Herpes Zoster Holistic Medicine

How To Cure Shingles

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Antiviral therapy for zoster

IV acyclovir is reserved for the severely immunosuppressed (bone marrow transplant patients), disseminated infection, or ophthalmic zoster. d. The IV dose for zoster is 10 mg kg, administered over a one-hour, q8h. Nephrotoxicity can usually be avoided if the patient remains wellhydrated. The dosage should be reduced in renal failure. 6. Ophthalmic distribution zoster is a medical emergency which requires IV acyclovir and topical antivirals. A. PNH is the most common complication of herpes zoster. It is defined as chronic pain persisting for at least one month after the skin lesions have healed. B. The incidence of PHN after an episode of herpes zoster is 5-50 . Those aged 60 and older have a 50 chance of developing PHN. PHN resolves within two months in about half of those affected.

Disorders of the Skin and Margin of the Eyelid 35 255 Herpes Zoster Ophthalmicus Definition

Facial rash caused by the varicella-zoster virus. Etiology The disorder is caused by the varicella-zoster virus, which initially manifests itself as chickenpox. If activation or reinfection occurs, the latent neurotropic viruses present in the body can lead to the clinical syndrome of herpes zoster ophthalmicus (Fig. 2.14). Symptoms The incubation period is 7-18 days, after which severe pain occurs in the area supplied by the first branch of the trigeminal nerve (the ophthalmic nerve with its frontal, lacrimal, and nasociliary branches). Prodromal symptoms of erythema, swelling, photosensitivity, and lacrimation may occur before the characteristic clear watery vesicles appear. The vesicles burst and brownish scabs form, which are later shed. Blepharitis (see p.33) is also present in 50-70 of all cases. As herpes zoster usually affects immunocom- Herpes zoster ophthalmicus. Herpes zoster ophthalmicus. Fig. 2.14 The facial rash of herpes zoster is caused by the neurotropic...

Varicella zoster virus

Encephalitis accounts for 90 of the neurological complications of varicella, which are in themselves rare, affecting only 01 of cases.24,25 In half, the encephalitis is of the cerebellar type with ataxia, dysarthria, headache, and drowsiness coming on about a week after the rash begins, but the neurological onset may precede the rash. Convulsions are common26 and progression to hemiplegia, cranial nerve palsies, aphasia, and coma may ensue. Patients with the cerebellar form usually recover completely but 10 of those with the general form die. Encephalitis may rarely follow shingles.27 Management of VZV-associated encephalitis is with aciclovir as described for HSE.

Viral infections varicellazoster infection

Varicella (chickenpox) and herpes zoster (shingles) are different clinical manifestations of infection by the same virus - Varicella-Zoster, a DNA human herpes virus, conditions caused - an acute encephalitis - postinfectious encephalomyelitis Shingles Motor weakness occurs in 20 due to damage of the anterior horn cell. More widespread spinal (myelitis) or encephalic involvement occurs in the immunodeflcient. In these patients extensive cutaneous lesions are common (disseminated zoster). Cranial nerve ganglia involvement ulceration - herpes zoster ophthalmicus. Occasionally patients, 7-10 days after onset, develop a necrotising granulomatous angiitis causing stroke-like syndromes. Zoster virus antigen is detected in thrombin in major vessels.

Herpes Zoster Keratitis Definition

Keratitis due to endogenous recurrence of chickenpox (caused by the varicella-zoster virus see herpes zoster ophthalmicus). Diagnostic considerations Herpes zoster ophthalmicus also occurs in superficial and deep forms, which in part are similar to herpes simplex infection of the cornea (red eye with dendritic keratitis, stromal keratitis, and ker-atouveitis). Corneal sensitivity is usually decreased or absent.

