Herpes Zoster Holistic Treatments

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Varicellazoster Virus

Like the herpes simplex viruses, varicella-zoster virus (VZV) is an enveloped, dou-ble-standed, DNA virus of the herpesvirus family. VZV causes two distinct clinical syndromes. Primary exposure to VZV results in varicella (chickenpox), a usually benign, highly contagious infection of children. Reactivation of latent VZV results in herpes zoster (shingles), an illness most commonly seen in adults over the age of 45 yr. Herpes zoster is more common in adults and the immunocompromised, 75 of cases occurring in those over the age of 45 yr. Immunocompetent children, adolescents, and young adults can develop herpes zoster, so a single episode in these individuals should not suggest underlying immunodeficiency. Herpes zoster may result in varicella in a susceptible host but exposure to someone with varicella does not cause herpes zoster. Herpes Zoster After primary infection, latent VZV persists within the sensory dorsal root ganglia. Herpes zoster presents as a unilateral vesicular rash...

Herpes Virus Infections 51 Varicella Zoster

Varicella-zoster virus (VZV) is a DNA virus and a member of the herpes virus family. It causes two distinct clinical syndromes primary disseminated infection, which is manifested as chickenpox, and reactivation of latent virus in the dorsal root ganglia, leading to herpes zoster or shingles. Herpes zoster is a painful, vesicular exanthem which erupts in one to two dermatomes after a prodrome of days to weeks and may take up to a month to heal (86). Most patients report a deep aching or burning sensation, altered sensation to touch with paresthesias, dysesthesia, or hyperesthesia. Herpes zoster is a common condition with a cumulative lifetime incidence of 10-20 with most of the risk concentrated in older age (87). The overall incidence is 215 per 100,000 person-years, but rates rise sharply with increasing age to 1425 100,000 for persons older than 75 yr. Therapy for Acute Herpes Zoster Within 72 Hours of Rash Because PHN is often refractory to treatment, efforts have been directed...

Inhibitors of Viral DNA Polymerase

Herpes simplex viruses types 1 and 2 (HSV-1 and -2) are both very susceptible to acyclovir varicella-zoster virus (VZV) is susceptible at somewhat higher concentrations of the drug. Other human herpesviruses, which do not possess a gene coding for TK, are susceptible to acycloguanosine only at much greater doses this results from limited production of ACG-P by cellular GMP kinase. The relative sensitivity of different herpesviruses seems to de-

Immune Control Of Viral Replication

Although complete viral eradication remains a worthy goal of HIV treatment, these preliminary observations and studies suggest that long-term immunologic control over HIV replication may be more eminently achievable and just as beneficial in the long run. Analogous to other common human viral pathogens (cytomegalovirus, Epstein-Barr virus, varicella-zoster virus, and so on) that maintain some form of clinical latency following a temporary or subclinical illness, it is conceivable that immune-based therapies can induce a life-long truce with HIV that falls short of a complete cure. Avoidance of damaging high levels of viral replication without the need for costly and complex ongoing therapies would result in a dramatic change in the natural history of HIV infection for each infected individual and could potentially alter our perspective on the overall AIDS epidemic.

Postoperative Care and Complications

Infection from either a viral, bacterial, or yeast fungal source can also prolong erythema. Infections need to be treated promptly with a change in oral agents based on culture identification and sensitivity results or based on empiric observation. If herpes simplex viral infection (HSV) is suspected, the antiviral medication should be increased to a herpes zoster dose. Valcyclovir is the antiviral agent of choice, recommended for its ability to attain higher blood levels in comparison to other anti-HSV drugs (Data on file, GlaxoSmithKline). For suspected yeast infections, additional doses of fluconazole or spectazole are recommended.

Infection Associated Hemophagocytic Lymphohistiocytosis

Table 22-14 lists the triggering organisms and clinical outcomes for IAHLH. Viruses include Epstein-Barr virus, human herpes virus 6 (HHV-6), cytomegalovirus (CMV) (most common of the viruses), adenovirus, parvovirus, varicella zoster, herpes simplex virus (HSV), Q-fever virus, and measles.

