Herpes zoster treatment guidelines pdf jama,can you test positive then negative for herpes,harvard school of medicine admission requirements - Downloads 2016

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This program is funded through Health Resources and Services Administration, US Department of Health and Human Services. Figure 1Figure 1 - Vesicular Rash in a Dermatomal DistributionThis patient developed characteristic herpes zoster as shown by the clusters of vesicles and surrounding erythema, all in a dermatomal pattern. Which of the following statements is TRUE regarding varicella zoster virus (VZV) infection in HIV-infected patients? A positive Tzanck stain is diagnostic for VZV infection and it rules out other causes of vesicular skin lesions, such as herpes simplex virus infection.IncorrectThe finding of multinucleated giant cells on Tzanck (Giemsa) staining is neither sensitive nor specific for diagnosing viral vesicular lesions. The preferred therapy for dermatomal herpes zoster in HIV-infected patients consists of acyclovir (Zovirax), valacyclovir (Valtrex), or famciclovir (Famvir).CorrectThe medications acyclovir, valacyclovir, and famciclovir are all considered acceptable options for the treatment of dermatomal herpes zoster in HIV-infected patients.
The preferred therapy for dermatomal herpes zoster in HIV-infected patients consists of oral valganciclovir (Valcyte).IncorrectIn HIV-infected patients, therapy for localized herpes zoster consists of oral therapy with acyclovir (Zovirax), famciclovir (Famvir), or valacyclovir (Valtrex). The incidence of herpes zoster in HIV-infected individuals is the same as age-matched HIV-negative persons.IncorrectThe incidence of zoster among HIV-infected adults is more than 10-fold greater than age-matched immunocompetent persons.
Figure 1Figure 1 - Acute Varicella Infection (Abdominal Region)Diffuse vesicular lesions as shown early in the course of varicella infection in an HIV-infected patient.
Figure 2Figure 2 - Healing Varicella Infection (Back Region)Lesions of varicella on back that have started to crust and heal in this HIV-infected patient. Figure 3Figure 3 - Zoster on the Anterior Chest WallClusters of vesicular lesions surrounded by an erythematous base. Figure 4Figure 4 - Hemorrhagic Zoster on ThighSevere acute hemorrhagic zoster on the inner thigh. Figure 5Figure 5 - Healing Zoster on Buttock and Posterior LegExtensive zoster lesions on the buttock and posterior leg have crusted and show no sign of secondary bacterial infection.
Figure 6Figure 6 - Secondary Infection of Zoster on NeckZoster in the neck region that has become secondarily infected.
Primary varicella infection (chicken pox) occurs infrequently in HIV-infected adults, as more than 90% of adults in the United States possess antibodies to the virus as a result of childhood varicella infection.[1] Given the widespread prevalence of varicella-zoster virus (VZV) infection in adults, most HIV-infected adults are at risk of developing VZV reactivation and herpes zoster. As with all human herpesviruses, primary infection with VZV is followed by a period of viral latency, or "hibernation." Latent VZV resides in dorsal spinal ganglia, until a cycle of "lytic" or active viral replication is initiated. Primary varicella infection ("chickenpox") in HIV-infected patients manifests as a generalized outbreak of vesicular lesions that follow a 1 to 2 day prodrome of malaise and fever (Figure 1) and (Figure 2). New skin lesions typically continue to emerge for 3 to 4 days.
Significant scarring may result from cutaneous herpes zoster and this is most problematic with facial involvement. Persons infected with HIV have a greater risk of developing disseminated infection, including development of widespread cutaneous lesions, ocular infection, visceral organ inflammation, and central nervous system disease.[8,9] With dissemination and ocular involvement, patients may develop acute retinal necrosis or progressive outer retinal necrosis ("PORN"), conditions that represent necrotizing retinopathy. In most circumstances, the diagnosis of cutaneous herpes zoster is made on clinical grounds.
In general, HIV-infected patients with uncomplicated varicella infection can be treated with oral antiviral therapy. Initiation of VZV-specific antiviral therapy for localized zoster may prevent serious morbidity among HIV-infected patients.