And Herpes Zoster

Chickenpox is a highly contagious infection caused by the herpes virus Varicella zoster. It is typically seen in children where it causes crops of pruritic cutaneous vesicles. It is usually transmitted by direct contact and has an incubation period of 2-3 weeks. The exanthem is frequently preceded by a slight fever, malaise and mild headache. The cutaneous lesions start as an itchy macular rash, which progressively becomes vesicular and pustular before breaking down to form focal crusting lesions. They tend to erupt in crops, but lesions at all stages of evolution are frequently present. The back and chest are often the first sites of involvement, but later lesions appear on the face, neck and limbs. They can involve the nose, ears, conjunctiva and genital areas. In the mouth they form small, non-specific, scattered ulcers. The symptoms last from a few days to 2 weeks. In many cases the virus remains latent in dorsal root ganglia. Herpes zoster (shingles) is due to reactivation of the...

Clinical Evaluation

Zoster is usually heralded by dermatomal pain, sometimes accompanied by fever. Within a few days, the skin overlying the dermatome reddens and blisters. A few vesicles are usually grouped on one erythematous base, in contrasttothe scattered, single vesicles of chickenpox. Several days later the vesicles become pustular and develop crusts, followed by scabs. B. Zoster may occur in any dermatome, but the thoracic dermatomes are most often affected. In 90 of patients, pain eventually disappears completely. C. The frequency of zoster increases markedly after age 55, but people of any age can be affected. Less than 5 of immunocompetent patients who have one episode of herpes zoster will have another, and the episodes are usually separated by years. HIV-infected patients are more likely to have recurrent herpes zoster infections.

Laboratory evaluation

The diagnosis of herpes zoster can be made on clinical grounds without the need for laboratory tests. Viral isolation and culture assays are not useful for varicella-zoster. 2. An isolated case of zoster in an apparently healthy young or middle-aged adult is probably not an indicator of an underlying immunodeficiency. HIV testing is considered when a patient who engages in high-risk behavior (sexual activities, drug use) develops zoster. Testing for HIV is also indicated when herpes zoster is protracted, recurrent, or involves multiple dermatomes.

Examination of the eye

Herpes labialis or a dermatomal vesicular eruption (suggestive of shingles) is indicative of a herpetic conjunctivitis. B. Purulent discharge suggests a bacterial infection. Stringy mucoid discharge suggests allergy. Clear watery discharge suggests viral infection. C. Ocular herpes simplex and herpes zoster is managed with topical agents, including trifluridine (Viroptic) and systemic acyclovir, famciclovir or valacyclovir.

S Evidence statements Steroids

The effectiveness of steroids in the long-term treatment of MS was investigated in one systematic review (Ia), six RCTs (Ib) and one CCT (IIa). The review117 included four placebo-controlled RCTs comparing the effects of ACTH (n 1), prednisolone (n 1) and methyl-prednisolone (n 2) given for 9-18 months. It reported no significant effect on long-term functional improvement or on relapse occurrence. The review also reported the occurrence of both major and minor side effects including herpes simplex, herpes zoster, severe ankle oedema, femur fracture, acute anxiety and severe depression.117 Four of the controlled trials also compared steroids to placebo. Two RCTs, one of ACTH and the other of two different doses of zinc hydroxide corticotrophin, found no effect of treatment on any of the outcomes investigated.142,143 One reported a greater incidence of adverse effects including steroid diabetes, increased blood pressure, oedema, acne and hirsutism in the intervention groups.142 A...

Treatment of nonbacterial infections

Viral infections such as herpes simplex, varicella zoster, cytomegalovirus, and adenoviruses frequently occur in neutropenic patients, particularly those with impaired cell-mediated immunity. These infections can be primary, for example when a renal transplant patient who is seronegative for cytomegalovirus is grafted with a kidney from a seropositive donor. More often they result from reactivation of latent virus, as when a patient with Hodgkin's disease develops varicella zoster following irradiation or chemotherapy. Varicella infection is not uncommon in children with malignancy (e.g. acute lymphocytic leukemia) who are receiving chemotherapy. As a preventive measure, immunocompromised children with no immunity against varicella should receive varicella zoster immune globulin (VZIG) as soon as possible if exposed to either chickenpox or varicella zoster. Those with active infection should be treated with intravenous acyclovir. Foscarnet is usually effective in patients with...