Complications Of Hematopoietic Stem Cell Transplantation

The importance of the recognition of the delayed overall immunologic reconstitution relates to the clinically observed incidence of recurrent bacterial (Streptococcus pneumoniae) and opportunistic infections (Pneumocystis carinii, fungal, herpes zoster, CMV) that can occur many months after transplantation. In addition to the use of prophylaxis against P. carinii infection, many centers add penicillin as a post-transplant prophylaxis against S. pneumoniae infection, particularly if the patient has chronic GVHD. The suppressed immunity also has major practical implications for consideration of the timing of vaccinations after HSCT. It is probably reasonable to consider the following approach

Clinical Features

When the CD44 T-cell count falls below about 400 per (xl the patient may develop a constellation of constitutional symptoms (fever, night sweats, oral candidiasis, diarrhea, and weight loss) which used to be known as AIDS-related complex (ARC). Early opportunistic infections begin to be seen. At this intermediate stage of immune depletion these infections are generally not life-threatening. They particularly include infections of the skin and mucous membranes such as tinea, seborrheic dermatitis, bacterial folliculitis, warts, molluscum contagiosum, gingivitis, oral and esophageal candidiasis, oral hairy leukoplakia (Fig. 35-10D), and chronic sinusitis. Reactivation of latent herpesviruses, particularly herpes simplex and zoster, also occurs (see Chapter 20). Gastrointestinal infections, caused by any of a wide vanety of organisms, including the yeast Candida albicans and parasites such as Cryptosporidia, are common. Mycobacterial infections are also common in these patients, and this...

Case 76 Mass In Left Lung With Elevated Left Hemidiaphragm

Raised Left Hemidiaphragm

The CXR shows a mass in the left upper lobe (Fig. 76.2), representing a primary lung cancer. In addition, the left hemidiaphragm is elevated such that it is higher than the right. Normally the right hemidiaphragm is 1-2 cm higher than the left. The left hemidiaphragm elevation here is likely due to left phrenic nerve palsy, probably due to mediastinal lymph node metastases. Other causes of an elevated hemidiaphragm include recent cardiac bypass surgery, trauma, and previous herpes zoster involving the phrenic nerve. The commonest cause, however, is idiopathic phrenic nerve palsy.

Common abnormalities

Allergic Dermatitis Insect

Fig. 2.19 Distribution of rashes as a key to diagnosis. 0 Herpes zoster. E Griseofulvin photosensitivity eruption. BEI Atopic dermatitis. 0 Allergic dermatitis from contact with rubber gloves. Fig. 2.19 Distribution of rashes as a key to diagnosis. 0 Herpes zoster. E Griseofulvin photosensitivity eruption. BEI Atopic dermatitis. 0 Allergic dermatitis from contact with rubber gloves.

Clinical Manifestations 21 Orofacial Infections

Vesiculobullous lesions of the oral mucosa and perioral region are commonly caused by viral agents, especially from reactivation of herpes simplex virus infection. Other viruses that may produce vesicular oral lesions include varicella-zoster, type A Coxsackie viruses, and cytomegalovirus (CMV). Oromucosal herpetic lesions typically occur on the gingiva, palate, or the tongue. The initial symptoms are sore throat, enlarged submandibular lymph nodes, and a burning sensation of the oral mucosa. This is rapidly followed by mucosal ulcers that may be small at first but often coalesce into large shallow lesions with serpiginous borders, and may become covered by a fibrinous, yellowish, firmly adherent membrane. The ulcer is very painful, and the patient is febrile and has considerable difficulty talking, eating, and swallowing. Varicella-zoster, or shingles, occurs in the elderly at rates exceeding 10 per 1000 annually at age 80 yr (13). Clinical manifestations include vesicular eruptions...

