HERPES INFECTION of - medkorat.in.th virus in neulrology2.pdf · since 1960 medicine korat pawut...
Transcript of HERPES INFECTION of - medkorat.in.th virus in neulrology2.pdf · since 1960 medicine korat pawut...
Since 1960
โรงพยาบาลมหาราชนครราชสมีา
Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine KoratKoratKoratKoratKoratKoratKoratKorat
PAWUT MEKAWICHAI
DEPARTMENT of MEDICINE
MAHARAJ NAKHONRATCHASIMA HOSPITAL
HERPES INFECTION of
THE NERVOUS SYSTEM
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CONTENT
HERPES SIMPLEX VIRUS2
HERPES VERICELLA-ZOSTER3
NATURE of HERPES VIRUS1
Zoster and post herpetic neuralgiaZoster and post herpetic neuralgia
Herpes simplex encephalitis
Vericella
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NATURE OF HERPES VIRUS
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FAMILY of HERPESVIRUS
� Herpes simplex virus type 1 (HSV-1)
� Herpes simplex virus type 2 (HSV-2)
� Varicella-Zoster virus VZV
� Cytomegalovirus (CMV)
� Ebstein-Barr virus (EBV)
� Human herpes virus type 6 (HHV-6)
� Human herpes virus type 7 (HHV-7)
� Human herpes virus type 8 (HHV-8)
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HERPES VIRUS
�primary infection at epithelial surfaces
�state of latency at sensory ganglia after primary infection
�back down from ganglia to cutaneous surface
� HSV-1
- oral, eye
- latent at trigerminal ganglia
� HSV-2 genital
- genital
- latent at sacral ganglia
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COMMON HERPES VIRAL INFECTION of
HSV-1
ENCEPHALITIS
MENINGITIS
MYELITIS
MENINGITIS
ENCEPHALITIS
MYELITIS
HSV-2 HVZ
MYELITIS
ENCEPHALITIS
MENINGITIS
ADEM
NERVOUS SYSTEM
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HERPES SIMPLEX ENCEPHALITIS
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� HSV-1 transmitted by respiratory or salivary
secretion
� spread from olfactory fiber (nose) to orbitofrontal
cortex and temporal lobe
HERPES SIMPLEX
ENCEPHALITIS (HSE)
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HERPES SIMPLEX
�most common sporadic, fatal encephalitis
�reduce mortality 70% (untreated)
to 20% (treated)
�morbidity up to 70% of survivors
�HSV-1 > HSV-2 in adult
�HSV-2 in congenital/acquire neonatal
ENCEPHALITIS (HSE)
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CLINICAL
CSF
BRAIN IMAGING
DIAGNOSISDIAGNOSIS
HERPES SIMPLEX
ENCEPHALITIS (HSE)
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� increase pressure
� lymphocytic pleocytosis (10-1000 per mm3)
�RBC or xanthochromia may be present but
not sensitive and non specific
�moderately elevated protein
�normal glucose
CSF FINDING
HSE
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�virus culture positive < 5%
�sensitivity and specificity > 95%
�false negative in first 24 hours of illness
Polymerase chain reaction (PCR)
for HSV DNA
HSE
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�CT and MRI has been useful
�CT hypodensity at temporal region but 40% of
HSE normal CT
�MRI abnormal hypersignal intensity at T2W in
temporal region
�MRI is more sensitive than CT
BRAIN IMAGING
HSE
CT brian MRI brain
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� abnormal in early course
� diffuse slow and focal abnormalities
in temporal region
� periodic lateralizing epileptiform discharge (PLED)
ELECTROENCEPHALOGRAM (EEG)
HSE
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�mortality 70%
�most survivors severe neurological deficit
before effective antiviral treatment
after effective antiviral treatment-acyclovir
�6-months mortality 20%
�25-30% morbidity
�50% normal life
HSE
PROGONOSIS
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�memory impairment
�personality, behavioral and psychiatric disorder
�anosmia
�epilepsy
�speech disorder
COMPLICATION
HSE
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�delay in diagnosis and treatment
�coma before treatment
�CT abnormalities
COMPLICATION-factor
HSE
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�empiric therapy with acyclovir immediately
�acyclovir 10 mg/kg q 8 hr 14-21 days or
until negative PCR (about 72 hours)
�monitor renal function and hydration
(crystal induce nephropathy)
TREATMENT
HSE
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Acyclovir 10mg/kg q 8 hr
�reduce mortality from 70 to 20%
� 30% treated with acyclovir recover with mild or
no neurological impairment