Viral Diseases Hivaids

The worldwide use of highly active antiretroviral therapy (HAART) has played an important role in changing the incidence of neurological complications in AIDS patients. Recent studies have shown that HAART has produced both quantitative and qualitative changes in the pattern of HIV neuropathology an overall decrease in the incidence of some cerebral opportunistic infections such as toxoplasmosis and cytomegalovirus encephalitis, for which successful treatment is available, whereas other uncommon types and new variants of brain infections, such as varicella-zoster encephalitis, herpes simplex virus encephalitis or HIV encephalitis, are being reported more frequently as ART promotes some immune recovery and increases survival (8). In developing countries, some endemic infections such as tuberculosis and Chagas disease have re-emerged in direct association with the spreading of HIV, and are now being considered as markers of AIDS.

Stage 3 clinical symptoms

Marked by onset of symptoms, rising titre of circulating virus and decline in circulating CD4 T-cell count to < 0.5 x 109 L. Wide variation in individual patient's rate of progression at this stage. A number of minor opportunistic infections are common oral genital candida, herpes zoster, oral leucoplakia. Lethargy, PUO and weight loss occur frequently. Deepening lymphopenia (CD4 < 0.2 x 109 L) invariably present when opportunistic infection occurs. Persistent generalised lymphadenopathy is a condition where lymphadenopathy > 1cm at 2 or more extra-inguinal sites persists for > 3 months. It is a prodrome to severe immunodeficiency, opportunistic infection and neoplasia.

Clinical Presentation

Varicella Zoster Virus Post-transplantation, VZV causes herpes zoster in seropositive individuals (90 of the adult population). The remaining 10 of patients are at a risk for primary infection. Up to 13 of transplant recipients develop herpes zoster during the first six months post-transplantation. Typical dermatomal skin lesions are the usual presentation of herpes zoster. Disseminated disease occurs as well, with multiple dermatome involvement. Der-matomal pain without skin eruption has been described. The treatment of localized dermatomal zoster is treated with oral acyclovir, valacyclovir, or famciclovir. In severe cases, disseminated disease, or primary infection, intravenous acyclovir is administered initially and patients are monitored carefully. The duration of treatment is usually ten days.

Viral Infections of the Lower Respiratory System

DNA viruses such as varicella-zoster virus and the adenoviruses sometimes cause serious pneumonias, and some adenovirus infections can mimic pertussis. RNA viruses are of greater over-all importance, however, because of the large number of people they infect and their potential for serious outcomes. The following examples come from the orthomyxovirus, paramyxovirus, and bunyavirus families of RNA viruses. RNA viruses, p. 343

Antiherpesvirus Agents

The following drugs are used primarily in the treatment of herpesviruses. Among these are herpes simplex virus-1 (HSV-1), which typically causes herpes labialis (cold sores) or herpes esophagitis herpes simplex virus-2 (HSV-2), which is responsible for most cases of genital herpes varicella zoster virus (VZV), which produces chickenpox and shingles Epstein-Barr virus (EBV), which is the major cause of infectious mononucleosis and cytomegalovirus (CMV), which can produce pneumonia, gastroenteritis, retinitis, encephalitis, and mononucleosis in immunocompromised individuals.

Classification of Disease

An endemic disease is the average or normal number of cases of a disease in a certain population.The number of people contracting the disease and the severity of the disease is so low that it raises little concern and does not constitute a health problem. An example is the varicella-zoster virus (the virus that causes chickenpox). Chickenpox is an endemic disease that usually affects children and is seasonal. An endemic disease can give rise to epidemics.

