Risk of Herpes Zoster and Opportunistic Infections with Treatments for Autoimmune Rheumatic Disease

Incidence and Risk of Postherpetic Neuralgia after Varicella Zoster Virus Infection in Hematopoietic Cell Transplantation Recipients: Hokkaido Hematology Study Group

Background and Aims Kidney disease (KD), including end stage renal disease (ESRD), is a global health problem. Both are associated with impaired immune systems, which can lead to infections. Complications such as cardiovascular disease and various infections are leading causes of morbidity and mortality in KD patients. Notably, patients with KD have an increased risk of herpes zoster (HZ). While the link between ESRD and renal transplant with increased HZ risk is understood, knowledge gaps regarding the burden of HZ across the KD spectrum still exist. This review aims to describe the risk and impact of HZ across the KD spectrum in order to guide preventive care strategies for patients with renal diseases. Method A structured literature review was conducted in PubMed using a combination of keywords and Medical Subject Heading (MeSH) terms to identify studies related to HZ risk in adult KD patients aged ≥18 years published in the English language between 01/11/2003–31/10/2023. Data extracted from published studies included the burden of HZ infection in patients with KD (risk of HZ and related complications), impact of HZ on underlying KD, and the efficacy/effectiveness of HZ vaccines among patients with KD. Results A total of 47 studies were identified (Randomized controlled trials [RCT] = 2; observational studies = 45) in this review (Fig. 1). Included studies presented evidence from regions in Europe (n = 18), Asia (n = 17), North America (n = 7), South America (n = 1), multinational (n = 2) and Australia (n = 1); country not reported in one study. Evidence from observational studies (n = 37) reported a high risk of HZ infection and related complications, such as disseminated HZ, and recurrent HZ across the KD spectrum, including chronic KD, polycystic KD, hemodialysis, peritoneal dialysis and kidney transplant patients. Infection with HZ was reported to accelerate KD progression and increased the risk of ESRD and cardiovascular events. In general, for ESRD patients with an inpatient HZ diagnosis, mortality increased with age, followed by malnutrition and bacteremia/septicemia. Studies reporting vaccine efficacy (n = 2) and effectiveness results (n = 8) suggest that HZ vaccination was associated with a reduced risk of HZ when compared to unvaccinated individuals. Furthermore, the recombinant zoster vaccine (RZV) was found to be immunogenic in kidney transplant recipients, with immunogenicity persisting through 12 months post-vaccination. An RCT post-hoc analysis showed high vaccine efficacy in patients aged ≥50 years with medical conditions at enrollment, including KD, which was consistent with the overall population. A favorable benefit-risk profile was reported in randomized and observational studies. Studies evaluating the effectiveness of the zoster live-attenuated vaccine (ZVL) found a lower risk of HZ in patients with ESRD immunized against HZ compared to unvaccinated individuals. In many countries, vaccination guidelines specifically recommended immunization of people with KD to protect against HZ. However, ZVL is contraindicated for immunocompromised (e.g. kidney transplant) patients. Conclusion Findings indicate that HZ has a significant HZ burden across the KD spectrum, which may negatively impact renal disease progression. With effective vaccines offering durable protection against HZ and its complications, the immunization of renal patients at earlier stages could enhance healthcare management and patient outcomes.

BackgroundCurrently, there is an advancing interest in the Janus kinase (JAK) intracellular pathway since targeted inhibitors are proving to be excellent in the treatment of Rheumatoid arthritis (RA). Nevertheless, this...

Issue Highlights

The varicella-zoster virus (VZV) vaccine strain may reactivate to cause herpes zoster. Limited data suggest that the risk of herpes zoster in vaccinated children could be lower than in children with naturally acquired varicella. We examine incidence trends, risk and epidemiologic and clinical features of herpes zoster disease among children and adolescents by vaccination status. Population-based active surveillance was conducted among <20 years old residents in Antelope Valley, California, from 2000 through 2006. Structured telephone interviews collected demographic, varicella vaccination and disease histories, and clinical information. From 2000 to 2006, the incidence of herpes zoster among children<10 years of age declined by 55%, from 42 cases reported in 2000 (74.8/100,000 persons; 95% confidence interval [95% CI]: 55.3-101.2) to 18 reported in 2006 (33.3/100,000; 95% CI: 20.9-52.8; P<0.001). During the same period, the incidence of herpes zoster among 10- to 19-year-olds increased by 63%, from 35 cases reported in 2000 (59.5/100,000 persons; 95% CI: 42.7-82.9) to 64 reported in 2006 (96.7/100,000; 95% CI: 75.7-123.6; P<0.02). Among children aged<10 years, those with a history of varicella vaccination had a 4 to 12 times lower risk for developing herpes zoster compared with children with history of varicella disease. Varicella vaccine substantially decreases the risk of herpes zoster among vaccinated children and its widespread use will likely reduce overall herpes zoster burden in the United States. The increase in herpes zoster incidence among 10- to 19-year-olds could not be confidently explained and needs to be confirmed from other data sources.