Infections In The Solid Organ Transplant Recipient

The etiologic organisms are often dictated by the site of infection in the solid organ transplant recipient (22-25). Skin infections are very common, although rarely life threatening. The most common causative agents are viral, such as herpes simplex virus (HSV) and varicella zoster virus (VZV), with other agents such as Papillomavirus and various dermatophytes being less common. The skin may also represent a target organ for disseminated infection, with a variety of bacterial (including atypical mycobacte-ria), fungal, and viral etiologies. The incidence of wound infections varies with the type of transplant, being most common in liver transplant recipients. Although S. aureus is the most common wound isolate, Gram-negative enteric organisms, coagu-lase-negative staphylococci, and rarely Mucor may also be etiologic.

Ongenital and Perinatal Viral Infections

Cytomegalic Inclusion Disease

In contrast to these congenital (prenatal) infections, several other viruses may infect the fetus during or shortly after birth (Table 36-11). Such perinatal (alias neonatal, natal, or intrapartum) infections may be acquired during passage of the baby through an infected birth canal (herpes simplex, cytomegalovirus) or by contamination with feces (coxsackie B, echovirus 11). Disseminated neonatal herpes, disseminated varicella-zoster, and myocarditis of the newborn (Fig. 23-5) are all overwhelming generalized infections with high case-fatality rates these are usually primary maternal infections, and because

Generation Of Cellmediated Immune Responses

Cytokine Network

CD4+ Th-lymphocytes recognize exogenous antigens that are phagocytosed, processed, and presented in the context of MHC class II. Only APCs that are MHC class II-positive can activate CD4+ Th-lymphocyte precursors. Their major antiviral effect appears to be secreting cytokines and activating other effector cells, such as B-lymphocytes and CTLs. They may also have indirect antitumor activity via release of toxic cytokines (e.g., tumor necrosis factor-a TNF-a ). CD4+ Th-lymphocyte help is crucial for the maintenance of an effective CTL response. When the infected cell is MHC class II-positive, CD4+ T-lymphocytes can also be cytolytic to the target cells (7). This function has been clearly demonstrated for herpesvirus infections including cytomegalovirus, herpes simplex virus, varicella-zoster virus, and EBV (8).

Butterflies And Moths

Like all insects, the bodies of butterflies and moths are divided into three regions head, thorax, and abdomen. In most species, the head has prominent, large, compound eyes and a long pair of antennae used as feelers mounted above. Lepidopterans also have well-developed olfactory organs, and some moths are capable of hearing. Below the eyes is a coiled proboscis used to suck nectar. The thorax of the insect has three segments, each of which bears a pair of legs, the last two of which support pairs of wings, referred to as the fore and hind wings, respectively. The wings of butterflies and moths are supported by a series of tubular struts, called veins, that form complex patterns, which are often of great taxonomic significance in distinguishing species. The abdomen is a roughly tubular structure composed of ten segments ending with external genitalia which, because they vary greatly from species to species, are also of great taxonomic significance. The entire body, with the exception...

Mechanisms of Survival of Viruses in Nature

Although chickenpox is also an acute exanthema in which infection is followed by lifelong immunity to reinfection, it requires a dramatically smaller critical community size for indefinite persistence of the disease less than 1000, compared with 500,000 for measles. This is explained by the fact that varicella virus, after being latent for decades, may be reactivated and cause zoster (see Chapter 10). Although zoster is not as infectious as chickenpox itself (secondary attack rates of 15 , compared with 70 for varicella), it can, in turn, produce chickenpox in susceptible children and grandchildren.

Viral Diseases of the

Corneal ulceration Ophthalmic zoster Pandemics radiculomyelitis Herpes simplex Herpes zoster Herpes simplex Herpes zoster Keratoconjunctivitis is potentially more dangerous, as it involves the cornea. Adenoviruses 8 and 37 are major causes of epidemic keratoconjunctivitis, which spreads readily by contact to adults, and usually involves only one eye, but may take up to a year to resolve. The main cause of sporadic keratoconjunctivitis, indeed the commonest infectious cause of blindness in the Western World, is herpes simplex virus (Fig. 20-5). Pathognomic dendritic or geographic ulcers develop on the cornea (Fig. 20-6), and if infection progresses lo involve the stroma beneath, the immunologic reaction may lead to disciform keratitis, scarring, and loss of vision. Recurrent attacks are particularly damaging, as can be the application of corticosteroids. When herpes zoster involves the fifth cranial nerve, ophthalmic zoster (Fig. 20-7) can cause lasting damage to the eye.