The Development of Disease

The varicella-zoster virus, which causes varicella (chickenpox), has an incubation period of two weeks. The human immunodeficiency virus, the virus that causes AIDS, has an incubation period of 7 to 11 years. During this phase, the disease can be spread from the infected individual to a non-infected individual.

Prophylaxis for patients treated with purine analogues

The purine analogues fludarabine and 2-CDA used in standard lympho-proliferative protocols induce neutropenia in all cases. Nadir 14d post-treatment initiation and neutrophil counts may fall to zero for several days or even weeks. They are therefore associated with the usual neutropenic infections. In addition, purine analogues have a particular property of inhibition of T4 helper lymphocyte subsets within weeks of initiation of therapy (nadir at 3 months) and may last for > 1 year following cessation of therapy. This profound T4 function inhibition predisposes to fungal infection, as well as a higher incidence of Herpes zoster infection and PCP. I lymphocyte function also predisposes to transfusion associated GvHD in passenger lymphocytes of donor blood transfusions.

Inflammatory or Infectious

In one series, 15 of 34 children with rheg-matogenous retinal detachment had a history of inflammatory or infectious disease in the eye with the detachment 44 . Acute retinal necrosis, characterized by anterior uveitis, occlusive retinal vasculitis and progressive peripheral retinal necrosis, occurs primarily in nonim-munocompromised adults as a result of reactivated herpes simplex or varicella zoster virus infection. The risk of retinal detachment is high, reported to be between 25 and 75 and due to retinal breaks, usually following posterior vitreous detachment after the acute phase is over. Although less common, it has been reported to occur in children 6 .

The Infectious Process

Steroids can alter host-parasite interactions, suppress fever, decrease inflammation, and change the usual character of the symptoms produced by most infectious organisms. There is a heightened susceptibility to serious bacterial, viral, and fungal infections. Local infections may reactivate and spread, and infections acquired during the course of therapy may become more severe and even more difficult to recognize. By interfering with fibroblast proliferation and collagen synthesis, glucocorticoids cause dehiscence of surgical incisions, increase risk of wound infection, and delay healing of open wounds. This untoward effect of steroids may make it mandatory to administer antibiotics with the steroids, especially when there is a history of a chronic infectious process (e.g., tuberculosis). On the other hand, individuals with normal defenses who are treated with low to moderate doses of glucocorticoids are not at great risk of infection. While the incidence of infections has probably...

Neurological presentations of hiv infection

Cytomegalovirus Herpes zoster simplex Toxoplasmosis Progressive multifocal leukoencephalopathy Cerebral abscess E. coli Aspergillus -Candida Nocardia Meningitis HIV-1 Herpes zoster radiculopathy Cauda equina syndrome (cytomegalovirus) Acute reversible demyelination Chronic demyelination herpes zoster simplex

Survey of Recombinant Viral Vaccines Currently under Development 6211 Herpes viruses

6.2.1.1c Varicella Zoster Varicella Zoster (VZV or human herpes virus 3 (HHV-3)) causes chickenpox. In adults, complications can develop leading to 20-25 deaths per year in England and Wales (Rawson et al. 2001). VZV is currently controlled by a live attenuated vaccine. Animal studies with recombinant VZV glyco-proteins B, C, E and I (gB, gC, gE and gI), have confirmed the role of antibody in protection, while the intermediate early protein IE62 appears to be implicated in the generation of VSV-specific CTL responses. A recombinant HSV-1 vector expressing either gE or IE62 induced antibody and CTL responses in mice, supporting the feasibility of a combined HSV VZV vaccine (Lowry et al. 1997).

Potential Applications

DNA amplification methods can assist laboratories in detecting viruses that are present in low numbers, for example, HIV in antibody-negative patients or cytomegalovirus in transplanted organs. We have used molecular diagnostic methods to detect HSV in culture- and antibody-negative cerebrospinal fluids from patients with biopsy-proven HSV encephalitis. Molecular diagnostic methods are also important when a tiny volume of specimen is available (e.g., forensic samples or intra-ocular fluid specimens). For example, we routinely perform five PCR tests (HSV, cytomegalovirus, varicella-zoster virus, Epstein-Barr virus, and human herpesvirus 6) on a single 100- a1 intra-ocular fluid specimen. This specimen volume is barely sufficient for a single culture procedure.

