Herpes Zoster Infection Research Articles

Multidisciplinary model for administration of recombinant Zoster vaccine in fragile patients

Abstract Background Target populations eligible for vaccinations are not comprehensively reached by out-of-hospital health services, particularly frail people with immunization deficits. The aim of this study was to evaluate the effectiveness of a model of shared management between hospital - IRCCS Fondazione Policlinico Universitario A.Gemelli (FPG) - and out-of-hospital health services -ASL Roma1- of fragile patients with an indication for herpes zoster (HZ) vaccination, based on counseling carried out by a multidisciplinary team in the hospital setting. Methods From June 2022 to April 2023, patients with congenital and/or acquired immunodepression, who were treated at the IRCCS FPG in the Units of Hematology, Geriatrics, Infectious Diseases, Rheumatology were offered vaccination with the recombinant Zoster vaccine. At the time of enrollment, all patients completed the Vaccination Attitudes Examination (VAX-I) scale, for the purpose of assessing vaccine hesitancy. Patients received multidisciplinary counseling focusing on HZ and contrasting vaccine hesitancy. Multiple linear regression was used to analyze the impact of demographic and clinical characteristics on the VAX-I items. Results Sixty fragile patients were included. Mean vaccine hesitancy score was 2.1 ± 0.9. A significant correlation between vaccine hesitancy and the age group 45-64 years, female sex and patient with HIV was demonstrated. These patients had significantly higher score of “mistrust of vaccine benefits”, “worries about unforeseen future effects”, “concerns about commercial profiteering” and “preference for natural immunity”. After counseling, all patients adhered to the vaccination with two doses of a recombinant zoster vaccine. No serious adverse events or breakthrough HZ infections were observed during a median follow-up of 65.5 days. Conclusions Although vaccine hesitancy in some age groups is high, hospital-based multidisciplinary counseling achieved full HZ vaccination compliance. Key messages • herpes zoster vaccination coverage of frail patients is not fully achieved in the community health setting. • The adoption of a multidisciplinary model for administration of recombinant Zoster vaccine in fragile patients based on a Hospital-Territory Vaccination Center may help overcome vaccine hesitancy.

Willingness to receive Herpes Zoster vaccination among adults and older people: A cross sectional study in Italy

The objective of this study was to explore the Herpes Zoster (HZ) knowledge and the willingness to receive the HZ vaccination in adults and older people in Italy. The study was conducted on a sample of patients aged ≥65 years and over 50 years with chronic conditions who went to the clinics of general practitioners (GPs) in Campania region, Italy. Data was collected with a questionnaire administered through an interview. Multivariate logistic regression analysis was performed. 427 participants (83.2 %) had heard about HZ infection and correctly knew the main symptoms of the HZ disease, and 196 of them (45.9 %) were aware of the main complications of the infection, such as post-Herpetic Neuralgia (NPE) and Herpes Zoster ophthalmicus (HZO). Only 61 participants (11.8 %) had heard of the availability of a vaccination against HZ in Italy and 39 of them (63.9 %) knew that the vaccination is recommended in at-risk patients aged at least 50 years and for adults aged ≥65 years. 137 participants (26.6 %) had a positive attitude toward the willingness to receive the HZ vaccination. Participants aged 50–64 years, those who have more than one chronic disease, those who have received at least one recommended vaccination, those who had a positive attitude on the usefulness of HZ vaccination, and those who feel the need to receive additional information about HZ vaccination were more likely to have a positive attitude toward the willingness to receive the HZ vaccination. It is needed to implement effective strategies to improve HZ vaccination coverage in order to protect especially frail patients from the most serious complications of the disease.

Safety and efficacy of biological agents in the treatment of Systemic Lupus Erythematosus (SLE)

BackgroundTo determine the safety and efficacy of biological agents used in the treatment of systemic lupus erythematosus (SLE) in adults.MethodsSystematic review and meta-analysis following PRISMA guidelines.Data sourcesMEDLINE (through Pubmed), EMBASE, Cochrane library, Clinicaltrials.gov, Australianclinicaltrials.gov.au, ANZCTR.org.au and WHO International Clinical Trials Registry Platform for studies published from 20 May 2021 and 15 years prior. A grey literature search was performed and completed on 31 May 2021.Study criteriaPhase II, III or quasi randomised controlled trials, studies with only cerebral or cutaneous lupus were excluded. Data extraction: Two authors independently screened studies for eligibility, extracted, reviewed data for accuracy, and used the Cochrane tool to assess risk of bias.ResultsForty-four studies were identified, consisting of 15 groups of drugs and 25 different biological agents, totalling 16,889 patients. The main outcomes assessed included Systemic Lupus Erythematosus Responder Index (SRI), BILAG-Based Composite Lupus Assessment (BICLA) and combined combined/partial renal remission (CRR/PRR).Four groups of biologics were found to improve outcomes. Anti-interferons: Anifrolumab increased BICLA response and SRI 5 to 8, decreased prednisone dosages, with increased herpes zoster infections, but fewer serious adverse events. Sifalimumab improved SRI but also increased herpes zoster infections. Anti BAFF/BLyS and/or APRIL: Belimumab consistently improved SRI 4, decreased prednisone dosages, increased combined CRR/PRR, and had no adverse safety outcomes. Tabalumab increased SRI 5 at 52 weeks with no steroid sparing effect but was associated with increased infusion related adverse events. Telitacicept improved SRI 4 at 52 weeks, with no increased adverse events, though data was rather sparse. Anti CD-20 monoclonal antibody, Obinutuzumab increased combined CRR/PRR at 1 and 2 years. Anti IL12/23 monoclonal antibody, Ustekinumab, increased SRI 4 to 6, but not BICLA at 24 weeks, with no concerning safety outcomes.ConclusionMultiple biologic agents are shown in high quality studies to have a significant therapeutic impact on outcomes in SLE.

