retardation, hearing loss
Stillbirth
88
What are s/s of CMV Acute viral syndrome - persons?
Fever, malaise, arthralgias
Mono-like illness without the pharyngitis
89
What are s/s of CMV disease - immunocompromised persons (HIV)?
CMV Retinitis
GI (gastritis/colitis), Respiratory (pneumonitis), Neurologic (encephalitis) CMV
90
How do you diagnose CMV and what is the treatment?
serologic testing
ganciclovir- only for serious illnesses (CMV retinitis, encephalitis)
91
___ and ___ strains of HPV cause genital warts
HPV 6 and 11
92
___ and ___ strains of HPV cause cervical cancers
16 and 18 cause 70% of cervical cancers
93
How is HPV Condyloma acuminata transmitted? More common in men/women?
Sexually transmitted (vaginal, oral, anal)
More common in women
94
What is the incubation period for Condyloma acuminata HPV? When do they resolve?
3 weeks to 8 months
most resolve within 2 years
95
What is the clinical presentation of Condyloma acuminata HPV?
**Pedunculated lesion**
Scaly, raised, skin colored to pearly lesions
May have associated pruritus, burning, bleeding, or pain
96
How do you dx Condyloma acuminata? Do you need to biospy?
visual inspection
NO! clinical presentation is okay
97
What is the treatment for Condyloma acuminata HPV?
Chemical destruction
Podophyllin/Podofilox topical cream
Imiquimod (Aldara) topical cream
Cryotherapy (office)
Systemic treatment- Interferon
Laser surgery
OR
Surgical excision
98
What are the steps for HPV turning into cancer? What types of cancers can HPV cause?
HPV virus infection - sexually transmitted
Persistence of HPV infection
Progression of normal epithelial cells to precancerous cells
Development of carcinoma
Cervical
Anogenital
Oropharyngeal
Vulvar
Penile cancer
99
How are cervical cancers dx?
Typically asymptomatic
Found on routine screening: Pap smear
Can take bx to examine for other diseases
100
What is the treatment for cervical cancers?
Laser ablation
“Cone biopsy”/LEEP
Surgery
101
What is the prevention for cervical and anogentital cancer?
Gardasil - protects against HPV strains 6, 11, 16, 18, 31, 33, 45, 52, and 58
102
What is the HPV vaccine recommendation? What is the goal?
Females and males aged 11 - 12 (earliest is 9)
Catch up for females up to 26; males 21
No recommendations for >26; but approved up to age 45
Goal is to start BEFORE female or male is sexually active
103
Seasonal flu is caused by ___ or ___
flu A or B
104
Antigenic drift is (slow/sudden) change
slow, gradual change
105
Antigenic shift is (slow/sudden) change
sudden change
Little to no immunity/responsible for pandemics
106
How is the seasonal flu spread? What is the typical incubation period?
infected persons via respiratory droplets
Also by touching contaminated objects
1-4 days
107
H1N1 and H3N2v are considered the ___ flu
swine flu
108
H5N1 and H7N9 are considered the ___ flue
Bird flu
109
What is the clinical presentation of influenza?
Sudden onset fever, chills, headache, myalgia, malaise
Non-productive cough, sore throat, nasal discharge
110
How are strep and flu PE different from each other?
Strep: NO cough or nasal discharge
Flu: will have cough and nasal discharge
111
What are some complications from flu?
Secondary bacterial infections - pneumonia, sinusitis
Rhabdomyolysis, myositis
CNS involvement - encephalitis, aseptic meningitis
Cardiac complications
112
What is the testing for influenza? what is the common problem?
Rapid Influenza Diagnostic Test (RIDTs)
NP swab, nasal aspirate
Detects both A and B within several minutes
Problem - high false negative rate
113
If you patient is in the hospital will flu, what should you order to help confirm your diagnosis?
Viral culture:more definitive testing
Should be conducted for all hospitalized patients or if different strain suspected
Results in 2-3 hours; but culture may take up to 5 days
114
What is the treatment for influenza?
Antipyretics
Fluids
Analgesics
Antiviral Medications
115
Which flu medications cover both A and B? What class of medication?
oseltamivir (Tamiflu)- oral
zanamivir (Relenza)- inhaled
peramivir (Rapivab)- IV
Neuraminidase Inhibitors
116
What medications only cover flu A? What class of medication?
amantadine
rimantadine
NMDA receptor antagonists
117
**What is the dosing for Oseltamivir capsules? What is the dosage based on?
75mg bid x 5 days
age and weight
118
**What form is Zanamivir come in? Dosing?
inhaler
2 inhalations BID for 5 days
119
What is the Neuraminidase Inhibitors MOA?
prevents replication so the s/s do not last as long and are not as severe
120
When do you need to start Neuraminidase Inhibitors?
