Viral infections in the immunocompromised Flashcards
There are two strains of the herpes simplex virus (HSV) in humans.
Cold sores nearly always []
Genital herpes classically []
Cold sores nearly always HSV-1
Genital herpes classically HSV-2
Describe how you manage these complications of HSV”
gingivostomatitis: [2]
cold sores: [1]
genital herpes: [1]
gingivostomatitis:
- oral aciclovir
- chlorhexidine mouthwash
cold sores::
- topical aciclovir although the evidence base for this is modest
genital herpes:
- oral aciclovir. Some patients with frequent exacerbations may benefit from longer term aciclovir
What is the protocal for pregnant patients if they are < 28 weeks and have a primary attack of HSV? [1]
elective caesarean section at term is advised if a primary attack of herpes occurs during pregnancy at greater than 28 weeks gestation
Passmed:
- elective caesarean section at term is advised if a primary attack of herpes occurs during pregnancy at greater than 28 weeks gestation
women with recurrent herpes who are pregnant should be treated with suppressive therapy and be advised that the risk of transmission to their baby is low
Describe the presentation of genital herpes [5]
- Ulcers or blistering lesions affecting the genital area
- Neuropathic type pain (tingling, burning or shooting)
- Flu-like symptoms (e.g. fatigue and headaches)
- Dysuria (painful urination)
- Inguinal lymphadenopathy
How do you diagnose genital herpes? [2]
The diagnosis can be made clinically based on the history and examination findings.
A viral PCR swab from a lesion can confirm the diagnosis and causative organism.
Primary genital herpes contracted before [] weeks gestation is treated with [] during the initial infection.
This is followed by regular prophylactic [] starting from 36 weeks gestation onwards to reduce the risk of genital lesions during labour and delivery.
Primary genital herpes contracted before 28 weeks gestation is treated with aciclovir during the initial infection.
This is followed by regular prophylactic aciclovir starting from 36 weeks gestation onwards to reduce the risk of genital lesions during labour and delivery.
Recurrent genital herpes in pregnancy, where the woman is known to have genital herpes before the pregnancy, carries a low risk of neonatal infection (0-3%), even if the lesions are present during delivery.
Regular prophylactic [] is considered from [] weeks gestation to reduce the risk of symptoms at the time of delivery.
Recurrent genital herpes in pregnancy, where the woman is known to have genital herpes before the pregnancy, carries a low risk of neonatal infection (0-3%), even if the lesions are present during delivery.
Regular prophylactic aciclovir is considered from 36 weeks gestation to reduce the risk of symptoms at the time of delivery.
HSV
After an initial infection, the virus becomes latent in the associated [].
Typically this is the [] with cold sores and the sacral nerve ganglia with genital herpes.
. After an initial infection, the virus becomes latent in the associated sensory nerve ganglia.
Typically this is the trigeminal nerve ganglion with cold sores and the sacral nerve ganglia with genital herpes.
What is the name for this complication of HSV? [1]
hepatic whitlow
What is the name for this complication of HSV? [1]
herpes keratitis
Describe if HSV in post-transplant suffer from new / old infections [1]
90% UK adults will have evidence of past infection with HSV-1
Most HSV infections post transplant are therefore due to reactivation not primary infection
How do you diagnose HSV? [1]
Swab area/lesion -> PCR
Describe the difference in primary and recurrent HSV infections [2]
Primary infection: frequently asymptomatic, may experience pharyngitis, fever, ulceration and lymphadenopathy
Recurrence: very common, classically, prodromal tingling followed by localised painful blisters that resolve over 5 – 7 days
What does VZV have a risk of causing in an IC patient? [1]
Shingles
How do you distinguish between shingles and chickenpox? [1]
The lesions in shingles are all at a similar stage, whereas in chickenpox they are all different (e.g blister / ulcer / papule)
State 5 complications of VZV infection [5]
- A common complication is secondary bacterial infection of the lesions
- pneumonia
- encephalitis (cerebellar involvement may be seen)
- disseminated haemorrhagic chickenpox
- arthritis, nephritis and pancreatitis may very rarely be seen
VZV infection
immunocompromised patients and newborns with peripartum exposure should [].
If chickenpox develops then [] should be considered
immunocompromised patients and newborns with peripartum exposure should receive varicella zoster immunoglobulin (VZIG).
If chickenpox develops then IV aciclovir should be considered
How does VZV specifically cause disease? [1]
Inhibits viral DNA polymerase.
