20 babik herpes virus - ucsf cme€¦ · 1.recognize the key clinical features of the most common...
TRANSCRIPT
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Herpesviruses
Jennifer Babik, MD, PhDAssociate Clinical ProfessorDivision of Infectious Diseases, UCSF
40th Annual Advances in Infectious DiseasesMarch 2019
Disclosures
I have no disclosures.
Learning Objectives
By the end of this talk, you will be able to:
1. Recognize the key clinical features of the most common herpes virus infections.
1. Describe the important principles of diagnosis and management of common herpes virus infections
Roadmap
Case‐based approach to:
HSV‐1
HSV‐2 (non‐genital infections)
VZV
CMV
EBV
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Case #1
A 28 year old man presents with fever and severe sore throat after returning from his honeymoon. He has mild anterior cervical LAN and the oral exam shown. The rest of his exam is normal.
Tests for Group A Strep, acute HIV, and EBV are negative.
Photo courtesy of Matt Russell.
1. Throat swab for VZV DFA
1. Throat swab for HSV PCR
2. Throat swab for CMV PCR
3. Tonsillar biopsy to r/o lymphoma
The next best test is:
Oral HSV: Primary Infection
Children/young adults, HSV‐1
Symptomatic in 10‐30%:
Gingivostomatitis
Pharyngitis/tonsillitis ‐ may not have vesicles!
Systemic sx (can look like mono)
Duration of symptoms 10‐14d
Oral antivirals duration of sx
ACV 200mg PO 5x/day x 7 days
Valacyclovir 1gm PO bid x 7 days
Ardino and Porter, J Oral Pathol Med 2008; 37:107. McMillan et al, Pediatr Infect Dis J 1993; 12:280. Ireland, Oxford Dictionary of Dentisty 2010. Cernik et al, Arch Intern Med 2008; 168:1137.
Case #2
A 30 year old man presents to clinic complaining of “fever blisters” for the past 24 hours. He has moderate pain but mostly feels a great degree of stress and embarrassment about the lesions. This is his 5th
episode in the last year.
Photo courtesy of Laura Pincus.
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Oral antivirals
1. Shorten the time for lesions to heal
2. Are effective as suppressive therapy
3. Both #1 and #2
4. Have no treatment effect
Recurrent Oral HSV: Herpes Labialis
Almost always HSV‐1
Recurrences in 20‐40% of HSV‐1 (+)
1.5 recurrences/year
Triggers: Fever, URI
UV light exposure (sun)
Emotional stress, fatigue
Immunosuppression
Oral/facial surgery or trauma
Menstruation
Cernik et al, Arch Intern Med 2008; 1168:1137. Ardino and Porter, J Oral Pathol Med 2008; 37:107.
Oral HSV Reactivation in Immunocompromised
Test Sensitivity Specifcity Take home points
HSV: Diagnostics
Mosely et al, J Clin Microbiol 1981; 13:913. Wald et al, J Infect Dis 2003; 188:1345. Van Wagoner and Hook, Curr Infect Dis Rep 2012; 14:175. Lafferty et al, J Clin Microbiol 1987; 25:323.
PCR ~90% overall 99% Most sensitive test
DFA Vesicle 70‐90%Ulcer 30%Crusted 10%
99% Rapid (hours)Slight sensitivity c/w culture
Culture Vesicle 70‐90%Ulcer 30‐40%Crusted 20‐30%
100% Moderate sensitivityTakes 1‐2 days
*Oral HSV is often a clinical diagnosis. May need to confirm if immunocompromised, severe, atypical, or not responding to Rx.
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Oral HSV: Treatment
Episodic therapy
time to heal by 0.5‐2.5 days (does not abort lesions)
Antivirals: Acyclovir 200mg PO 5x/day x 5 days
Valacyclovir 2gm PO bid x 1 day
Suppressive therapy
recurrences by 40‐50% (if ≥4‐6 recurrences/year)
Not known if can oral HSV‐1 shedding or transmission
Antivirals: Acyclovir 400mg PO bid
Valacyclovir 500mg or 1000mg PO daily
Cernik et al, Arch Intern Med 2008; 168:1137.
Oral HSV: Take Home Points
Primary HSV‐1 can be a cause of pharyngitis in young adults (and may not present with vesicles)
HSV PCR of a lesion is the most sensitive diagnostic test for mucocutaneous herpes infections
Oral antivirals have a modest treatment effect: they can shorten healing time and be used as suppressive therapy to prevent recurrences
Case #3
55 year old man is brought in by his neighbor for bizarre behavior for 12 hours. He is found to be febrile and has a witnessed seizure in the ED. MRI is shown. He is started on vancomycin, ceftriaxone, and acyclovir and is tapped 24 h later.
