Viral Disease

50

_________% of the adult U.S. population is infected with Herpes Simplex virus 1

12

_________% of the adult U.S. population is infected with Herpes Simplex virus 2

Asymptomatic shedding

What is a common with HSV and serves as a source of transmission (70%)?

Mucocutaneous disease and ocular disease

Presentations of HSV

Vesicular lesions on erythematous base

Typical mucocutaneous presentation of HSV

Herpes labialis ("cold sores")

Mucocutaneous presentation of HSV on lips

Gingivostomatitis

Mucocutaneous presentation of HSV on gingiva, oral mucosa, and/or tongue

Both 1 and 2 (sometimes both simultaneously)

Mucocutaneous disease of the genital tract can be caused by which HSV types?

Ulceration causing tingling/burning

In the mucocutaneous presentation of HSV, what can occur with lesions after some time?

1. Only occur on non-keratinized tissue (HSV occurs on both)

2. HSV appears as blisters that rupture and form ulcers

3. Appear as a single or a few scatted lesion (HSV is multiple and scattered)

4. HSV has prodromal symptoms of tingling, burning, or itching prior to lesions

How are aphthous ulcers different from HSV gingivostomatitis?

Uveitis and keratitis

Common symptoms of ocular disease presentation of HSV

Dendritic pattern on eye with fluorescein dye

What is a common thing that can be observed with the ocular presentation of HSV?

HSV DNA PCR

How is HSV typically diagnosed?

more

A HSV DNA PCR is more/less sensitive than a viral culture

encephalitis/meningitis

HSV DNA PCR can also be used as a test of CSF for...

IgG antibody testing

HSV test that is a useful screening test to confirm history of HSV

Only if they have lesion

When should a patient be tested for HSV?

Valacyclovir 100 mg twice daily for 7-10 days

Typical treatment for HSV

No treatment

How do you treat recurrent HSV if symptoms are mild?

Antiviral suppressive therapy

How can HSV be prevented?

Acyclovir 400 mg twice daily and valacyclovir 500 mg once daily

What does antiviral suppressive therapy for HSV consist of?

"Dew drops on a rose petal" rash

What is the typical presentation pattern of Varicella?

vesicular; erythematous

Varicella causes a ___________ rash with a _______________ base

Face and trunk and spreads from there

Where does a varicella infection start?

It crusts over

What happens to a varicella rash over time?

Pruritis

Common symptom accompanying varicella rash

clinically

Diagnosis of varicella is usually made...

Conservative therapy for non-high risk child (<12 y/o) and valacyclovir for high risk patients

What is the typical treatment for varicella?

Aspirin; can cause Reye's syndrome

What medication should be avoided if one has varicella? Why?

Reye's syndrome

Swelling of liver and brain following varicella or flu infection that can be exacerbated by taking aspirin

Immunocompetent adults and unvaccinated adolescents (also pregnant women and immunocompromised)

What patients are at a high risk for varicella and would be prescribed valacyclovir?

HSV 3

Varicella is technically...

Varivax

What is typically given as a primary vaccination for varicella?

Live attenuated

Varivax is what kind of vaccine?

Shingles

Different infection caused by the same virus as chickenpox

>50%

___________% of shingles cases are in patients 60+ y/o

Reactivation of varicella (herpes zoster 3) after a previous infection

What causes shingles?

Prodromal phase and vesicular phase

What are the two phases of shingles?

Severe pain 2-3 days before rash

What is one symptom that occurs during the prodromal phase of shingles?

Unilateral, dermatomal distribution of grouped, erythematous vesicles and crusted lesions

What occurs during the vesicular phase of shingles?

Zoster sine herpete variant

What is one variant of shingles?

Pain without rash

What is unique about the zoster sine herpete variant of shingles?

trigeminal; ophthalmic; eye; keratitis

Shingles commonly infects the _____________ nerve, and more specifically the ________________ branch of that nerve. If it does, it can travel to the _______________ and cause ________________

Eschar

In immunocompromised patients, what can also be present at the site of a rash?

Clinically

How is shingles typically diagnosed?