Indications for the immunization of selected risk groups

Should obtain exemption certificates of immunization ratified by health authorities and immigration departments where international immunization requirements are the only reason for yellow fever immunization. MMR and varicella-zoster vaccines may be given to children with HIV infection who do not have evidence of severe immunosuppression. - Contacts of immunodeficient patients healthy siblings and close contacts of immunodeficient children should be immunized with MMR and varicella-zoster vaccines to prevent them from infecting their immunodefi-cient sibling there is no risk of transmission of the MMR vaccine viruses and there is an almost negligible risk of transmission of varicella-zoster vaccine virus these close contacts should be given IPV and not OPV when being given routinely scheduled vaccines. In adults, daily doses of oral corticosteroids in excess of 60 mg prednisolone (or equivalent), and in children doses in excess of either 2 mg kg per day for more than 1 week or 1 mg kg...

Viral infections myelitis and poliomyelitis

Acute viral transverse myelitis is rare. It can occur in association with measles, mumps, Epstein-Barr, herpes zoster simplex, enterovirus infections or small pox. Fever, back and limb pain precede paralysis, sensory loss and bladder disturbance. Initially paralysed limbs are flaccid, but over 1-2 weeks spasticity and extensor plantar responses develop. Good recovery occurs in 30 . Death from respiratory failure is rare (5 ).

Antiviral Agent for Treatment of Cytomegalovirus Retinitis

Human cytomegalovirus is a member of the herpesvirus family, which also includes the herpes simplex (discussed below), varicella zoster, and Epstein-Barr viruses (88,89). Cytomegalovirus (CMV) and herpes simplex are the most studied of the microorganisms responsible for the opportunistic infections associated with acquired immunodeficiency syndrome (AIDS) (90). Cytomegalovirus infection in AIDS patients is most commonly manifested as retinitis (CMV retinopathy) and is the most common cause of blindness in AIDS patients (90).

Topic 6 Herpetic Eye Diseases

N Stare the differences between the ocular manifestations of herpes simplex versus herpes zoster _ Herpes zoster is caused by the virus zoster varicella virus. The different manifestations can be divided into A frequent clinical examination case. Be careful, the skin signs may be subtle Know how to differentiate between the dendritic pattern of herpes simplex and zoster Herpes zoster Herpes zoster A) Acute herpes zoster Herpes zoster B) Chronic herpes zoster Herpes simplex (sectoral atrophy), herpes zoster

Classification of Viruses

Examples of DNA viruses and the diseases that they produce include adenoviruses (colds, conjunctivitis) hepadnaviruses (hepatitis B) herpesviruses (cytomega-lovirus, chickenpox, shingles) papillomaviruses (warts) and poxviruses (smallpox). Pathogenic RNA viruses include arborviruses (tick-borne encephalitis, yellow fever) arenaviruses (Lassa fever, meningitis) or-thomyxoviruses (influenza) paramyxoviruses (measles, mumps) picornaviruses (polio, meningitis, colds) rhab-doviruses (rabies) rubella virus (German measles) and retroviruses (AIDS).

Encephalopathy and encephalitis

The three main causes of encephalopathy and encephalitis in patients with advanced HIV disease and CD4 counts below 100 * 10 6 l are HIV encephalopathy, progressive multifocal leukoencephalopathy, and cytomegalovirus-related encephalitis. Less commonly, herpes simplex virus and varicella zoster virus infection may be implicated. Encephalopathy may also be metabolically induced by drugs or by liver or renal failure. Magnetic resonance imaging (MRI) of the brain will show cerebral atrophy and variable degrees of white matter change in HIV encephalopathy. Similar changes may be seen with cytomegalovirus. Progressive multifocal leukoencephalopathy produces asymmetrical white matter changes without a mass effect on MRI. Herpes simplex virus and varicella zoster virus lesions are usually more localized and may produce a mass effect in patients with encephalitis. A lumbar puncture should be performed to identify cytomegalovirus, herpes simplex virus (I and II), varicella zoster virus, and...

