Varicella and herpes zoster.pptx

VARICELLA CHICKENPOX Dr. Oana-Alexandra Ganea  Varicella is an infectious disease caused by VZV (varicella-zoster virus), one Definitio of the eight herpesviruses known to cause human n infection. VZV usually causes two disti...

VARICELLA CHICKENPOX Dr. Oana-Alexandra Ganea  Varicella is an infectious disease caused by VZV (varicella-zoster virus), one Definitio of the eight herpesviruses known to cause human n infection. VZV usually causes two distinct forms of disease: varicella (chickenpox) and herpes zoster (shingles).  Species Genus HHV-1 HSV-1 Simplexvirus Subfamily HHV-2 Alphaherpesviri HSV-2 nae HHV-3 Varicellovirus VZV HHV-5 Cytomegalovirus Family CMV Betaherpesvirin Herpesviridae ae HHV-6A HHV-6B Roseolovirus HHV-7 Lymphocryptovi HHV-4 rus EBV Gammaherpesvi rinae HHV-8 Rhadinovirus KSHV https://en.wikipedia.org/wiki/Varicella_zoster_virus#/media/File:Varicella_(Chickenpox)_Virus_PHIL_1878_lores.jpg; https://www.researchgate.net/figure/Taxonomy-of-the-family-Herpesviridae-as-determined-by-the-International-Committee-on_fig1_343269211; https://microbenotes.com/varicella-zoster-virus/; https://www.alamy.com/stock-photo/varicella-virus.html. Infecti on Incubation Prodrome Eruption 14 days 1-2 days 10-15 days 10-21 days Fever, chills, malaise, headache, sore throat Asymptomatic Polymorphic rash, lymphadenopathies Not contagious Contagious  Positive diagnosis Epidemiol Clinical Laborator ogy signs y findings Only in atypical presentations  1. Epidemiology Contact with Patient has a confirmed never had the varicella case disease/is not 2-3 weeks vaccinated prior to onset 2. Clinical presentation Rash: ◦ Vesicles with clear fluid and an erythematous base ◦ Generalised – including the head, palms, soles, mucous membranes ◦ Most elements are on the face and trunk ◦ Polymorphic (at the same time we can see macules, papules, vesicles, umbilicated vesicles, crusts) ◦ Develops in crops ◦ Very itchy ◦ The elements don’t scar unless they become superinfected (if the patient scratches) https://www.sciencephoto.com/media/252523/view/close-up-of-a-chickenpox-vesicle-lesion- 2. Rash in chickenpox Each element goes through the Umbilicated vesicle following stages: (pseudopustule) 1.macule 2. papule Crust 3.vesicle Vesicle 4.Umbilicate d vesicle (pseudopust Papule ule) 5.crust https://renumadan.files.wordpress.com/2017/04/varicella_stages-of-pox-rash.jpg Enantem ◦Because of the humidity, vesicles rapidly become erosions that are very painful https://www.verywellhealth.com/chicken-pox-pictures-402040 3. Laboratory findings – non- specific CBC - leukopenia or lymphomonocytosis Inflammatory syndrome absent (normal ESR, Fbg, CRP) If the lesions become superinfected  leukocytosis with neutrophilia. 3. Laboratory findings – specific tests VZV IgM antibodies present  varicella Serologic tests – ELISA - IgM + VZV IgG antibodies present (in the IgG antibodies detection absence of IgM)  previous immunisation ( natural or vaccine) – NOT varicella PCR – detection of VZV DNA from VZV DNA in CSF = varicella encephalitis. vesicle fluid, CSF, amniotic fluid– VZV DNA in BAL = varicella pneumonia useful in atypical cases VZV DNA in AF  fetal infection. Isolation of VZV on cell cultures – not used anymore Gigantic, multinucleated cells Tzanck test  VARICELLA (CHICKENPOX) Differential SCARLET FEVER diagnosis MEASLES RUBELLA  Rash Maculopapular “sandpaper” Scarlet fever Not itchy Respects palms/soles