Lumbar puncture: 50 WBC (89% lymphs), 50 RBC, protein 80, glucose 78
CSF culture is NGTD
PCR is negative for HSV and VZV
What Would You Do With His Antibiotics?
1. Stop acyclovir
2. Change acyclovir to ganciclovir
3. Continue acyclovir
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The HSV PCR May Be Negative Because:
1. He got 24 hours of acyclovir
2. It’s not a sensitive test
3. It’s early in the disease course
HSV Encephalitis
Epidemiology/Clinical:
Accounts for 10‐20% of encephalitis
>90% due to HSV‐1, most reactivation (HSV2 rare, in ICH)
Fever, personality change, seizures, focal neuro findings
CSF studies:
WBCs: lymphocytic pleocytosis (median 130 cells)
RBCs: elevated <500
Mildly protein (median 80 mg/dl), normal glucose
Whitley et al, JAMA 1982, 247:312. Whitley et al, JAMA 1989, 262:234. Tang et al, Clin Infect Dis 1999, 29:803. Domingues et al, Clin Infect Dis 1997, 25:86.
Can be normal in up to 15%
HSV Encephalitis: Diagnosis and Rx
CSF PCR:
96% sensitive, 99% specific
May have false (‐) in the first 3d if suspicion is high re‐tap
ACV has little effect on PCR (+) within the first 5 days of therapy
MRI: temporal/frontal lobe involvement in 90%
Treatment:
ACV 10mg/kg IV q8h x 14‐21 days
Can check HSV PCR at d14 to define duration
DeBiasi and Tyler, Clin Microbiol Rev 2004, 17:903. Tyler, Herpes 2004, 11 Suppl 2: 57A
HSV Aseptic Meningitis
1st episode in primary genital HSV‐2 (women>men)
Recurrences:
20‐30% of patients will have at least 1 recurrence
Mollaret’s = repeated self‐limited episodes +/‐ skin lesions
Antivirals needed?
Consider ACV 10 mg/kg q8h or valacyclovir 1gm PO tid x 7‐14d (some data for benefit in immunocompromised)
Suppressive therapy not effective to prevent recurrences
Tyler, Herpes 2004, 11 Suppl 2: 57A. Aurelius et al, Clin Infect Dis 2012, 54: 1304. Berger and Houff, Arch Neurol 2008, 65:596. Noska et al, Clin Infect Dis 2015;60:237.
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HSV Neuro Complications: Take‐Home
HSV encephalitis is usually caused by HSV‐1 and affects the frontal/temporal lobes
CSF HSV PCR is very sensitive for HSV encephalitis:
There can be false (‐) within the first 3 days of symptoms
ACV has little effect on sensitivity within the first 5 days
HSV meningitis is a complication of primary genital herpes from HSV‐2 and can be recurrent
Case #4
64 y/o man on prednisone 20mg/day for autoimmune hemolytic anemia presents with a painful progressive rash on his abdomen in the T8/T9 distribution.
He is admitted with concern for disseminated zoster.
Acyclovir is started but he still has new lesions on day 2
The Most Likely Diagnosis Is:
1. Disseminated zoster
2. Resistant zoster
3. Uncomplicated localized zoster
4. Herpetic whitlow
Zoster: Key Clinical Features
80% have prodrome (lasts 2‐3 days)
New vesicles appear for 2‐4 days (antivirals new lesions by 1‐2 days)
Overlap into adjacent dermatomes in
20% (normal variation in innervation)
PHN: pain lasting >3 months after zoster episode, occurs in 10‐20%
Dworkin et al, Clin Infect Dis 2007; 44 (Suppl1): S1.
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To confirm the dx, the most sensitive test is:
1. VZV DFA
2. VZV culture Test Sensitivity Specifcity Take home points
Cutaneous VZV: Diagnostics
Dworkin et al, CID 2007; 44 (Suppl1): S1. Helgason et al, Eur J Gen Pract 1996; 2:12. Kalman and Laskin, Am J Med 1986, 81:775.
PCR 95% 99% Most sensitive testNot always available
DFA 90% 95% Rapid if in‐house (hours)
Culture 60‐75% 100% Takes 1‐2 weeks to growUsually not done
• Zoster is often a clinical diagnosis (~90% accurate). • May need to confirm if immunocompromised, severe/disseminated (e.g., hospitalized), atypical, or not responding to Rx.
Which is the Best Choice to the Risk of PHN?