Need to start medications within 48 hrs of symptoms
121
All flu medications can be used for treatment and prophylaxis of flu except ____
Except peramivir (Rapivab) - treatment only
122
What is the population criteria in order to use zanamivir?
ages 7 and up (5 or up for prophylaxis)
Do not use zanamivir in persons with lung disorders
123
What is the prescribing information for peramivir (Rapivab)?
peramivir (Rapivab) 600 mg IV
Infuse over 15 - 30 minutes; Single dose
Only for adults > 18
124
What are the SE of Neuraminidase Inhibitors?
N/V/D, headache
Can cause behavioral disturbances (rare)
125
The SE _____ is seen with Zanamivir (Relenza)
bronchospasm
126
______ is primarily renally excreted and dosing needs to be adjusted for renal failure
Oseltamivir (Tamiflu)
127
Who is the flu vaccine recommended for? What pt population is it VERY important for?
Routine annual vaccinations of all persons aged 6 months and older
Young children
Persons >50
Persons with chronic cardiopulmonary disease
Persons with immunodeficiency
Pregnant women
Healthcare personnel (HCP)
Persons who live with or care for persons at high risk
128
What month should you get your flu vaccine in?
October
129
the normal flu shot is _____ vs the intranasal flu vaccine is ____
Inactivated Influenza Vaccine (IIV)
Live Attenuated Influenza Vaccine (LAIV)
130
What are the causative agents for viral pneumonia?
Influenza
Respiratory syncytial virus (RSV)
Parainfluenza virus
Adenovirus
Coronaviruses
131
______ also causes pneumonia and bronchiolitis in children
Respiratory syncytial virus (RSV)
132
_____ also causes laryngotracheobronchitis (Croup) in children
Parainfluenza virus
133
______ also a cause of the “common cold”
Adenovirus
134
What is the clinical presentation for viral pneumonia?
Fever, chills, myalgias
Nonproductive cough
May have rhonchi on PE
135
What would your treatment be for a patient with viral pneumonia?
antivirals and supportive care
136
Adenovirus can cause lots of other mild, self limiting presentations. Name some.
Respiratory illness (cold)
Viral pneumonia
Diarrhea
Conjunctivitis
Pharyngitis
137
What are the three arboviruses?
West Nile Virus
La Crosse encephalitis
Zika Virus
138
Name a rhabdovirus.
Rabies
139
West Nile Virus is ____ transmitted. In its mild form how does it present?
mosquito
Fever, HA
Body aches
N/V/D
Rash
can lead to more severe neurologic illness
140
What does serious west nile virus present as?
High fever
Severe HA/stiff neck
Confusion
Stupor/coma
Seizures
Muscle weakness
Paralysis
141
How do you dx West Nile? What is the treatment? Prevention?
Lumbar puncture with CSF testing
supportive care
mosquito control
142
_____ is transmitted by a mosquito, can be asymptomatic or present with fever, HA, N/V/D, fatigue. Is also neuroinvasive and can lead to seizures, coma, paralysis and death. Most severe disease presents in patients who are ____
La Crosse Virus
Most severe disease occurs in patients <16
143
What is the treatment for La Crosse Virus? Prevention?
Supportive care
mosquito control
144
What is the way a human can get infected with rabies? Name some common animals
through a bite of an infected animal
usually a bats, raccoons, skunks, foxes, woodchucks, and coyotes
145
What is the pathophys behind rabies?
Travels from site of bite through nervous system
Affects the brain = Encephalitis
Lead to death if untreated
146
What is the initial presentation of rabies? When do the neurologic symptoms start to appear?
flu like illness than lasts for 2-3 days
2-10 days: anxiety, confusion, agitation
Progresses: delirium, abnormal behavior, hallucinations, insomnia
147
Once a person starts to exhibit neurologic s/s, what is the prognosis?
survival is rare (only 10 documented cases per CDC) once neurologic
148
What should you do if your patient was bitten by a potentially rabid animal?
Wash wound immediately
Report to doctor / ED
Post exposure prophylaxis (PEP)
-1 dose immune globulin
-4 doses of rabies vaccine over a 14 day period
Given on day 1, 3, 7, and 14
Current vaccines are given in arm (not
as painful)
149