Risk of Serious Infection, Opportunistic Infection, and Herpes Zoster among Patients with Psoriasis in the United Kingdom

Background VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a genetic disorder characterized by bone marrow failure and systemic inflammation, putting patients at risk for infections. This study comprehensively examines the prevalence of opportunistic infections in patients with VEXAS, evaluating their impact on clinical outcomes and potential preventive measures. Methods Patients with confirmed VEXAS were included. Survival analysis and logistic regression were used to identify associations between opportunistic infections and mortality. Infection rates (IRs) for Pneumocystis jirovecii pneumonia (PJP) and alphaherpesviruses were calculated over a prospective 8-month observation period in relationship to prophylaxis. Results Of 94 patients with VEXAS, 6% developed PJP; 15% had alphaherpesvirus reactivation, with varicella zoster virus (VZV) being the most common herpesvirus; and 10% contracted a nontuberculous mycobacterial (NTM) infection. Risk of death was significantly increased per month following a diagnosis of PJP (hazard ratio [HR], 72.41 [95% confidence interval {CI}, 13.67–533.70]) or NTM (HR, 29.09 [95% CI, 9.51–88.79]). Increased odds for death were also observed in patients with a history of herpes simplex virus (HSV) reactivation (odds ratio [OR], 12.10 [95% CI, 1.29–114.80]) but not in patients with VZV (OR, 0.89 [95% CI, .30–2.59]). Prophylaxis for PJP (IR, 0.001 vs 0 per person-day, P &amp;lt; .01) and VZV (IR, 0.006 vs 0 per person-day, P = .04) markedly decreased infection rates with a number needed to treat of 4 and 7, respectively. Conclusions Opportunistic infections are common in patients with VEXAS. Patients who develop PJP, HSV, or NTM are at increased risk for death. Prophylaxis against PJP and VZV is highly effective.

BACKGROUND: Herpes Zoster (HZ), also known as shingles, is the reactivation of the varicella zoster virus (VZV). The incidence of HZ is 4 per 1,000 person-years. Though HZ can occur at any age and in any population, the incidence increases with age and is up to ten times higher in immunocompromised patients. Vaccine guidelines for inflammatory bowel disease (IBD) patients on immunosuppressive therapy recommend obtaining age appropriate non-live attenuated vaccinations while strongly considering risks and benefits when administering the live-attenuated vaccines. Currently, CDC guidelines recommend the new non-live HZ vaccine, Shingrix, in patients over the age of 50. As this is a non-live vaccine it is safe to administer in patients on immunosuppressive therapy. The purpose of our study was to identify risk factors associated with the development of HZ among IBD patients. METHODS: Using our institution’s electronic research data warehouse, we performed a case-control study including IBD patients enrolled in the prospectively maintained IBD patient database at the University of Chicago IBD Center between January 1, 2005 and January 1, 2017. Controls included individuals presenting to the general gastroenterology and hepatology clinics. The diagnosis of HZ was identified using ICD codes (053.9, 053.19, B029, B028) and documentation of a characteristic rash at the corresponding clinic visit. Demographic variables, disease-related and therapy-related factors including HZ vaccination were recorded. Data were analyzed using Wilcoxon rank-sum test for continuous variables and Fischer’s exact test for dichotomous variables. RESULTS: We identified 88 unique patients encounters (57 IBD, 34 non-IBD) with a diagnosis of HZ. The non-IBD controls primarily included individuals with a history of liver disease (n = 21). The IBD patients were predominantly Caucasian (80%) and of younger age when compared to the control population (P &lt; 0.001). Among the 57 IBD patients, 20 (35%) had active disease and 51 (89%) were on active immunosuppression. There were no other statistically significant demographic features between the groups with regards to active smoking or prior HZ vaccination. Only 6 (19%) IBD patients who were over the age of 50 were vaccinated. IBD patients were more likely to be on active immunosuppression or have a history of immunosuppression (P &lt; 0.001) compared to controls. Despite a high level of active disease and immunosuppression, IBD patients had higher albumin and hemoglobin levels compared to the controls. Following the onset of HZ, there was no significant difference in the onset of post-herpetic neuralgia. CONCLUSION(S): Active immunosuppression in IBD patients is a risk for HZ, but no other variables were identified. The disease course with respect to development of post-herpetic neuralgia is not different compared to controls. Only a small number of eligible patients received vaccination for HZ and none of these developed HZ. Further studies should identify independent risk factors for vaccination or expand the eligibility of vaccination to larger cohorts of patients in order to prevent the onset of HZ.

