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Varicella zoster virus is the causative agent of both chickenpox and shingles. Primary infection with chickenpox occurs mostly in children, with 90% of the population acquiring antibodies to VZV by the age of 10 years. After primary infection, the virus becomes latent in the dorsal root ganglia. Herpes zoster (HZ), caused by reactivation of the varicella zoster virus (VZV), occurs more often with age as cellular immunity wanes.

Reactivation results in the unilateral eruption of a painful rash known as herpes zoster or shingles.




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New vaccine :


An attenuated live vaccine (ZVL, Zostavax) has been available for a decade. However, its effectiveness in preventing both HZ and postherpetic neuralgia (PHN) decreases with age and over time.

Adjuvanted Subunit Zoster Vaccine

Recently, an adjuvanted subunit vaccine containing recombinant VZV glycoprotein E (HZ/su, Shingrix) has been developed. In previous studies, HZ/su had an efficacy of >90% in preventing HZ in people aged ≥50 years, and this efficacy was maintained for 4 years.

Now, in this industry-sponsored phase III, open-label, multicenter study, 215 individuals ≥65 years previously given ZVL ≥5 years ago were matched to 215 individuals who were ZVL-naive. All participants were given two intramuscular doses of HZ/su. The primary objective was to study the humoral immunogenicity of HZ/su 1 month after the second dose and to assess its safety. Levels of serum anti–glycoprotein E increased greatly and similarly in both groups, as did the number of glycoprotein E–specific CD4+ T cells. Similarly, the number of local and systemic adverse events was similar in the two groups.


These results demonstrate that the immunogenicity and safety of HZ/su is similar regardless of prior receipt of ZVL, suggesting that revaccinating with HZ/su may be reasonable. The results are timely given the recent decision by the Food and Drug Administration to approve HZ/su ( and the Advisory Committee on Immunization Practices to give preference to HZ/su over ZVL for HZ vaccination.


Vaccination to prevent herpes zoster

●For most patients who meet criteria for zoster vaccination, we suggest the recombinant zoster vaccine (RZV) rather than the live attenuated zoster vaccine (ZVL) (Grade 2B). For patients who previously received ZVL, we suggest revaccination with RZV (Grade 2C).

Two vaccines are available to prevent herpes zoster and postherpetic neuralgia in patients ≥50 years of age: a recombinant glycoprotein E vaccine (recombinant zoster vaccine [RZV], approved for use in the United States in October 2017) and a live attenuated vaccine (zoster vaccine live [ZVL]). We suggest RZV rather than ZVL for most patients who meet criteria for vaccination. RZV appears to provide greater protection against herpes zoster, and there is less concern for waning immunity. The choice of RZV as the preferred type of vaccine is consistent with recommendations from the Advisory Committee on Immunization Practices [3]. Disadvantages of RZV are the need for two doses (versus one with ZVL), and an increased risk of mild to moderate side effects (pain at the injection site, myalgia, fatigue, headache, fever) that typically resolve in one to three days. These factors rarely prevent patients from completing the RZV series. For patients who previously received ZVL, we suggest revaccination with RZV. The optimal use of RZV in immunocompromised patients is still to be determined.


Complications of Injecting Drug Use

  • Local problems—Abscess (Figures 240-2 
    Image not available.

    A 32-year-old woman with type 1 diabetes developed large abscesses all over her body secondary to injection of cocaine and heroin. Her back shows the large scars remaining after the healing of these abscesses. (Courtesy of ­Richard P. Usatine, MD.)

    and 240-3; Abscess), cellulitis, septic thrombophlebitis, local induration, necrotizing fasciitis, gas gangrene, pyomyositis, mycotic aneurysm, compartmental syndromes, and foreign bodies (e.g., broken needle parts) in local areas.2
    • IDUs are at higher risk of getting methicillin-resistant Staphylococcus aureus(MRSA) skin infections that the patient may think are spider bites (Figure 240-4).
    • Some IDUs give up trying to inject into their veins and put the cocaine directly into the skin. This causes local skin necrosis that produces round atrophic scars (Figure 240-5).
  • IDUs are at risk for contracting systemic infections, including HIV and hepatitis B or hepatitis C.
    • Injecting drug users are at risk of endocarditis, osteomyelitis (Figures 240-6and 240-7), and an abscess of the epidural region. These infections can lead to long hospitalizations for intravenous antibiotics. The endocarditis that occurs in IDUs involves the right-sided heart valves (see Chapter 50, Bacterial Endocarditis).2 They are also at risk of septic emboli to the lungs, group A β-hemolytic streptococcal septicemia, septic arthritis, and candidal and other fungal infections.


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A 65-year-old man comes to your office for the evaluation of lower back pain. For the past 3 days, he has had a sharp, burning pain in his left lower back, which would radiate to his flank and, sometimes, all the way around to his abdomen. The pain comes and goes, feels like an "electric shock," is unrelated to activity, and can be severe. He has had no injury to his back and has no history of back problems in the past. He denies fever, urinary symptoms, or gastrointestinal symptoms. His physical examination today, which included careful back and abdominal examinations, is normal. You prescribe a nonsteroidal anti-inflammatory drug for the pain. The next day, he returns to your office stating that he has had an allergic reaction to the medication because he's developed a rash. The rash is in the area where he had the pain for which he was seen the day before. On examination now, he has an eruption consisting of plaques and patches of erythema with overlying clusters of vesicles extending in a dermatomal distribution from his left lower back to the midline of his abdomen. The rash does not cross the midline anteriorly or posteriorly.

Summary: A 65-year-old man has a painful, dermatomal rash.


What is the cause of this rash?

The most likely cause of this man's rash is reactivation of varicella-zoster virus (VZV), causing the appearance of shingles.

Answer (Click)

What is the mechanism for the dermatomal distribution of the rash?

Answer (Click)




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A Tzanck smear is obtained from a scraping of a patient's skin lesion, and analysis of the smear shows the presence of multinucleated giant cells. Which of the following viruses are known to cause this type cytopathic effect in infected cells?

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The correct answer is C.

C. HSV-1, HSV-2, and VZV are all known to produce multinucleated giant cells resulting in a positive Tzanck smear, whereas CMV, EBV, HPV, and human herpesvirus 8 do not.


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Question 1 of 1

A 42-year-old African-American man has been diagnosed with hypertension for the past 10 years and treated with medication. One morning, he is found unresponsive by his wife. He is taken to the emergency department and pronounced dead by the physician. An autopsy revealed cardiac hypertrophy and a narrowing of the aorta just distal to the ligamentum arteriosum, with dilation of the intercostal artery's ostia. How could the death have possibly been prevented?



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