Strawberry tongue Desquamation Fadeson the24-48h after palms and soles Filatov Mask Grozovici-Pastia sign ttps://www.nhs.uk/conditions/scarlet-fever/ https://en.wikipedia.org/wiki/Scarlet_fever#/media/File:Scharlach.JPG ttps://dmp.umw.edu.pl/en/article/2020/57/4/455/ https://depositphotos.com/289162128/stock-photo-after-the-red-rash-and.html  VARICELLA (CHICKENPOX) Differential SCARLET FEVER diagnosis MEASLES RUBELLA  Koplik sign Measles Rash develops – D1 face  D2 trunk  D3 extremities (3 days) Maculopapular, not itchy Becomes brownish after a few days Conjunctivitis https://www.news-medical.net/news/20200217/Measles-re-emerging-globally.aspx https://medizzy.com/feed/23531181 https://medi-redi.com/childhood-illness-spotlight-conjunctivitis/  VARICELLA (CHICKENPOX) Differential SCARLET FEVER diagnosis MEASLES RUBELLA  Rubella Forscheimer dots Rash : Very discrete (it can pass unobserved) Pink-coloured Also begins on the face but only lasts for a day Lymphadenopathies – persist for weeks https://www.nhs.uk/conditions/rubella/ https://litfl.com/frederick-forchheimer/ COMPLICATIONS  Varicella pneumonia - often seen in adults, pregnant patients, ID patients, newborn. - can develop ARDS, that needs mechanical ventilation and, in the absence of specific antiviral treatment can cause rapid ◦Bacterial superinfection – if the patient scratches the lesions, they can become infected with the bacteria that colonizes the patient’s skin - staphylococci and streptococci. ! Do not mistake pseudopustules with real pustules ! ◦Neurologic complications: meningitis, encephalitis, neuritis, poliradiculoneuritis, mielitis, cerebral vasculitis. ◦Other organs can become affected: hepatitis, pancreatitis, etc. ◦Reye syndrome – acute encephalopathy associated with hepatic dysfunction – in case of aspirin administration. TREATMENT 1. Antiviral treatment (1) Recommended to: ◦ Patients aged >12 years ◦ Severe cases with complications (pneumonia, encephalitis) ◦ ID patients (also ID children) ◦ Newborns ◦ Patients aged < 1 year ◦ Pregnant patients ◦ Patients (also children) who have chronic treatment with aspirin/corticosteroids, have atopic dermatitis Immunocompetent children with mild varicella can be treated just with simptomatic treatment. 1. Antiviral treatment (2) ◦Acyclovir – doses: ◦ Adult – oral 800mg x 5/day (4g/day), iv 10-15mg/kg/8h, depending on the severity ◦ Children – iv 20mg/kg/8h ◦ Duration of treatment is usually 7 days – can be prolonged to 10-14 days in severe cases ◦Valacyclovir – po 1000mg x 3 /day, 7 days. Topical treatment with acyclovir does not work in varicella/HZ – lesions are deep! PROPHYLAXIS 1. Pasive immunisation ◦Specific anti-VZV immunoglobulins (anti-VZV IgG) – 0.3ml/kg (25UI/kg), IV. ◦Used in pregnant patients who come into contact with a confirmed case, in newborns ◦Must be administered in the first 72-96h after contact ◦Provide limited protection (only for 30 days) 2. Active immunisation Live attenuated vaccines – NOT to be given in immunosuppressed/pregnant patients https://www.medimfarm.ro/Products/Product/16862/varilrix-vaccin-varicelic-viu- https://immunizationinfo.com/varivax-vaccine/ atenuat-x-1 HERPES ZOSTER ”SHINGLES”, ”ZONA” Definition HZ –vesicular rash localised to 1-2 dermatomes, which is unilateral, and is caused by reactivation of VZV which remains dormant in the sensitive ganglia. Epidemiology ◦Usually occurs after the age of 50 (imunosenescence) ◦Can occur at any age in ID