1. Prednisone
2. Valacyclovir
3. Valacyclovir and prednisone
Zoster Treatment: Antivirals
Benefits of therapy
duration new lesion formation by 1‐2 days
severity and duration of acute pain and rash
risk of PHN (inhibits viral replication, neural damage)
Who to Treat?
≥50 years, mod‐severe pain/rash, immunocompromised
Consider in all as benefit ( PHN) likely outweighs risk
Dworkin et al, Clin Infect Dis 2007; 44 (Suppl1): S1. Chen et al, Cochrane Database Syst Rev 2010; Issue 12.
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Timing of Therapy
Timing: All RCTs initiate therapy within 72 hours
Starting at >72h hasn’t been well studied (?benefit up to 7d)
If a patient presents at >72 hrs, would still treat if: Presence of new vesicles (indicates ongoing viral replication)
Cutaneous, motor, ocular, neurologic complications
Advanced age, severe pain (since these are risks for PHN)
Immunocompromised
V1 zoster (VZV ophthalmicus)
Dworkin et al, Clin Infect Dis 2007; 44 (Suppl1): S1.
Antiviral Options
Drug options: Acyclovir 800 mg PO 5x/day, valacyclovir 1gm PO tid Duration 7‐10 days Immunocompromised: treat until all lesions crusted given risk of relapse
When to admit patients for IV acyclovir? Disseminated disease or CNS/eye complications
Severely immunocompromised patients with localized disease (to prevent dissemination)
Consider in VZV ophthalmicus (V1 zoster)
Dworkin et al, Clin Infect Dis 2007; 44 (Suppl1): S1.
Steroids in Acute Zoster
3 RCTs all show that addition of steroids to ACV:
Accelerated healing, reduced pain, improved QOL
But no decrease in PHN
So when to consider steroids?
Moderate to severe pain
Facial nerve paralysis
No contraindications to steroid use
Regimen: Prednisone 60 mg/d then taper over 10‐21 d
Wood et al, N Eng J Med 1994; 330:896. Whitley et al, Annals Int Med 1996; 125:376. Esmann et al, Lancet 1987; 330:126. Chen et al, Cochrane Database Syst Rev 2010; Issue 12.
Case #5
75 y/o man with well controlled HIV presents to clinic with a rash over his R eye in the V1 distribution associated with conjunctivalinjection.
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How Would You Treat Him?
1. High dose PO valacyclovir and close follow‐up
2. Admission and IV acyclovir
VZV Ophthalmicus
Defined as zoster in the V1 distribution
Without Rx, 50% will develop eye complications
Conjunctivitis
Anterior uveitis
Necrotizing retinitis
Keratitis
Corneal ulcer
Orbital apex syndrome
Harding et al, Br J Ophthalmol 1987.
VZV Ophthalmicus: Management
Ophtho consult for those with:
Eye symptoms
Lesions on the tip or side of the nose
Immunocompromised
Antivirals:
Treat all patients irrespective of duration of symptoms
Intravenous ACV if immunocompromiseor eye involvement
Dworkin et al, Clin Infect Dis 2007; 44 (Suppl1): S1
Hutchinson’s sign
Case #6
A 59 year old man with SLE on cellcept and prednisone (10 mg/day) presents with diffuse vesicular rash. VZV DFA is positive and he is started on high dose acyclovir. He still has new lesions on HD#4.
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What Would You Do?
1. Continue ACV and monitor for visceral involvement
2. Change to foscarnet given concern for resistance
Disseminated VZV
= lesions outside the primary or adjacent dermatomes
Usually immunocompromised, occurs by viremic spread to skin
Patients may have new lesions for up to 2 weeks
Patients are at high risk for pneumonitis, hepatitis, DIC
Cohen, NEJM 2013, 369:255. Pergam et al, Am J Transplantation 2013.
Treatment• Total duration 7‐14 days• Use IV at least 7 days anduntil all lesions are crusted
Another Complication of VZV: Encephalitis
Usually occurs in immunocompromised patients
Clinical: HA, fever, AMS, seizures Rash present in only 2/3 of cases
CSF profile: Lymphocytic pleocytosis (median 110 cells/mm3) Elevated protein, glucose normal to slightly low Positive VZV PCR (sensitivity 80‐100%, specificity 98%) Positive VZV IgG (more sensitive than PCR, especially if chronic)
Treatment: Acyclovir 10‐15 mg/kg IV q8 h for 10‐14 days
Gilden et al, NEJM 2000. Pahud et al, J Infect Dis 2011, 203:316. Tunkel et al, CID 2008, 47:303.