Difficulties And Disadvantages

Another disadvantage of nucleic acid detection is that these tests cannot detect unsuspected agents. Current organism-specific nucleic acid detection methods assume that the physician knows exactly which virus is causing the disease. This assumption is not true in most hospitals in our laboratory, HSV is isolated from 30 of all varicella-zoster virus cultures. Dual infections are also a problem for nucleic acid methods because dual infections will not be detected unless the laboratory is specifically instructed to look for both viruses. In our laboratory, about 2 of all positive respiratory specimens

Herpes simplex encephalitis

The herpes family (herpes simplex I and II, cytomegalovirus, varicella zoster, Epstein-Barr) deserves special emphasis because of both the high rates of morbidity and mortality associated with these infections and the availability of effective pharmacotherapy for some. All herpes group viruses contain double-stranded DNA, and

Viral Diseases of the Nervous System

Many different kinds of viruses can infect the central nervous system, including the Epstein-Barr virus of infectious mononucleosis the mumps, rubeola, varicella-zoster, and herpes simplex viruses and more commonly, human enteroviruses and the viruses of certain zoonoses. In most cases, nervous system involvement occurs in only a very small percentage of people infected with the viruses. The next section discusses four kinds of illness resulting from viral central nervous system infections meningitis, encephalitis, poliomyelitis, and rabies.

Other Facial Nerve Disorders

Herpes zoster infection of the geniculate (facial) ganglion causes sudden severe facial weakness with a typical zoster vesicular eruption within the external auditory meatus. Pain is a major feature and may precede the facial weakness. Serosanguinous fluid may discharge from the ear.

Causative Agent Of Cytomegalovirus

Cytomegalovirus (CMV) is a member of the herpesvirus family, which includes herpes simplex virus, Epstein-Barr virus, and varicella-zoster virus, any of which can cause troublesome symptoms in patients with immunodeficiency. CMV, like other her-pesviruses, is commonly acquired early in life and then remains latent. With impairment of the immune system, the infection activates and can cause severe symptoms.

Lymphopenia

Lg Chronic severe lymphopenia (< 0.5 x 109 L) is associated both with opportunistic infections notably Candida species, Pneumocystis carinii, CMV, Herpes zoster, Mycoplasma spp., Cryptosporidium and toxoplasmosis and with an increased incidence of neoplasia particularly NHL, Kaposi's sarcoma and skin and gastric carcinoma.

Viral pneumonitis

Viruses cause most pneumonia in infants and children, but viral pneumonia is uncommon in adults. Essentially, any virus can produce any syndrome, but severe pneumonia leading to ICU admission in adults is mainly due to influenza and herpes viruses, particularly varicella zoster virus. Hantavirus, which is known to cause hemorrhagic fever with renal syndrome, has been also responsible for multiple organ failure with non-cardiogenic pulmonary edema.

Previous conditions

Mucocutaneous candidiasis, oral hairy leukoplakia, hepatitis, pneumonia, sexually transmitted diseases, and tuberculosis should be sought. Past episodes of varicella-zoster, herpes simplex virus lesions, and opportunistic infections should be assessed. 2. Dates and results of earlier tuberculin skin tests should be obtained. Women should be are asked about dates and results of Pap smears. Previous immunizations and antiretroviral therapy should be documented.

Steroids

Side effects were reported in two of the systematic reviews and two RCTs. These included herpes simplex, herpes zoster, severe ankle oedema, fractured neck of femur, acute anxiety and severe depression 117 weight gain, oedema, gastrointestinal symptoms and psychological symptoms 119 raised blood glucose 126 infection and raised blood pressure.121 One review reported that the major side effects were significantly more frequent in the intervention group compared to the control group. The frequency of minor side effects was high in all the studies.