Background:SLE is burdened by an increased incidence and prevalence of Herpes Zoster (HZ) infection compared to the general population. Some patient features are known to be risk factors for HZ...

THE SUBSEQUENT IMPACT OF COVID-19 FOR BOTH IMMUNE DYSREGULATION AND OPPORTUNISTIC INFECTIONS

Pneumocystis carinii pneumonia: a review of current issues in diagnosis and management.

Introduction: Infection in Solid Organ Transplant Recipients

We examined the incidence of herpes zoster (HZ) before and after the initiation of antiretroviral therapy (ART), and risk factors for HZ among human immunodeficiency virus (HIV)-infected individuals in Tanzania. A cohort study was conducted among HIV-positive individuals enrolled in HIV care and treatment clinics in Dar es Salaam, Tanzania. A Cox proportional hazard model was used to examine the effect of ART on the risk of HZ after adjusting for sociodemographics and time-varying clinical and nutritional factors. Among 72,670 HIV-positive individuals, 2,312 incident cases of HZ (3.2%) occurred during the median follow-up of 15 months (interquartile range: 3-35). The incidence rate of HZ significantly declined from 48.9 (95% confidence interval [CI] = 46.7-51.0) per 1,000 person-years before ART to 3.7 (95% CI = 3.3-4.1) per 1,000 person-years after the initiation of ART (P < 0.001). The risk of HZ declined with longer duration on ART. Low CD4 cell count, older age, female sex, district of Dar es Salaam, and year of enrollment were independently associated with the risk of HZ in the multivariate analysis. Low body mass index and anemia were not associated with the risk of HZ. The risk of HZ substantially declined after ART initiation in this large cohort of HIV-infected individuals. Earlier initiation of ART could reduce the risk of HZ and other opportunistic infections among HIV-infected individuals in sub-Saharan Africa.

ABSTRACTAims: This study was designed to assess the impact of diabetes on the risk and severity of herpes zoster (HZ), and the impact of HZ on diabetes. It focused primarily on immunocompetent patients aged ≥ 50 years who would be eligible for preventive vaccination.Methods: Using population and healthcare databases of Valencia Region (Spain), a retrospective cohort of all subjects ≥ 50 years was followed up between 2009 and 2014. HZ and diabetes were defined using ICD-9 codes. We compared the incidence of HZ between non-diabetes and diabetes groups and healthcare resource consumption due to HZ in the 6 months following HZ diagnosis using different statistical generalized linear models (GLM). We also compared resources consumption due to diabetes treatment and haemoglobinA1c(HbA1c) levels before and after HZ.Results: The cohort consisted of 2,289,485 individuals ≥ 50 years old, 397,940 of whom had diabetes. HZ incidence rate was 9.3 cases/1000 persons with diabetes-year (95% CI: 9.1–9.4). Incidence increased with age in all groups. The risk of HZ increased in the diabetes group compared to the non-diabetes group (RR 1.2, 95% credibility interval [CrI] 1.17–1.22). Patients with diabetes utilized more health care resources due to their HZ episodes than patients without diabetes. In 24% of well controlled patients with diabetes (HbA1C levels ≤ 6.5%), HbA1C increased after HZ.Conclusions: Diabetes increased by 20% the risk of HZ. HZ contributed to the deterioration of glycaemic control and higher healthcare resource consumption in people with diabetes, becoming a priority population for HZ immunization.

BackgroundOpportunistic and chronic infections can arise in the context of treatment used for Autoimmune Rheumatic Diseases (ARDs). Although it is recognized that screening procedures and prophylactic measures must be followed,...