Varicella-Zoster Virus Disease Flashcards by Kentaro Kaneko

What percentage of adults born in the United States have immunity to varicella-zoster virus (VZV)?

More than 95%

This immunity is mostly due to primary VZV infection, known as varicella (or chickenpox).

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What is the incidence of herpes zoster in the general population?

About 3.6 cases per 1,000 person-years

Higher incidence is seen among elderly and immunocompromised individuals.

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How does antiretroviral therapy (ART) affect the incidence of herpes zoster in adults with HIV?

ART reduces the incidence of herpes zoster but the risk remains threefold higher than in the general population

This is likely due to immune restoration.

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What are the common clinical manifestations of varicella rash?

Central distribution with lesions evolving through stages: macules, papules, vesicles, pustules, and crusts

Accompanied by pruritus, fever, headache, malaise, and anorexia.

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What is the most common site for herpes zoster?

Thoracic dermatomes (40% to 50% of cases)

Followed by cranial nerve (20% to 25%), cervical (15% to 20%), lumbar (15%), and sacral (5%) dermatomes.

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What is Hutchinson sign in herpes zoster?

Vesicles on the tip of the nose indicating nasociliary branch involvement

This can lead to herpes zoster ophthalmicus (HZO).

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What are the complications associated with herpes zoster ophthalmicus (HZO)?

Keratitis, anterior uveitis, scarring, neovascularization, necrosis, and loss of vision

These complications can be chronic.

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What is the recommended treatment for acute retinal necrosis (ARN) and progressive outer retinal necrosis (PORN)?

No specific treatment is mentioned; both conditions are associated with high rates of vision loss

ARN can occur in immunocompetent and immunocompromised patients, while PORN occurs almost exclusively in patients with AIDS.

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How can varicella be diagnosed clinically?

Typically distinctive in appearance; can also be diagnosed by documenting seroconversion

In immunocompromised persons, distinguishing from disseminated herpes zoster may be challenging.

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What is the recommended prophylaxis for people with HIV who are susceptible to VZV after exposure?

Post-exposure prophylaxis with VariZIG as soon as possible, preferably within 96 hours

Up to 10 days after exposure is acceptable.

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What is the live attenuated varicella vaccine recommended for?

To prevent primary infection (varicella) in children with HIV who have relatively preserved immune systems (CD4 percentage ≥15%)

It also reduces the risk of subsequent herpes zoster.

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What is the FDA-approved vaccine for the prevention of herpes zoster in immunocompetent adults?

Recombinant zoster vaccine (RZV) Shingrix

It is administered on a 2-dose schedule.

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What is the efficacy of the recombinant zoster vaccine (RZV) against herpes zoster?

97.2% overall and 91.3% in those aged ≥70 years

Based on Phase 3 clinical trials involving over 30,000 participants.

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What is the recommended interval for varicella vaccination after administering VariZIG?

At least 5 months

If post-exposure acyclovir has been administered, an interval of at least 3 days is recommended.

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True or False: Long-term prophylaxis with anti-VZV drugs is recommended to prevent varicella.

False

Long-term prophylaxis is not routinely recommended.

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What is the risk associated with CD4 counts <200 cells/mm3 in relation to herpes zoster?

Highest risk of herpes zoster-related complications, including disseminated herpes zoster

The central nervous system is a target organ for herpes zoster dissemination in these patients.

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What percentage of vaccine recipients reported Grade 3 local reactions?

9.4%

This includes reactions such as redness and swelling.

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What percentage of vaccine recipients reported Grade 3 systemic events?

10.8%

Systemic events include myalgia, fatigue, headache, fever, and gastrointestinal symptoms.

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Which group had more frequent systemic Grade 3 reactions after vaccination?

Dose 2 recipients

Systemic Grade 3 reactions were reported more frequently after Dose 2 than after Dose 1.

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What is the median age of participants in the Phase 1/2 study of RZV for people with HIV?

46 years

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What is the schedule for administering the RZV vaccine?

0, 2, and 6 months

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What were the most common side effects reported in the RZV study?

Pain at the injection sites (98.6%)*
Fatigue (75.3%)*
Myalgia (74.0%)*
Headache (64.4%)

Grade 3 side effects were also noted for these symptoms.

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What is the recommendation for RZV vaccination in people with HIV aged 18 years and older?

Administer RZV following the FDA-approved schedule for persons without HIV (IM dose at 0 and 2–6 months) (AIII)

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Should RZV be administered during acute episodes of herpes zoster?

RZV is not a treatment for herpes zoster and should not be given during acute episodes.

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What is the preferred treatment for uncomplicated varicella in adults with HIV?

* Valacyclovir (1 g PO three times daily)* * Famciclovir (500 mg PO three times daily) ## Footnote Treatment should be initiated as early as possible after lesion onset.

What is the recommended initial treatment for severe or complicated varicella in people with HIV?

IV acyclovir (10 mg/kg every 8 hours for 7 to 10 days) (AIII)

What should be done if no evidence of visceral involvement with VZV is apparent after IV treatment?