DCommon adverse effects

Increased susceptibility to infection, primarily viral, such as herpes zoster, but also bacterial, and gastrointestinal intolerance, such as nausea and vomiting. aZa can lead to liver enzyme abnormalities and even clinically significant hepatitis. At times, hepatitis may be part of a hypersensitivity reaction with associated fever and hypotension. If this occurs, AZA should be stopped permanently. Pancreatitis may occur and clears when the drug is stopped.

Spaceoccupying Lesion Syndrome

In an immunosuppressed patient who presents with focal neurological signs and multiple cerebral ring enhancing lesions on neuroimaging, cerebral toxoplasmosis would be the most likely diagnosis. In fact, this presentation is so characteristic that current guidelines suggest that all such patients be treated with anti-Toxoplasma medications. A lack of response to such therapy should alert the clinician about the possibility of other conditions such as CNS lymphoma or progressive multifocal leokuencephalopathy. Rarely, cerebral infarcts, varicella zoster infection, and other bacterial and parasitic infections may mimic such a clinical presentation. In patients with solitary lesions, the possibility of cerebral lymphoma would be more likely. In patients who are seronegative for toxoplasmosis or are on prophylactic therapy for tox-oplasmosis other diagnoses should be considered (48).

Differential diagnosis

The more common of the life-threatening entities should be recorded. The esoteric diagnosis need not be recorded initially. A carefully thought out history and physical will guide the physician. If the more common entities are ruled out, then additional diagnostic possibilities should be considered. In the case of chest wall pain, historical facts may make it necessary to first rule out myocardial ischemia, pleurisy, and pulmonary emboli. As new information is gathered, it may become necessary to rule out dissecting thoracic aortic aneurysm, metastatic cancer, herpes zoster, and so on. In today's world of cost containment and cost-effective medicine, a logical sequential approach to differential diagnosis should be employed and documented. However, time is of the essence.

Invasion of the Central Nervous System

The other important route of infection of the central nervous system is via the peripheral nerves, as seen, for example, in rabies, varicella, and herpes simplex. Viruses may pass either (1) centripetally from the body surface to the sensory ganglia or (2) centrifugally from the ganglia to the skin, as in the reactivation of herpes simplex or varicella (as zoster). 1 he rate of travel is quite slow, at up to 10 mm per hour Herpesvirus capsids travel to the central nervous system in axon cytoplasm, and while doing so also sequentially infect the Schwann cells of the nerve sheath. Rabies virus travels to the central nervous system in axon cytoplasm without infecting cells of the nerve sheath. Following an animal bite, the virus enters the axon cytoplasm from motor axon terminals at neuromuscular junctions less commonly, after exposure to rabies virus aerosols (as among speleologists in some parts of the world), it passes up the olfactory nerve.

Postherpetic neuralgia PHN

PHN is a common consequence of infection with the herpes zoster virus, with damage to the sensory nerve cells in the dorsal root ganglion. The painful crusted lesions on the skin (on the dermatome corresponding to the infected nerve) heal after several weeks but the site often has persistent abnormal sensation, with light touch producing pain (allo-dynia). Antiviral agents, applied topically or sys-temically during the initial infection, may limit nerve damage and subsequent neuralgia, and early sympathetic blocks may be of benefit, for example stellate ganglion or lumbar sympathetic blocks.

Alphaherpesviruses

Eases it causes the childhood disease varicella (more commonly known as chickenpox) and the adult disease herpes zoster (commonly known as shingles). Varicella is the clinical outcome of a primary VZV infection, while herpes zoster is the result of the reactivation of latent VZV. Although HSV can reactivate frequently, VZV generally reactivates only once during the host's lifetime (21). Varicella zoster virus is fairly ubiquitous in the general population with the majority of individuals seroconverting during childhood (26). With the advent and use of the live attenuated varicella vaccine (LAVV), which is recommended to be given to pre-school-age children, the incidence of VZV infections should diminish. The LAVV vaccine has been shown to be quite effective (85-95 ) in preventing development of chickenpox (27,28). VZV genes in latently infected ganglia (47-49). Because these genes also are expressed during a lytic replication, what role, if any, they play in VZV latency is unclear...