VZV: Take Home Points
DFA or PCR are the diagnostic methods of choice for cutaneous zoster
Steroids provide no additional benefit to antivirals in risk of PHN
Admit patients for IV acyclovir if they are severely immunocompromised or have disseminated/CNS disease
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Case #7
47 year old M with no PMH is admitted with fever and respiratory distress. CT shows prominent GGO. HIV Ab test is positive and CD4 is 56. BAL is performed and is positive for PCP.
BAL is also positive for CMV culture. Plasma CMV PCR is positive at 970 IU/mL.
What Antibiotics Should You Start?
1. TMP‐SMX alone
2. TMP‐SMX plus ganciclovir
3. TMP‐SMX plus acyclovir
4. TMP‐SMX plus IVIG
Approach to CMV Infections
Immunocompetent
Primary infection
Asymptomatic or “heterophile(‐) mononucleosis”
Diagnosis by serology
Supportive Rx only
Navalpotro et al, J Clin Virol 2006; 35:193. Wreghitt et al, Clin Infect Dis 2003; 37:1603.
Immunocompromised
Primary or reactivation
• Asymptomatic viremia• CMV syndrome• End‐organ disease
Diagnosis by tissue biopsy,blood PCR, culture
Usually anti‐CMV therapy
Define the Host
Symptomatic CMV in Immunocompetent Patients
Clinical: viral syndrome, abnormal LFTs
Diagnosis (if testing is done):
Positive CMV IgM (but beware false positives) Can be elevated for > 4‐12 mo after infection, during reactivation, or polyclonal stimulation (e.g. during acute EBV infection)
Negative or low avidity IgG
Treatment: supportive
Wreghitt et al, Clin Infect Dis 2003; 37:1603.
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CMV Infection in Immunocompromised Patients
AsymptomaticViremia
Asymptomatic
Plasma CMV PCR (+)
Treatment depends on host
CMV Syndrome
Fever plus bone marrow suppression (leukopenia and/or thrombocytopenia)
Plasma CMV PCR (+)
Treat all patients
End‐Organ Disease
•Neuro: Encephalitis, Retinitis• Pneumonitis •GI: Colitis>Esophagitis•Others: hepatitis, nephritis,myocarditis, pancreatitis
Plasma CMV PCR (+) (GI can be compartmentalized)
Treat all patients
CMV Infection
CMV End‐Organ Disease: Examples
CMV Colitis• Fever, diarrhea (+/‐ bloody), abdominal pain
CMV Pneumonitis• Fever, mild to severe respiratory failure
CMV in HIV+ Patients
Asymptomatic viremia in up to 35% pts w/CD4<200
Most common end‐organ disease:
Retinitis
GI (colitis > esophagitis)
Pneumonitis is rare: BAL+ for CMV in ~50% of patients (without CMV pneumonitis)
Durier et al, Clin Infect Dis 2013;57:147. Deayton et al, Lancet 2004; 363: 2116. Hayner et al, Chest 1995;107;735. Miles et al, Chest 1990;97;1072. CDC/NIH/HIVMA Guidelines for the prevention and treatment of OIs in HIV‐infected adults, 2015.
CMV Treatment
IV vs PO?
IV ganciclovir if severe infection, high viral load (e.g., >1 million copies/mL), poor oral absorption
PO valganciclovir okay for mild‐moderate disease
How long to treat?
2‐3 weeks and until PCR negative (check weekly)
May consider secondary prophylaxis in selected patients
Razonable et al, Am J Transplant 2013; 13:93. Asberg et al (VICTOR study group), Am J Transplant 2007; 7:2106.
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CMV: Take‐Home Points
Define your host: immunocompetent or immunocompromised (HIV vs transplant/other)
Determine which type of CMV infection your patient has: Asymptomatic viremia
CMV syndrome
End‐organ disease
HIV+ patients are a special category: Commonly have asymptomatic viremia
Can have severe end‐organ disease (retinitis, GI most common)
Rarely have pneumonitis despite frequent +BAL for CMV
Case #8
57 year old woman s/p renal transplant 4 months prior who has been off her CMV prophylaxis (valganciclovir) due to leukopenia. She presents to clinic with fatigue and fever to 39.1 and is found to have pancytopenia. She has no other localizing signs/symptoms.
Labs:
WBC 1.0 (previously 2.5)
Platelets 81 (previously normal)
CMV viral load in the plasma is 56,000 IU/mL
Review Question: What is the Diagnosis?