Pain Syndromes

Following activation of a latent infection with varicella zoster virus lying dormant in the dorsal root or gasserian ganglion, the patient develops a burning, constant pain with severe, sharp paroxysmal twinges over the area supplied by the affected sensory neurons. Touch exacerbates the pain. Thick myelinated fibres are preferentially damaged, possibly opening the 'gate'.

Childhood Diseases

One of the great fears when pediatric transplantation began was that because of immunosuppression, the child would be at risk for severe complications from common childhood diseases. In actual experience, with careful triple therapy immunosuppression, most common childhood illnesses are well-tolerated. Routine immunizations (except for live virus vaccines) should resume at 12 weeks posttransplant. Transplant recipients have a normal response to routine immunization with diptheria, pertussis, typhoid, and Hepatitis B. Pediatric transplant recipients and their siblings should receive only inactivated polio. Measles, mumps and rubella vaccines are not given to these patients. Varicella-Zoster immune globulin should be given to pediatric heart transplant recipients within 72 hours after exposure to chicken pox. Currently, varicella vaccine is given to siblings, but not to the transplant recipient.

Anatomic Causes

Include cytomegalovirus (CMV), rubella, hepatitis A though G, herpesviruses (simplex, zoster, HHV 6), adenovirus, enteroviruses, Epstein-Barr virus (EBV), reovirus 3, parvovirus B19, HIV, bacterial sepsis, E coli UTI, cholangitis, syphilis, listeriosis, tuberculosis, toxoplasmosis. Most of these patients present with other signs of infection. Laboratory evaluation usually reveals evidence of hepatocellular injury with elevated ALT and AST in addition to cholestasis.

Recipient Evaluation

The recipient evaluation is shown in Table 12B.2.2 Potential recipients are evaluated by a team composed of pediatric nephrologists,surgeons, neurologists, nutritionists, psychologists, and social workers. The history and physical examination are aimed at identifying associated congenital anomalies, documenting height, weight, and head circumference, and determining neurologic development. Blood is obtained for CBC, platelet count, electrolytes, calcium, phosphorus, albumin, type and crossmatch, HLA typing, and viral serology (i.e., cytomegalovirus, Epstein-Barr virus, herpes simplex virus, varicella zoster, measles, mumps, and rubella). A urinalysis, chest x-ray, electrocardiogram, electroencephalogram, abdominal ultrasound, and vesicourethrogram (if indicated by history or prior renal ultrasound) or voiding cytourethrogram are also obtained. Pneumococcal and hepatitis B vaccines are given 6 weeks pretransplant.

Ocular Disease

Transplant patients with diabetes mellitus should have regular eye examinations to prevent the complications of diabetic retinopathy. Whether patients with diabetic retinopathy would benefit with stabilization or improvement in their vision following early pancreas transplant remains unanswered. Eye infections in transplant patients can be devastating and require emergent diagnosis and treatment. Herpetic keratoconjunctivitis, CMV retinitis, toxoplasma chorioretinitis and ophthalmic herpes zoster are among the eye infections which require timely diagnosis and treatment.

External Anatomy

The skin of the yellow perch is covered with scales. Scales are thin, round disks of a bonelike material that grow from pockets in the skin. As Figure 39-10 shows, scales overlap like roof shingles. They all point toward the tail to minimize friction as the fish swims. Scales grow throughout the life of the fish, adjusting their growth pattern to the food supply. The scales grow quickly when food is abundant and slowly when it is scarce.