Hepatitis

Several viruses are capable of causing hepatic inflammation. These include the Epstein-Barr virus, cytomegalovirus, herpes simplex virus, mumps, rubella, rubeola and varicella-zoster viruses, yellow fever virus, Coxsackie viruses, and adenoviruses. In most cases, infection or inflammation of the liver is part of a systemic infection with the above agents. In addition, there are a number of viruses that are primarily hepatotropic and are given alphabetical designations hepatitis A-E. Several other viruses that were initially thought to cause posttransfusion hepatitis, including hepatitis G virus or GBV-C and SEN viruses, are not currently believed to be human pathogens. Of the truly hepatotropic viruses, hepatitis A and hepatitis E generally produce self-limited disease, although fulminant hepatic failure has been reported in up to 1 -2 of infected individuals. Hepatitis D virus (or the delta agent) can produce coinfections in patients who are infected with hepatitis B, but it appears...

Clinical Application

Diseases against which no satisfactory vaccine is available, including those with a large number of different etiologic agents, are prime targets for antiviral chemotherapy. The common cold is an admirable example on both counts, but there are so many serotypes that chemotherapeutic agents, to be sufficiently broad spectrum, will need to be directed at molecules (or ligands) that are conserved across the genus Rhinovirus. Other respiratory infections, gastroenteritis, hepatitis, and infectious mononucleosis must also be high on the list of priorities. Effective chemotherapy is also needed to treat reactivation of latent infections such as herpes simplex and zoster, even though the latent infection itself will not be eliminated. Reactivation of herpesvirus infections is a particular problem in immunocompromised individuals, such as AIDS patients or transplant recipients. Chronic infections, for example, hepatitis B and C, AIDS, congenital rubella, or cytomegalovirus infections, may be...

Diagnostic Tests

Because most infections that originate from the oral cavity are polymicrobial in nature, care must be taken during specimen collection to avoid contamination by the resident oral flora. Aaerobic and anerobic blood cultures should always be obtained. In selected patients with pyogenic infections of the face and neck, particularly compromised hosts, needle aspiration of the spreading edge of the skin lesion (using a tuberculin syringe containing 0.5 mL nonbactericidal saline and a 23-gauge hypodermic needle) is a worthwhile procedure. For ulcerative oromucosal lesions, scrapings from the ulcer base should be obtained for Gram-stain, potassium hydroxide, and Tzanck preparations, and cytologic examination. The diagnosis of herpes simplex or varicella-zoster is readily confirmed by a positive Tzanck smear (prepared from scrapings of the ulcer base), which demonstrates the presence of multinucleated giant cells with intranuclear inclusions. Cultures for bacterial, fungal, mycobacterial, and...

Fungal arthritis

Rubella virus, hepatitis B virus, and parvovirus are the most common identifiable viral pathogens, although arthritis can be a manifestation of mumps, infectious mononucleosis (Epstein-Barr virus), herpes simplex, or infection with arbovirus, enterovirus, varicella-zoster, or adenovirus.

Sideeffect profile

Prophylactic folic acid supplementation can reduce the rate of gastrointestinal and oral side effects. The optimal dosage of folic acid is uncertain, although 5mg weekly appears adequate and has no more than a modest impact on efficacy. Alopecia is fairly frequent and causes particular concern to female patients. Other skin reactions include urticaria, and cutaneous vasculitis. Occasionally, methotrexate causes accelerated nodulosis, usually involving small nodules on the fingers or elbows. These nodules are indistinguishable from rheumatoid nodules except for their rapid onset and the fact that they can develop in patients negative for rheumatoid factor. Controversy surrounds their management ie, whether to stop methotrexate treatment or add an antirheumatic drug such as hydroxychloroquine which has been shown to reduce nodules in this circumstance. Other adverse events related to methotrexate therapy include fever, fatigue or myalgia. Infections sometimes occur, including...

