Wednesday Case Conference Yvonne L. Carter, MD 04 June 2008

HPI 87yo CM with 3d h/o right facial swelling and rash Started as a little spot on the forehead Spread to involve entire right face, causing him to be unable to open his right eye Denies burning/itching/pain Denies any vesicles or pustules Skin feels very sensitive Denies HA, ear pain, vision loss, neck stiffness

PMH Osteoporosis HTN CAD, s/p MI 2005 GERD Hypothyroidism IBS Diverticulosis Raynaud’s Iron Def. Anemia BPH Anxiety Allergic Rhinitis Basal Cell CA, 1999 Peripheral Neuropathy

SocHx Lives with wife No sick contacts No tobacco/Etoh No travel No pets FamHx Mom – pancreatic cancer Dad – CAD, MI

Allergies Penicillin Bactrim Medications Aspirin Tylenol Ca/Vit D MVI Fosamax Lovastatin Synthroid Vesicare

Physical Examination T 36.3, P 54, BP 112/65, R 20, 97% RA Elderly, thin, kyphotic Neck supple, OP clear, No LAD RRR, Nrml S1S2, No m/g/r Lungs CTA b/l Abd benign Skin: Right scalp with a few flaccid vesicles, some areas of denuded skin, and some scab formation. Erythema and edema surrounding right eye

Lab Data

Imaging Maxillofacial CT: Soft tissue swelling seen about the right orbit anterior to the globe, likely representing preseptal cellulitis

Discussion

Hospital Course Received Vancomycin in ED Started on Clindamycin upon admit Lesions swabbed for HSV/VZV Positive for VZV Started on IV Acyclovir with improvement Discharged on Valacyclovir and Clindamycin

Herpes Zoster Opthalmicus with Bacterial Superinfection

VZV (Zoster) Human pathogen that infects 98% of the population in the US Enters sensory nerves in mucocutaneous sites and travels through retrograde axonal transport to the sensory dorsal root ganglia adjacent to the spinal cord where the virus establishes permanent latency in neuronal cell bodies Latent VZV present in 1-7% of sensory ganglion neurons, with <10 genomic copies per cell infected

Clinical Features Headache Photophobia Malaise Abnormal skin sensations of varying severity Unilateral vesicular rash distributed across closely overlapping dermatomes Thoracic, cervical, opthalmic dermatomes most common

Rash Initially erythematous and maculopapular but progresses to form coalescing clusters of clear vesicles containing high concentrations of VZV Vesicles evolve through pustular, ulcer, and crust stages Usually lasts 7-10 days, with complete healing in 2-4 weeks

Complications Post-herpetic neuralgia (PHN) Herpes Zoster opthalmicus (HZO) 10-25% of affected patients Occurs when reactivation involves the nasociliary branch of the trigeminal nerve, sometimes preceeded by presence of vesicles on the nose (Hutchinson sign) Ramsay Hunt Syndrome

Other Ocular Complications Keratitis, leading to corneal ulceration Conjunctivitis Uveitis Episcleritis and scleritis Retinitis Choroiditis Optic Neuritis Lid Retraction Ptosis Glaucoma Extraocular muscle palsies

Prevention of Herpes Zoster CDC released MMWR May 15, 2008, with Recommendations of the Advisory Committee on Immunization Practices

Recommendations for Use of Zoster Vaccine Routine Vaccination of Persons Aged > 60 Persons who report a previous episode of zoster and persons with chronic medical conditions can be vaccinated unless those conditions are contraindications Not indicated to treat acute zoster, to prevent PHN, or treat ongoing PHN It is NOT necessary to ask about history of varicella or conduct serologic testing for immunity prior to vaccination

Zoster Vaccination Offers an opportunity to decrease the burden of disease and its complications among persons with high level of risk In placebo-controlled clinical trial, vaccination reduced overall incidence of zoster by 51.3%, and reduced incidence of PHN by 66.5% Oxman MN, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med 2005;352:

Zoster Vaccine Zostavax® (Merck & Co., Inc) liscensed for use in US In 2006 Live, attenuated VZV (Oka strain - same strain used in varicella vaccines) Each dose is 0.65ml, and contains a minimum of 4.29 log of Oka strain of VZV 14x more potent than Varivax Also contains additional VZV antigenic component from nonviable Oka VZV Administered as single subcutaneous dose in the deltoid region of the upper arm

Vaccine NOT licensed for: Persons <60 yrs old Persons who have received varicella vaccine

Special Groups Persons with a History of Zoster Persons Anticipating Immunosuppression Give at least 14 days prior to use of immunosuppressants Persons Receiving Antiviral Medications Acyclovir, Famciclovir, and Valacyclovir should be held for 24hrs prior to vaccination Persons Receiving Blood Products Nursing Mothers Vaccine not secreted in breast milk Moderate to Severe Illness

Contraindications Allergy to Vaccine Components (gelatin, neomycin) Immunocompromised Patients Pregnancy Having a pregnant household member is not a contraindication to vaccination