Switch from IV to oral antiviral therapy after the patient has defervesced (BIII)

What antiviral therapy should be initiated for herpes zoster diagnosed within 1 week of rash onset in people with HIV?

* Oral valacyclovir (AII)* * Famciclovir (AII)* * Acyclovir (BII) ## Footnote Treatment should be for 7 to 10 days.

Is adjunctive corticosteroid therapy recommended for herpes zoster in people with HIV?

No ## Footnote No data support its benefit in this population (AIII).

What is the treatment recommendation for patients with Herpes Zoster Ophthalmicus (HZO)?

Topical corticosteroids ## Footnote Chronic, low-dose therapy may be necessary to maintain suppression of inflammation.

What is the recommended treatment for Acute Retinal Necrosis (ARN)?

* High-dose IV acyclovir (10 mg/kg every 8 hours for 10 to 14 days)* * Followed by prolonged high-dose oral valacyclovir (1 g three times daily) (AIII) ## Footnote Intravitreal injections of ganciclovir may also be included.

What should be done for patients with suspected or proven acyclovir-resistant VZV infections?

Treatment with IV foscarnet is recommended (AII)

What is the timing recommendation for starting ART in people with HIV?

As soon as possible after diagnosis (AIII)

What should be monitored after starting ART in relation to VZV?

Increased frequency of VZV reactivation ## Footnote This peaks around 3 months after ART initiation.

What is the risk of herpes zoster after initiating ART?

Increased twofold to fourfold between 4 and 16 weeks after initiation

What should pregnant women with HIV do if exposed to VZV?

Receive VariZIG as soon as possible (within 10 days) (AIII)

What is the risk of transmitting VZV to the infant when varicella occurs during pregnancy?

* 0.4% if infection occurs at or before 12 weeks* * 2.2% if infection occurs at 13 to 20 weeks* * Negligible after 20 weeks

What is the recommended treatment for pregnant women with HIV who have uncomplicated varicella?

Oral acyclovir or valacyclovir (BIII)

What antiviral therapy is recommended for uncomplicated herpes zoster in pregnant women with HIV?

Oral acyclovir or valacyclovir (BIII)

What is the indication for varicella vaccination in adults and adolescents with HIV?

Adults and adolescents with HIV who have CD4 counts ≥200 cells/mm3 and lack documentation of vaccination, history, or diagnosis of varicella or herpes zoster.

What should VZV-susceptible household contacts do to prevent transmission to at-risk individuals?

They should be vaccinated.

What is the recommended administration schedule for primary varicella vaccination in VZV-seronegative persons aged ≥18 years?

Two doses (0.5 mL SQ) 3 months apart.

What is the recommended treatment if vaccination results in disease due to live-attenuated vaccine virus?

Treatment with acyclovir is recommended.

How long should one wait before varicella vaccination after receiving post-exposure VariZIG?

≥5 months.

What is contraindicated for severely immunocompromised individuals with HIV regarding varicella vaccination?

Administration of varicella vaccine.

What is the preferred prophylaxis for close contacts of individuals with active varicella or herpes zoster?

VariZIG 125 IU/10 kg IM, administered as soon as possible and within 10 days after exposure.

What alternative prophylaxis can be used 7-10 days after exposure to VZV?

* Acyclovir 800 mg PO 5 times daily for 5 to 7 days * Valacyclovir 1 gm PO 3 times daily for 5 to 7 days.

What is the only available vaccine for the prevention of shingles in the United States?

Recombinant zoster vaccine (RZV, Shingrix).

What is the vaccination schedule for RZV in adults with HIV?

2-dose series at 0 and then at 2 to 6 months.

What is the preferred therapy for uncomplicated primary varicella infection?

* Valacyclovir 1 g PO 3 times a day * Famciclovir 500 mg PO 3 times a day.

What is the recommended treatment duration for uncomplicated primary varicella infection?

5 to 7 days.

What is the preferred therapy for severe or complicated primary varicella infection?

Acyclovir 10 mg/kg IV every 8 hours for 7 to 10 days.

What is the preferred therapy for acute localized herpes zoster?

* Valacyclovir 1,000 mg PO 3 times a day * Famciclovir 500 mg PO 3 times a day.

What should be done for extensive cutaneous lesions or visceral involvement in herpes zoster?

Acyclovir 10 mg/kg IV every 8 hours until clinical improvement.

What is the recommended treatment for acute retinal necrosis (ARN)?

* Acyclovir 10 mg/kg IV every 8 hours for 10 to 14 days * Followed by valacyclovir 1 g PO 3 times a day for ≥14 weeks.

What is strongly recommended for treating progressive outer retinal necrosis (PORN)?

Involvement of an experienced ophthalmologist.

What should be considered when determining the duration of therapy for PORN?

Clinical, virologic, and immunologic responses in consultation with an ophthalmologist.

What is the maximum dose of VariZIG for prophylaxis?

625 IU.

True or False: Valacyclovir should be given within 72 hours after the last dose of antiviral drug if used as pre-emptive intervention.

False.

Fill in the blank: The duration of therapy for herpes zoster is ________.

7 to 10 days.

Varicella-Zoster Virus Disease Flashcards

(60 cards)