Mechlorethamine

The dose-limiting toxicity of mechlorethamine is myelosuppression maximal leukopenia and thrombocytopenia occur 10 to 14 days after drug administration, and recovery is generally complete at 21 to 28 days. Lymphopenia and immunosuppression may lead to activation of latent herpes zoster infections, especially in patients with lymphomas. Mechlorethamine will affect rapidly proliferating normal tissues and cause alopecia, diarrhea, and oral ulcerations. Nausea and vomiting may occur 1 to 2 hours after injection and can last up to 24 hours. Since mechlorethamine is a potent blistering agent, care should be taken to avoid extravasation into subcutaneous tissues or even spillage onto the skin. Reproductive toxicity includes amenorrhea and inhibition of oogenesis and spermatogenesis. About half of premenopausal women and almost all men treated for 6 months with MOPP chemotherapy become permanently infertile. The drug is teratogenic and carcinogenic in experimental animals.

Acyclovir aciclovir

It is active against herpes simplex viruses 1 and 2 and varicella-zoster virus, but poorly active against cytomegalovirus. The intravenous route is most reliable and it is distributed to all tissues including the meninges. Acyclovir is excreted by the kidneys and dose reduction is necessary in renal failure, although it is removed by hemodialysis. For the immune-suppressed patient with herpes zoster or varicella, acyclovir prevents dissemination and reduces shedding. It is effective in the treatment of herpes simplex encephalitis. Chickenpox in adults should be treated with acyclovir to reduce the morbidity associated with pneumonia. Phlebitis, reversible renal impairment, and elevation of transaminases are minor side-effects.

Skin Disorders

The skin is the site of several common disorders that include acne vulgaris, psoriasis, eczema dermatitis, contact dermatitis, drug-induced dermatitis, and burns. Some disorders result from viral infections such as herpes simplex and herpes zoster. Some result from fungal infections such as tinea pedis (athlete's foot) and tinea capitis (ringworm).

Herpes

Shingles or herpes zoster, which is the same virus that causes chicken pox, is characterized by a painful rash usually on one side of the body. Nerve pain, called postherpetic neuralgia, may persist after the rash has disappeared and can be helped by 1200 to 1600 IU vitamin E orally and 30 IU applied topically and by intramuscular injections of Vitamin B12. Intramuscular injections of 100 mg three times weekly of adenosine monophosphate, a naturally occurring compound in the body, can accelerate healing of shingles, reduce pain, and may prevent postherpetic neuralgia. Capsaicin containing cream from red pepper applied topically can help relieve pain.

Viral pneumonias

Intravenous acyclovir (aciclovir) has been used early in the onset of severe varicella zoster virus pneumonia and seems to reduce the respiratory rate and the duration of fever, and to improve oxygenation. It probably favors the healing of bronchial lesions. The same treatment might be recommended for the rare cases of severe necrotizing herpes simplex virus pneumonia, although there are no published data, as acyclovir is highly active in vitro and is non-toxic. The dose for severe pneumonia due to varicella zoster virus is 500 mg m2 intravenously every 8 h for 5 to 10 days.

Human Viral Diseases

Chickenpox and Shingles Chickenpox and shingles are caused by the same varicella-zoster herpesvirus. The virus multiplies in the lungs and travels to blood vessels in the skin. The symptoms of chickenpox include fever and skin rash. The virus is spread through direct contact with the skin rash and through the air. After recovery, a person has lifelong resistance to reinfection. The virus, however, can sometimes stay in nerve cells as a provirus. The virus can later cause a disease called shingles. The shingles rash, shown in Figure 24-5, can shed new chickenpox viruses and infect susceptible children and adults.

Antiviral Therapy

There are very few effective antiviral drugs because it is difficult to formulate a drug that eradicates the virus from the cells without also killing the cells themselves. The currently available antiviral therapeutics are mostly effective in treating the herpes virus, of which there are 4 main types. The first is the herpes simplex virus (the cause of cold sores), genital herpes, and herpes simplex keratitis. The second is the varicella zoster virus, the virus causing chicken pox and shingles. The third variety is the Epstein-Barr virus, which causes mononucleosis. Last, is the cytomegalovirus, a common infectious agent in AIDS patients.

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