1. Asymptomatic CMV viremia
2. CMV syndrome
3. CMV end‐organ disease
CMV: Take‐Home Points
Define your host: immunocompetent or immunocompromised (HIV vs transplant/other)
Determine which type of CMV infection your patient has: Asymptomatic viremia
CMV syndrome
End‐organ disease
HIV+ patients are a special category: Commonly have asymptomatic viremia
Can have severe end‐organ disease (retinitis, GI most common)
Rarely have pneumonitis despite frequent +BAL for CMV
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Case #9
22 y/o woman presents with fever, sore throat, and cervical lymphadenopathy for 2 days. Heterophileantibody test is negative.
The Sensitivity of Heterophile Ab in 1st Week is:
1. 25%
2. 50%
3. 75%
4. >90%
Case #10
A 28 year old man with no PMH is admitted with fever to 39.6, diffuse lymphadenopathy, and pancytopenia. 10 days prior he had a sore throat (now resolved) for which he was prescribed azithromycin.
His EBV testing is as follows:
‐ Monospot positive
‐ EBV IgM negative, IgG positive
‐ EBV PCR negative
The Most Likely Diagnosis is:
1. Acute EBV infection (Mononucleosis)
2. Prior EBV infection and a different acute process
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EBV
75% of US is seropositive by age 18
Clinical:
Incubation period 4‐6 weeks
<18 y/o: Most are asymptomatic or nonspecific illness
>18 y/o: Most are symptomatic
Infectious mononucleosis = classic triad of sore throat, cervical lymphadenopathy, fever
Balfour et al, J Infect Dis 2013; 207:80.
Diagnosis of IM: Heterophile Antibody (Monospot)
Patient’s blood: IgM against viral antigens
+
Sheep or horse RBCs
Agglutination
X‐reactivity
Sensitivity: 90‐95% after 1st week, but only 75% in the 1st week
Specificity: 94%. False (+): infections (CMV, Toxo, acute HIV), malignancy, autoimmune (SLE)
*No longer recommended by the CDC given false (+) and (–)*
Luzuriaga and Sullivan, N Engl J Med 2010; 362:21.
Diagnosis of IM: EBV Serologies
Luzuriaga and Sullivan, N Engl J Med 2010; 362:21.
IgM VCA
IgG VCA
IgGEBNA
Acute Infection
+ +/− −
Prior Infection
− + +
• Sensitivity 85‐90%
• Specificity >95%
EBV IgG(EBNA)
EBV IgG (VCA)
EBV IgM(VCA)
Weeks
Diagnosis of IM: EBV PCR
Not a lot of data
Positive early on, usually undetectable by week 3
2016 meta‐analysis of 4 small studies in kids/young adults:
Pooled sensitivity: 80%
Pooled specificity: 95%
May be helpful when other tests are inconclusive
Jiang et al, J Med Virol 2016; 88:871. Berth et al, J Clin Virol 2011; 50:184. Bauer et al, J Med Virol 2005; 75:54.
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Diagnosis of IM: CBC with Differential
Absolute lymph count > 4,000 x 106/L
Sensitivity 84%
Specificity 94%
Atypical lymphs >10%
Sensitivity 75%
Specificity 92%
Luzuriaga and Sullivan, N Engl J Med 2010; 362:21. Vouloumanou et al, Curr Opin Hematol 2012; 19:14. Biggs et al, Laryngoscope 2013, 123:2401.
Complications of EBV Infection
Hematologic 25‐50%
Hemolytic anemia
Thrombocytopenia
Aplastic anemia
TTP/HUS
DIC
Trigger for HLH
Splenic rupture
Luzuriaga and Sullivan, N Engl J Med 2010; 362:21.
Neurologic 1‐5%
Guillain–Barre syndrome
Facial paralysis
Aseptic meningitis
Encephalitis
Transverse myelitis
Peripheral neuritis
Optic neuritis
Mononucleosis: Treatment
Steroids? Not for all, maybe in select cases
Cochrane review 2015: “insufficient evidence to the efficacy of steroids for symptom control…lack of research on the side effects and long‐term complications”
Consider short course to treat severe complications (e.g., upper‐airway obstruction)
Antivirals? NO, multiple RCTs show no benefit
Luzuriaga and Sullivan, N Engl J Med 2010; 362:21. Rezk et al, Cochrane Database Syst Rev 2015, issue 11. Balfour et al, J Clin Virol 2007; 39:16.
EBV Take Home Points
Monospot testing can lead to false negatives and false positives and is no longer a recommended test
Serology is 85‐90% sensitive
PCR is positive early on with overall 80% sensitivity
Lymphocytosis and atypical lymphs can be an important clue to diagnosis
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Thank You!
Questions?