Acylcvir toxicity can cause what syndrome? [1]
Describe it x
Cotard syndrome.:
- rare mental disorder in which the affected person holds the delusional belief that they are dead, do not exist, are putrefying, or have lost their blood or internal organs
Which viruses do you screen for in stem cell transplant patients? [3]
ACE
- Adenovirus
- CMV
- EBV
Describe the presentation of CMV [1]
Which cells is it latent in? [1]
mononucleosis like picture and hepatitis
Latent in monocytic cells (blood and bone marrow) and can reactivate in immunosuppression
Describe the highest risk of CMV transfer for a solid organ transfer [1]
Recipient is CMV recipient -ve but CMV donor status is +ve
Describe the highest risk of CMV transfer for a stem cell transfer [1]
CMV donor status: -ve
CMV recipient status: +ve
Giving the recipient stem cells that aren’t able to respone to previous CMV infection
what is the gold standard CMV dx? [1]
Histology
What are three key manifestations of CMV in IC patients? [3]
Retinitis
Pneumonitis
Oesphagitis
How do you manage CMV:
- prophylactically
- pre-emptive therapy
Prophylactically:
- ARV use after transplant to bridge period with highest risk
Pre-emptive therapy:
- monitor CMV activity after transplant and start ARV at first indication of active CMV replication (because tx can suppress bone marrow - so you dont want to do this if not needed)
Describe typical CMV congenital infection presentation [6]
- growth retardation
- pinpoint petechial ‘blueberry muffin’ skin lesions
- microcephaly
- sensorineural deafness
- encephalitiis (seizures)
- hepatosplenomegaly
Describe how CMV retinitis presents [1]
Which patient population? [1]
common in HIV patients with a low CD4 count (< 50)
presents with visual impairment e.g. ‘blurred vision’. Fundoscopy shows retinal haemorrhages and necrosis, often called ‘pizza’ retina
How do you treat CMV retinitis? [1]
IV ganciclovir is the treatment of choice
Which are the CMV anti-viral drugs can use? [3]
Ganciclovir
Ciclovir
Foscarnet - used for CMV resistence
Describe the two main complications of EBV in IC patients [2]
Post Transplant Lymphoproliferative Disorder (PTLD)
* Usually first year post transplant
* 3- 10% of patients post SOT
* 40 – 60% mortality
Lymphoma - NHL in transplant patients, also common in HIV patients
What are the risk factors for Post Transplant Lymphoproliferative Disorder (PTLD) [5]
- EBV seronegative prior to transplant i.e. associated with primary infection
- Children < 5 years
- Antirejection therapy(OKT3 or ATG)
- CMV seromismatch
- Type of transplant
Which type of transplant is most likely to have Post Transplant Lymphoproliferative Disorder (PTLD) in EBV infection?
Heart/lung, lung, pancreatic-renal
Small bowel
Heart, liver
Renal, bone marrow
Which type of transplant is most likely to have Post Transplant Lymphoproliferative Disorder (PTLD) in EBV infection?
Heart/lung, lung, pancreatic-renal
Small bowel
Heart, liver
Renal, bone marrow
Describe the symptoms of PTLD EBV [5]
- Unexplained fever
- GI upset
- Lymphadenopathy - retroperitnoneal
- Tonsillar hypertrophy
- IM
- Hepatic /splenic enlargement
- Anaemia/pancytopenia
- Graft dysfunction
What is a main stay treatment for PTLD? [1]
Rituximab
How does adenovirus present in healthy people [3] and IC people [6]
Healthy people:
* Respiratory disease (usually mild and self-limiting)
* Keratoconjunctivitis
* Gastroenteritis
Immunosuppressed:
* pneumonia
* hepatitis
* haemorrhagic cystitis
* enterocolitis
* encephalitis
* disseminated infection
State the risk factors for adenovirus disease in transplant patients [4]
Children»_space; adults;
severe GVHD
cord blood transplant,
alemtuzumab conditioning;
liver, heart, multivisceral SOT
How do you detect adenovirus in immunosuppressed? [2]
What should you do if test postive in ^? [1]
Screening via blood & urine PCR
If positive - test at other sites including resp & stool
How do you treat adenovirus in IC? [1]
Brincidofovir (or reduce level of immunosuppression)
Name two polyomaviruses that are cirtical in IC [2]
JC virus and BK virus
Describe life cycle of JC virus and BK virus [2]
Initial viraemia and seeding of kidney –> latency
Reactivation: viruria –> viraemia –> end-organ disease
Describe the three main syndromes with of JC and BK viruses [3]
BK virus-associated haemorrhagic cystitis (usually allogeneic HSCT recipients)
BK virus-associated nephropathy (BVAN, renal transplant recipients)
JC-PML
How do you detect COVID-19? [1]
Detection of viral RNA viral by PCR
Nasopharyngeal swab
How do you treat COVID (in normal patients):
- Moderate infection [1]
- Severe infection [3]
Mild-mod: conservative
Hospital: dexamethasone + remdesivir
(nucleotide analogue), CPAP