Although cases of acyclovir-resistant VZV have been reported in HIV-infected persons, they appear to occur infrequently and typically involve patients with very advanced immunosuppression. Management of patients with progressive outer retinal necrosis (PORN) or acute retinal necrosis (ARN) requires a multi-pronged approach (Figure 9), including intravenous and intravitreal therapy, and should include an ophthalmologist who has experience managing complicated eye-related infections.[4] The duration of therapy, frequency of intravitreal injections, and number of intravitreal injections depend on the patient's clinical course and should be determined by an ophthalmology expert.
In the rare instance when an HIV-infected person who is non-immune to VZV has significant exposure to a patient with active varicella or zoster, varicella zoster immune globulin (VZIG) should be administered as soon possible after the exposure, but within 10 days.[15] In December, 2012 the United States Food and Drug Administration approved the VZIG product (VariZIG), made by Cangene Corporation in Canada.
Use of PCR or direct fluorescent antibody (DFA) testing would be more appropriate and can specifically differentiate VZV from other viruses. The duration of therapy is typically 7 to 10 days, but longer courses should be considered if the lesions are slow to resolve. Neither intravenous ganciclovir (Valcyte) nor oral valganciclovir (Valcyte) are recommended to treat herpes zoster. Preferred and Alternative TreatmentSource: Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Preferred and Alternative TherapySource: Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. The incidence of zoster among HIV-infected adults is more than 15-fold higher than age-matched VZV-infected immunocompetent persons, with nearly 30 cases per year observed for every 1,000 HIV-infected adults.[2] The diagnosis of herpes zoster should prompt the clinician to consider HIV testing, particularly in persons with known HIV risk factors, those younger than 50 years of age, or those who develop multi-dermatomal herpes zoster. The factors governing the maintenance of latency or the progression to viral replication remain poorly understood, but the increased incidence of zoster among immunocompromised persons suggests that cell-mediated immunity probably plays a critical role. Patients with herpes zoster often present with dysesthesias of the skin several days prior to the onset of cutaneous lesions.
Reactivation of herpes zoster in the trigeminal ganglia may lead to the development of herpes zoster ophthalmicus, a condition that includes a number of inflammatory manifestations in the eye, such as conjunctivitis, episcleritis, keratitis, and iritis.
For patients who have an atypical clinical presentation or a questionable diagnosis, confirmatory VZV-specific tests should be performed.
In contrast, HIV-infected persons with complicated primary varicella infection, including involvement of visceral organs, retina, or the central nervous system, should receive treatment with intravenous acyclovir and undergo hospitalization for observation (Figure 7). Ideally, consultation should be obtained with a medical provider who has experience and expertise in managing serious VZV infections.
The recommended antiviral treatment options (Figure 8) for localized dermatomal zoster in HIV-infected persons consist of valacyclovir (Valtrex), famciclovir (Famvir), or acyclovir (Zovirax).[4] Note these antiviral medications are administered at doses higher than those commonly used for the treatment of uncomplicated herpes simplex virus infections.
In general, resistance should be suspected in patients who have lesions that do not improve within 10 days of starting antiviral therapy. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America.
Herpes zoster as an immune reconstitution disease after initiation of combination antiretroviral therapy in patients with human immunodeficiency virus type-1 infection. Neurological complications of varicella-zoster virus infection in adults with human immunodeficiency virus infection. Acyclovir-resistant herpes zoster in human immunodeficiency virus-infected patients: results of foscarnet therapy.
The DFA uses fluorescent labeled antibodies that detect antigens specific to VZV, and it yields more rapid and accurate results than culture.


Replication of VZV in the ganglia leads to inflammation and cell death, followed by transport of the virus down the neuronal axons to the skin, with the migrating virus subsequently causing vesicles to emerge along the path of sensory nerves in a dermatomal distribution. Some patients develop dysesthesias of the skin without developing skin lesions in a condition referred to as "zoster sine herpete." The cutaneous lesions of zoster initially appear as clusters of vesicles surrounded by an erythematous base (Figure 3), with the individual lesions ranging in size from several millimeters to a centimeter. Aseptic meningitis commonly occurs in both immunocompetent and HIV-infected patients, and may be characterized by headache, cerebrospinal fluid (CSF) pleocytosis and the presence of VZV DNA in the CSF. The direct fluorescent antibody (FA) assessment of a cellular rich sample from the base of the lesion offers the most sensitive, specific, and rapid diagnosis for herpes zoster.
In most antiviral studies, therapy was initiated within 3 days of the onset of rash, but one study in immunocompromised patients suggested substantial benefit from administering antiviral drugs even after 72 hours had elapsed.[12] Many experts would consider using intravenous acyclovir for zoster ophthalmicus. One report described 18 HIV-infected patients with advanced immunosuppression and acyclovir-resistant VZV-related skin lesions that failed to heal despite treatment with acyclovir[14]; most of these patients had an excellent respond to treatment with foscarnet (Foscavir).
Bacterial superinfection of vesicles can also complicate cutaneous herpes zoster (Figure 6). Encephalitis, presenting as delirium, may either precede or follow the cutaneous manifestations of VZV in the severely immunocompromised patient, and can lead to white matter demyelination, vasculitis, and stroke.[11] Direct spread from the dorsal root ganglion to the spinal cord may result in transverse myelitis and manifest as flaccid paraplegia. For a high yield on cutaneous vesicular lesions, it is critical to unroof the vesicle and vigorously scrape the base of the lesion. The National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group.
May 7, 2013.Figure 7Figure 7 - Treatment of Primary Varicella Infection (Chickenpox)Image B. Although herpes zoster can occur anywhere on the body, the skin of the thorax is the most frequently involved region.
Use of Tzanck smears is not recommended, mainly because of low sensitivity and very poor specificity. Rating Scheme for 2013 Opportunistic Infections GuidelinesSource: Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. The vesicles characteristically progress to form crusted lesions (Figure 5) during the subsequent one to three weeks. Culture of these lesions often fail to yield VZV and may take longer than 7 days before final results are available.
Although other infections, such as herpes simplex virus and smallpox, may cause similar appearing vesicular lesions, the characteristic dermatomal distribution of herpes zoster helps to distinguish herpes zoster from these other disorders.
Evidence of VZV DNA may be detected in other body fluids, including cerebrospinal fluid, vitreous humor, or bronchoalveolar lavage fluid, but there is little clinical utility in looking for VZV in the serum.



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