Viral Conjunctivitis

Adenovirus is by far the most common cause of viral conjunctivitis and tends to be the most virulent. Herpes simplex virus (HSV) (usually type 1) primarily causes conjunctivitis in children and usually produces a mild inflammatory response. Other viral pathogens, which can cause viral conjunctivitis in the elderly, include enterovirus, coxsackievirus, and varicella-zoster.

Liverworts

Stems are creeping or ascending and usually bear three rows of leaves two rows of dorsal leaves and (in most species) one row of ventral leaves or underleaves. Leaves generally overlap and are attached to the stem at a slanted angle (a transverse angle is less common). The arrangement of the leaves in leafy liverworts can be referred to as being either succubous or incubous, based on the way the leaves overlap. In succubous species the leaves overlap, as do the shingles of a roof the upper part of a leaf is covered by the next leaf above it (toward the apex). In incubous species, leaves overlap in the opposite way (away from the apex). Leaves of many species are divided into lobes and filaments, giving the gametophyte a delicate appearance. For example, Frullania has two rows of dorsal leaves, one

Perfoliate

Common Leaf Arrangement

The scales are imbricate or overlapping, much like shingles on a roof. The leaves of the yew (Taxus) are sharp-pointed, flattened, and narrowly lance-shaped. They are spirally arranged on the branches but almost always give the appearance of being 2-ranked. This is also true for the dawn redwood (Metasequoia) and bald cypress (Taxodium distichum), both of which are deciduous in the fall, dropping entire branchlets with the attached leaves. Yew podocarpus (Podocarpus macrophylla) in the podocarpus family (Podocarpa-ceae), on the other hand, has a obvious spiral arrangement of the leaves.

Viral Skin Rashes

Types Viral Rashes

Vesicles are blisters, containing clear fluid from which virus can readily be isolated. Vesicular rashes do not present a great diagnostic problem, particularly now that smallpox (Fig. 36-5A) has disappeared. A generalized vesicular rash in a febrile child today is usually chickenpox (varicella). The lesions occur in crops, initially concentrated on the trunk, then spreading centrifu-gally. Each vesicle progresses lo a pustule and a scab which then falls off. In herpes zoster the lesions are largely (but not necessarily exclusively) confined to a particular dermatome (Fig. 20-7), as is also the case with the recurrent form of herpes simplex (Figs. 20-5 and 20-6). However, in the case of disseminated herpes simplex or zoster, as seen in newborn infants or immunocompromised patients, the lesions may be widespread throughout the body. Something of a curiosity is the condition known as hand-foot-and-mouth disease caused by certain coxsackieviruses, in which vesicles or even bullae occur...

Scales

Excretory System Evolution Reptiles

Modern bony fish, which comprise the vast majority of familiar fish species, have abandoned the heavy ganoid scales in favor of greater mobility and other protective devices. Their thinner and lighter scales contain neither cosmine nor ganoine, but rather consist of an osteoid layer (bonelike, but containing no bone cells) and an inner fibrous layer. There are two principal forms of these scales, cycloid scales, which are smoothly rounded in shape, and ctenoid scales, in which the free rear surface has comblike teeth (ctenii). Both types are fully embedded in the dermis and arranged in an overlapping fashion similar to roof shingles. The scales are covered with a thin layer of epidermis that contains single-celled mucous glands. Like the trunks of trees, these scales also exhibit growth rings (lamellae), the shape of which are uniquely characteristic to an individual species.

Infection

Lumbar Puncture

Virus and, rarely, common infections such as measles and chickenpox. Aseptic meningitis is a benign, nonbacterial form of the disease caused by a virus. Herpes zoster, the chickenpox virus, is also responsible for shingles, an infection that spreads along peripheral nerves, causing lesions and inflammation.

