Chickenpox + Shingles

Question 1

which of the following is false regarding human herpesviruses
1. there is a property of latency with specific host cells
2. different viruses may exhibit different clinical sx
3. chicken pox is caused by varicella zoster virus 3
4. there are 6 herpes viruses that routinely infect only humans

Answer 1

4- there are 8

Question 2

acute infection with varicella zoster causes

Answer 2

chickenpox/ varicella

Question 3

reactivation with varicella zoster causes

Answer 3

shingles or herpes zoster

Question 4

how can the herpes simplex 1 virus be reactivated

Answer 4

fever, sunlight to face, menstruation, stress, etc

Question 5

how can the varicella virus be reactivated

Answer 5

age, x ray irradiation

Question 6

herpes zoster begins as _______ which evolve into ______ that coalesce into ______________ with _________ component

Answer 6

erythematous papules
evolve into vesicles
coalesce into large confluent blisters with hemorrhagic component

Question 7

herpes zosters lesions continue to form over

Answer 7

3-5d

Question 8

healing of herpes zoster lesions occurs over

Answer 8

2wks

Question 9

what are some permanent changes that may happen after herpes zoster

Answer 9

scarring and discoloration

Question 10

what are the most commonly affected dermatomes by herpes zoster

Answer 10

T1-L2

Question 11

hallmark characteristic of herpes zoster is

Answer 11

unilateral- does not cross body’s midline

Question 12

~20% patients have systemic sx from herpes zoster, including

Answer 12

fever, HA, malaise, fatigue

Question 13

herpes zoster is diagnosed ________

Answer 13

clinically

Question 14

why might confirmatory lab tests be used for herpes zoster dx

Answer 14

to differentiate from HSV (dep on location of rash) or in pts with typical pain but no rash

Question 15

3 lab tests you can use for herpes zoster dx

Answer 15

PCR
immunohistochemistry
viral culture from vesicular fluid

Question 16

describe immunohistochemistry for herpes zoster dx

Answer 16

cells scraped from base of lesion + stained with fluorescein conjugated monoclonal Abs to detect viral glycoprotein

Question 17

which is more sensitive
1 .immunohistochemistry
2. culture

Answer 17

1

Question 18

list 3 differential dx for herpes zoster

Answer 18

herpes simplex virus
contact dermatitis
impetigo
cellulitis
candidiasis
dermatitis herpetiformis (skin manifestation of celiac disease)
drug eruptions

Question 19

what is the most common complication of HZ

Answer 19

post herpetic neuralgia

Question 20

3 major risk factors for HZ

Answer 20

> 50yrs
HIV
other immunosuppression (ex- CS, chemo)

Question 21

which of the following is true
1.HIV increases the risk of HZ by 10x
2. there is an increasing trend of shingles in the US
3. there is a decreasing trend of shingles in Japan
4. being >40yrs is a major RF for HZ

Answer 21

2

Question 22

acute herpetic neuralgia is

Answer 22

pain preceding or accompanying rash that persists up to 30 days from onset

Question 23

subacute herpetic neuralgia is

Answer 23

pain that persists beyond rash healing but resolves within 3-4mths

Question 24

what is post herpetic neuralgia

Answer 24

pain >3-4mths from initial onset rash

Question 25

pain preceding or accompanying rash that persists up to 30 days from onset

Answer 25

acute herpetic neuralgia

Question 26

pain that persists beyond rash healing but resolves within 3-4mths

Answer 26

subacute herpetic neuralgia

Question 27

incidence of PHN increases with 1. age 2. worse initial shingles pain 3. larger area of initial shingles 4. all of the above

Answer 27

4

Question 28

3 types of PHN

Answer 28

constant pain without stimulus intermittent pain without stimulus evoked pain (allodynia and/or hyperalgesia)

Question 29

PHN can persist for

Answer 29

mths-yrs

Question 30

4 major RF for PHN

Answer 30

older age, severe acute pain, greater rash severity, immunosuppressive conditions

Question 31

list 3 nonpharm ways to prevent spread of HSV/ comfort measures

Answer 31

Keep rash clean + dry to reduce risk of bacterial superinfection Prevent transmission of virus to another person: keep fluid filled blisters/rash covered, wash hands often, do not touch or scratch rash Avoid topical antibiotics and dressing with adhesives- can cause irritation + delay rash healing Sterile wet (hydrocolloid) dressings to ↓ discomfort in somepts (Ex- Tegaderm (3M), bandaid) Wear loose fitting clothing for comfort

Question 32

systemic antivirals if started within 72hrs of rash can

Answer 32

Reduce acute pain Accelerate rash healing by 1-2 days and decrease formation of new lesions Reduce period for viral shedding

Question 33

T or F: antivirals prevent PHN

Answer 33

insufficient evidence- may reduce intensity, duration, incidence of prolonged pain by decreasing neural damage (inhibits viral replication)

Question 34

which 3 antivirals are used in HZ

Answer 34

famciclovir valacyclovir acyclovir

Question 35

rank the antivirals on worst to best resolution of pain famciclovir acyclovir valacyclovir

Answer 35

acyclovir < famciclovir = valacyclovir

Question 36

SEs of HZ antivirals

Answer 36

generally well tolerated- nausea, HA most common sx

Question 37

fam/vala/ acyclovir are _________ eliminated

Answer 37

renally

Question 38

T or F: herpes zoster vaccines are used to protect against infection with virus

Answer 38

F- already infected, only intended to boost T cell immunity to avoid reactivation

Question 39

how is famciclovir dosed for HZ

Answer 39

500mg TID F7d

Question 40

how is valacyclovir dosed for HZ

Answer 40

1000mg TID F7d

Question 41

how is acyclovir dosed for HZ

Answer 41

800mg 5x/d F7d

Question 42

in pts presenting <72hrs since rash onset, cost benefit favors tx of pts:

Answer 42

>50yrs, esp those with severe pain and large area of skin involved optional for younger pts with mild pain/ limited skin involved

Question 43

in pts presenting >72hrs since rash, should they receive antivirals?

Answer 43

consider if continued new vesicles, immuncomp, or has complications (ex- ocular, motor, neuro)

Question 44

tx of mild acute HZ pain

Answer 44

NSAIDs, APAP

Question 45

tx of mod acute HZ pain

Answer 45

tramadol (can adjuvant w/ gabapentin or TCAs)

Question 46

tx of severe acute HZ pain

Answer 46

opioids, CS

Question 47

PHN tx for pain

Answer 47

TCAs SNRIs (venla) gabapentin or pregabalin opioids topical lido cannabinoids

Question 48

Studies show _________________________or _______________________________yield greater reductions in PHN pain than either alone

Answer 48

gabapentin + nortrityline gabapentin + morphine

Question 49

ramsay hunt sx can cause

Answer 49

facial paralysis and hearing loss in affected ear