patients (malignancy, HIV, CS treatment)  Clinical presentation I. The first symptom - PAIN in 1-2 dermatomes, unilateral, (acute neuritis) ◦ Intense, sometimes atrocious ◦ Can be described as a burning sensation ◦ Accompanied by paresthesia, hyperesthesia ◦ Precedes the rash by 1-4 days ◦ Rarely accompanied by fever https://no.wikipedia.org/wiki/Dermatom#/media/Fil:Dermatoms.svg Clinical presentation II. Rash ◦ Vesicular ◦ Localised to 1-2 dermatomes, unilateral (does not exceedhttps://ro.wikipedia.org/wiki/Zona_zoster the median line) ◦ Vezicles are grouped – can become bulae ◦ The fluid inside the vesicles becomes turbid in D5  crusts in D7  crusts fall in D10  depigmented scars  restitutio ad integrum Antiviral therapy – very important! If correct antiviral treatment is not initiated early in the course of the disease, then the patient is at high risk of developing bulae, of prolonged evolution (2-3 weeks), and to develop postherpetic neuralgia   Herpes zoster ophtalmicus – VZV reactivates in the sensitive ganglion of the trigeminal nerve, ophtalmic branch ◦ Rash on the forehead + superior eyelid ◦ Ocular complications! – conjunctivitis, keratitis, loss of vision ◦ OPHTALMOLOGIC EXAM MANDATORY (2-3 times a week, 2-3 weeks) ◦ Hutchinson’s sign = the presence of lesions at the tip, side, or root of the nose. This is a strong predictor of ocular inflammation, especially if both branches of the nasociliary nerve are involved. https://www.aao.org/eyenet/article/herpes-zoster-ophthalmicus-pearls  Herpes zoster ophtalmicus – VZV reactivates in the sensitive ganglion of the trigeminal nerve, ophtalmic branch ◦ Rash on the forehead + superior eyelid ◦ Ocular complications! – conjunctivitis, keratitis, loss of vision ◦ OPHTALMOLOGIC EXAM MANDATORY (2-3 times a week, 2-3 weeks) https://www.aao.org/eyenet/article/herpes-zoster-ophthalmicus-pearls  Ramsay Hunt syndrome ◦VZV reactivation in geniculate ganglion (facial nerve in very close contact) ◦Rash in the auditory canal and in the auricle, ipsilateral altered taste and tongue lesions, hearing abnormalities (decreased hearing, tinnitus), vestibular disturbances (vertigo) ◦Geniculate ganglion tumefaction will compress on the facial nerve motor branch  ipsilateral facial paralysis tps://observatornews.ro/sanatate/ce-este-sindromul-ramsay-hunt-virusul-care-ataca-fata-lui-justin-bieber-474875.html  Ramsay Hunt syndrome tps://observatornews.ro/sanatate/ce-este-sindromul-ramsay-hunt-virusul-care-ataca-fata-lui-justin-bieber-474875.html Antiviral treatment ◦Acyclovir – doses: ◦ Adult – oral 800mg x 5/day (4g/day), iv 10-15mg/kg/8h, depending on the severity ◦ Children – iv 20mg/kg/8h ◦ Duration of treatment is usually 7 days – can be prolonged to 10-14 days in severe cases ◦Valacyclovir – po 1000mg x 3 /day, 7 days. +PAINKILLERS! (Acetaminophen, Metamizole, Tramadol, Gabapentin, Pregabalin)  Prophylaxis ◦ Patients over 50 years ◦ A single dose https://www.biospectrumasia.com/news/37/19562/gsk-singapore-launches-shingrix-vaccine-against-shingles-herpes-zoster.html https://immunizationinfo.com/zostavax-vaccine/ Bibliografie 1. Streinu-Cercel A, Aramă V., Calistru I – Boli infecțioase. Volumul 1: Curs pentru studenți și medici rezidenți. Editura Universitară “Carol Davila” București, 2019. 2. Pilly E. Maladies Infectieuses et tropicales. College des Universitaires des Maladies Infectieuses et Tropicales; 2020. 3. https://www.who.int/news-room/fact-sheets/detail/monkeypox