wednesday case conference
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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 - PowerPoint PPT PresentationTRANSCRIPT
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Wednesday Case Conference
Yvonne L. Carter, MD04 June 2008
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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
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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
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SocHx Lives with wife No sick contacts No tobacco/Etoh No travel No pets
FamHx Mom – pancreatic
cancer Dad – CAD, MI
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Allergies Penicillin Bactrim
Medications Aspirin Tylenol Ca/Vit D MVI Fosamax Lovastatin Synthroid Vesicare
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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
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Lab Data130
4.5
99
25
32
1.5481
3.733.3
187
9.5
3.92.3
11.0
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Imaging Maxillofacial CT:
Soft tissue swelling seen about the right orbit anterior to the globe, likely representing preseptal cellulitis
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Discussion
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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
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Herpes Zoster Opthalmicus with Bacterial Superinfection
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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
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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
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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
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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
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Other Ocular Complications Keratitis, leading to
corneal ulceration Conjunctivitis Uveitis Episcleritis and
scleritis Retinitis
Choroiditis Optic Neuritis Lid Retraction Ptosis Glaucoma Extraocular muscle
palsies
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Prevention of Herpes ZosterCDC released MMWR May 15, 2008, with
Recommendations of the Advisory Committee on Immunization Practices
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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
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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;352:2271--84.
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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
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Vaccine NOT licensed for:
Persons <60 yrs old
Persons who have received varicella vaccine
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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
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Contraindications Allergy to Vaccine Components (gelatin,
neomycin)
Immunocompromised Patients
Pregnancy Having a pregnant household member is not a
contraindication to vaccination