Valacyclovir within first 72 hours and medication for pain control (ibuprofen, Tylenol, opioids, nerve blocks, steroids)

What is the typical treatment for dermatomal shingles?

Post-herpetic neuralgia (PHN)

Pain in dermatomal distribution persisting >90 days after a shingles rash resolves

Shingrix vaccine in patients 50+ y/o

How can shingles be prevented?

Bacterial superinfection and herpes zoster ophthalmicus

What are some complications of shingles?

check the skin

For diagnosis of a herpes zoster infection, always...

Cytomegalovirus (CMV)

Most common congenital infection (TORCH)

asymptomatic; "mononucleosis-like" syndrome; negative monospot

In immunocompetent patients, CMV is ___________________ or causes __________________ with a _______________________ test

Bone marrow transplants and solid organ transplant patients

What immunocompromised population is at most risk of a CMV infection?

CMV inclusion disease

Congenitally, CMV causes...

Reassurance

What is the typical treatment for immunocompetent patients with a CMV infection?

Pregnant women

In what population is it especially important to prevent a CMV infection?

Blindness (retinitis) in kids from congenital infection

What are some complications of CMV?

late

Blindness due to a congenital CMV infection in kids has a(n) early/late onset

Coxsackie virus

What causes hand, foot, and mouth disease?

children

Hand, foot, and mouth disease is a common diagnosis in...

Day 1 = fever

Days 2-4 = vesicular rash on hands, feet, and butt

What is the typical timeline for how symptoms present with hand, foot, and mouth disease?

Herpangia

Symptom of hand, foot, and mouth disease where a sudden high fever and sore throat occurs

Soft palate petechiae/ulcers

What symptoms accompany the sore throat with herpangia caused by hand, foot, and mouth disease?

Symptomatic care and withheld from school until fever subsides

What is the typical treatment for hand, foot, and mouth disease?

non-tuberculous mycobacteria (NTM)

Atypical mycobacterial disease is also referred to as...

No

Is a pulmonary NTM communicable?

TB; more slowly

A chronic pulmonary NTM infection is similar to _______________ but progresses ________________

pulmonary (bloody chronic cough, chronic night sweats, chest discomfort)

Pulmonary NTMs typically have a similar _________________ presentation to TB

immunocompromised, CF, smokers, and underlying lung disease

Pulmonary NTM infections have similar risk factors to TB, such as...

Mycobacterium avium complex (MAC)

Most common NTM in the United States

5

How many main NTMs are there in the US?

Clinical and radiographic findings and microbiologic confirmation with smear and culture

What is needed to diagnose a pulmonary NTM?

Clarithromycin, ethambutol, and rifabutin until negative cultures for 12 months

How is MAC and Mycobacterium kansasii treated?

Late stages of HIV infection

When is disseminated MAC typically seen?

Persistent fever, night sweats, weight loss, abdominal pain, and diarrhea

Clinical presentation of disseminated MAC

Blood or liver culture, lymph node, or bone marrow biopsies

What labs can be taken for a disseminated MAC infection?

Clarithromycin + ethambutol +/- rifabutin

What is the typical treatment for disseminated MAC?

Clarithromycin or azithromycin

What can be used as a prophylactic treatment for disseminated MAC in advanced HIV patients?

Lesions in cooler skin tissues and neurologic/motor abnormalities secondary to nerve infiltration and thickening

What are some signs and symptoms of leprosy NTM infections?

Bilateral ulnar neuropathy

What is a highly specific finding for a leprosy NTM infection?

Lepromatous and tuberculoid

What are the types of leprosy NTM infections?

Acid fast bacilli on skin biopsy or M. leprae DNA by PCR on skin biopsy/nasal swab

How is a leprosy NTM infection diagnosed?

Rifampin and dapsone

What is the typical treatment for a leprosy NTM infection?

Lymphadenitis

What are the symptoms of a lymph node NTM infection?

M tuberculosis; disseminated disease

What NTM typically causes lymphadenitis and with what disease in adults?

MAC

What NTM typically causes lymphadenitis in children?

hematogenous seeding or as complication of surgery

Skin/soft tissue NTM infections typically occur due to...