Conifers

Swamp Cypress Trees With Knees

Wood of the bald cypress, found in southern swamps, is like that of the redwood in being very resistant to decay. In the past, it was used for railroad ties, coffins, general construction, guttering, and shingles. The trees are well known for their knees, which rise above the water as tapering growths from the roots (Fig. 22.19). At one time, it was widely believed that these were a means of admitting oxygen

Herpesviridae

Varicella-Zoster Virus .330 All herpesviruses have the capacity to persist in their hosts indefinitely in the form of an episome in the nucleus of the cells that harbor them. Virtually every vertebrate species that has been carefully searched is found to support at least one host-specific herpesvirus which has evolved with that host species for millennia. Sometimes, as in humans, host-specific herpesviruses of different subfamilies occupy distinct ecologic niches, noncompetitively, in particular types of cells within a given individual (Table 20-1). Varicella (chick-enpox) and herpes simplex viruses establish latent infections in neurons. On reactivation, the varicella virus precipitates an attack of herpes zoster (shingles), whereas herpes simplex type 1 typically causes recurrent attacks of labial herpes herpes simplex type 2 is mainly responsible for genital herpes. Cytomegalovirus, Epstein-Barr (EB) virus, and human herpesvirus 6 (HHV-6) persist in lymphocytes. With the control of...

Rna Viruses

Papovaviridae Diseases Caused

Subfamily Alplmherpesvirmae (herpes simplex-like viruses) Genus Swiplexvirus (herpes simplex-like viruses) Genus Vartcellovtrus (varicella-zoster virus) Subfamily Bctaher csvirinae (cytomegaloviruses) Genus Cytomegalovirus (human cytomegalovirus) Genus Kospo ouirns (human herpesvirus 6) Subfamily Gammaherpesvirime (lymphoproliferative herpesviruses) Genus- Lywphocryptovirus (Epstein-Barr virus) The herpesviruses (herpes, creeping) have enveloped virions about 150 nm in diameter, with icosahedral nudeocapsids about 100 nm m diameter. The genome is a single linear molecule of dsDNA, 125-229 kbp. The herpesviruses replicate in the nucleus and mature by budding through the nuclear membrane, thus acquiring an envelope. This large family includes several important human pathogens and has been divided into three subfamilies. Alphaherpesvmme includes herpes simplex types 1 and 2, varicella-zoster virus, and B virus of monkeys, which is pathogenic for humans. Betaherpes-virinae comprises the...

Latent Infections

All six human herpesviruses are common and important pathogens which establish lifelong latency and may be reactivated at any time. When the trigger is profound immunosuppression, for example, in AIDS or organ transplantation, reactivation of a latent herpesvirus infection may be lethal. Paradoxically, although all herpesviruses share the common lifestyle of latency, they have evolved divergent strategies for achieving that end A key distinction is that herpes simplex and varicella-zoster viruses persist in neurons, which are nondividing but long-lived cells, whereas cytomegalovirus, EB virus, and human herpesvirus 6 persist in lymphocytes, which are dividing but short-lived (Table 10-1),

Case History

A middle-aged man presented to the pain clinic with a 10-year history of intractable burning and itching pain affecting the area of the face supplied by the infra-orbital nerve, following an episode of Herpes Zoster some 10 years previously. His pain was of such severity he was passively suicidal and he had been unable to touch his left cheek for many years. After he was placed on antidepressants his distress was reduced and three sessions of hypnosis using glove anaesthesia enabled him for the first time to control his pain. The imagery technique involved taking him back to his European childhood and asking him to imagine that he was holding a snowball against the affected area of his face.

Cellulitis

Patients who have cellulitis typically present with erythematous, edema-tous tender skin lesions that are warm to palpation. Regional lymphadenop-athy and lymphangitis may be present. Systemic signs usually are more prominent in patients who have associated bacteremia. The differential diagnosis for cellulitis is broad and includes deep and superficial venous thromboses gout herpes zoster angioedema contact dermatitis relapsing polychondritis local reactions to chemicals, foreign bodies, and insect venom and lymphedema, among others 29 .

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