�Foscarnet in acyclovir resistance strain
TREATMENT
HSE
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HSV-2
�most common agent in neonatal
meningoencephalitis
�HSV-2 myelopathy rare, immunocompromise
� treated empirically with intravenous acyclovir
20 mg/kg q 8 hr 14-21 days
�risk of infection
duration of rupture membrane
severity of maternal infection
maternal immune status
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CONCLUSION
�proven efficacy both experimental
and clinical trial
�administration is well-tolerate
�for adult with fever and altered
consciousness should be empirically treated
ACYCLOVIR
HSE
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HERPES VERICELLA-ZOSTER
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VERICELLA-ZOSTER VIRUS
�primary infection of HZV, latent at sensory ganglia
�chicken pox
�encephalitis, meningitis, myelitis in
immunocompromise host (treated by acyclovir)
�encephalitis in healthy patient (rarely)
�self-limited cerebellar ataxia
VERICELLA
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�primary infection is chicken pox
�latency in sensory (dorsal root) ganglia
�secondary at age > 50 years (zoster)
�trunk 60%, head 20%, arm 15%, leg 15%
VERICELLA-ZOSTER VIRUS
งูสวดั คอืความทรงจาํในวยัเดก็ที�ควรถูกลมืไปแล้ว แต่กลบัมาใหม่ในวยัชรา
HERPES ZOSTER
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HERPES ZOSTER
� reactivation of varicella-zoster virus
� incidence increases with advancing age
� doubling in each decade past the age of 50
� uncommon in persons less than 15 years
VERICELLA-ZOSTER VIRUS
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HERPES ZOSTER
HERPES ZOSTER
COMPLICATION
CORNEAL CORNEAL
ULCERULCER
SKIN SKIN
INFECTIONINFECTIONVERTIGOVERTIGO
FACIAL WEAKNESSFACIAL WEAKNESS
ENCEPHALITISENCEPHALITIS
MYELITISMYELITIS
POST POST
HERPETIC HERPETIC
NEURALGIANEURALGIA
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GOAL 1GOAL 1 GOAL 2GOAL 2 GOAL 3GOAL 3
treatment
of
infection
treatment
of
acute pain
prevention
of
PHN
GOAL for TREATMENT
HERPES ZOSTER
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� about 20 % of zoster develop PHN
� the most established risk factor is age;
patients > 50 years, 15 times risk
� other possible risk factors
ophthalmic zoster
prodromal pain before lesions appear
immunocompromised state
POST HERPETIC NEURALGIA (PHN)
HERPES ZOSTER
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POST HERPETIC NEURALGIA (PHN)
HERPES ZOSTER
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� decrease the duration of rash and severity of pain
� benefits shown within 72 hours after onset of rash
� may be beneficial as long as new lesions are actively
� unlikely helpful after lesions have crusted
� effectiveness in preventing PHN is controversial.
ANTIVIRAL AGENT
HERPES ZOSTER
Triamquinolone Placebo > 2 Mo Yes Yes Yes
16 mg tid taper 21 d at 3 yr
Prednisolone Carbamazepine > 2 Mo Yes Yes40mg/d taper 28 d at 1 yr
Prednisolone Placebo > 6 Wk Yes No No
45 mg/d taper 21 d at 4 mo
Prednisolone Placebo Zoster Yes No No40 mg/d taper 21 d associated at 26 wk
Prednisolone Acyclovir Zoster Yes Yes No
60 mg/d taper 21 d or placebo associated at 6 mo
ACTIVE
TREATMENT
COMPARATIVE
TREATMENT
PAIN
DEFINITION
EFFICACY
REDUCED
EARLY
PAIN
REDUCED
PAIN
1 MO
REDUCED
PAIN
LAST VISIT
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� Commonly used, trials shown variable results
� Prednisone with acyclovir shown reduce the pain
� If prednisone is not contraindicated, adjunctive
treatment with antiviral agent for reducing pain
� for concern about immunosuppression
may used only > 50 years
� no study about steroid with valacyclovir, famciclovir
CORTICOSTEROID
HERPES ZOSTER
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TREATMENT
�Severity depend on location and immune status
�Acyclovir 800 mg 5 times/d 7-10d
�Famciclovir ( 500 mg 3 times/d 10-14d)
Decrease pain at onset, viral spreading/complication
Increase healing
NOT reduce post herpetic neuralgia (PHN)
HERPES ZOSTER
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CONCLUSION
�Severity depend on location and immune status
�Acyclovir 800 mg 5 times/d 7-10d
�Famciclovir ( 500 mg 3 times/d 10-14d)
Decrease pain at onset, viral spreading/complication
Increase healing
NOT reduce post herpetic neuralgia (PHN)
HERPES ZOSTER
ACYCLOVIR