Ayurveda Perspective on Visarpa Vyadhi and its Management

Skin is the largest organ of the body which acts as a first line of defense in providing resistance to the body. The aggravation of various Dhatus and Doshas result in skin diseases. More than one-fifty skin related diseases are mentioned in various Ayurvedic texts. They are categorized as Visarpa, Kustha, Shotha, Upadansh etc. Visarpa is a very common disease mentioned in Ayurvedic texts which spreads in body in various directions. It is said to be caused by Varicella zoster virus as per modern concept. It manifests as Daha, Jwara, Anunnatashopha and Vedana. Around 20-30% sufferers of various skin ailments are demonstrated through large community prevalence study. A 40-year-male presented along with the vesicular lesions on his neck region associated with mild fever, itching, and pain on the local lesion. He was administered with 250mg of Kamadudha rasa (plain) twice a day before meals with milk, Chandrakala rasa 250mg twice a day, Paripathadi kwatha 2 tsp twice a day and Shatadhauta ghrita for local application on the lesions. The patient reported on the 5th day with significant relief in the size and shape of the facial lesions and other symptoms. The scars limited to minimal without any inflammatory signs by the 7th day of follow-up. Above medications are two readily available and cost-effective compound Ayurvedic formulations, which can be used in the management of herpes zoster infection, especially in low-resource settings.

Herpes zoster associated with stroke incidence in people living with human immunodeficiency virus: a nested case–control study

BackgroundThe incidence of stroke is increasing among younger people with human immunodeficiency virus (HIV). The burden of stroke has shifted toward the young people living with HIV, particularly in low- and middle-income countries. People infected with herpes zoster (HZ) were more likely to suffer stroke than the general population. However, the association of HZ infection with the incidence of stroke among patients with HIV remains unclear.MethodsA nested case–control study was conducted with patients with HIV registered in the Taiwan National Health Insurance Research Database in 2000–2017. A total of 509 stroke cases were 1:10 matched to 5090 non-stroke controls on age, sex, and date of first stroke diagnosis. Logistic regression models were used to estimate the odds ratio and 95% confidence intervals (CI) of stroke incidence.ResultsThe odds ratio of stroke was significantly higher in the HIV-infected population with HZ (adjusted odds ratio [AOR]: 1.85, 95% CI: 1.42–2.41). A significantly increased AOR of stroke was associated with hypertension (AOR: 3.53, 95% CI: 2.86–4.34), heart disease (AOR: 2.32, 95% CI: 1.54–3.48), chronic kidney disease (AOR: 1.82, 95% CI: 1.16–2.85), hepatitis C virus infection (AOR: 1.49, 95% CI: 1.22–1.83), hyperlipidemia (OR: 1.41, 95% CI: 1.12–1.78), and treatment with protease inhibitors (AOR: 1.33, 95% CI: 1.05–1.69).ConclusionsOur findings suggest that HZ concurrent with HIV may increase the risk of stroke. The incidence rates of stroke were independent of common risk factors, suggesting strategies for early prevention of HZ infection among people living with HIV.

Herpes zoster is not associated with subsequent gastrointestinal cancer: data from over 200,000 outpatients in Germany

PurposeGastrointestinal (GI) cancers are an increasing global health challenge. Viral diseases play an important role in the development of GI cancers. For example, Epstein-Barr virus, which belongs to the human herpesvirus family, is a well-recognized risk factor for the development of gastric cancer. The purpose of this study was to investigate a possible association between varicella-zoster virus reactivation and subsequent diagnosis of GI cancer.MethodsIn this retrospective cohort study, a total of 103,123 patients with a first diagnosis of herpes zoster (HZ) between 2005 and 2021 were propensity score matched to a cohort of 103,123 patients without HZ. Patient data was extracted from the Disease Analyzer database (IQVIA). The incidence of GI cancer was compared as a function of HZ. Cox regression analysis was used to examine the association between HZ and GI cancer.ResultsOver a follow-up period of up to 10 years, the incidence of GI cancer did not differ between the two cohorts (HZ cohort 2.26 cases per 1000 patient-years vs. non-HZ cohort 2.37 cases per 1000 patient-years, p = 0.548). In regression analysis, HZ was not associated with an increased risk of developing GI cancer (HR: 0.97; 95% CI 0.89–1.05). Furthermore, no significant effect of the presence of HZ on the incidence of different GI cancer entities was found.ConclusionIn this retrospective cohort study consisting of well-matched patients, we observed no significant association between a HZ infection and the development of GI cancer during a long-term follow-up.

OA14 The role of anifrolumab in treating life threatening systemic lupus erythematosus with severe mucocutaneous involvement

OA14 The role of anifrolumab in treating life threatening systemic lupus erythematosus with severe mucocutaneous involvement

Post Varicella Neurological Complication: A Case of Transverse Myelitis

Longitudinal extensive transverse myelitis is defined as a spinal cord lesion that extends over three or more spinal segments. Varicella zoster virus is an exclusively human neurotropic virus that reactivates following the weaning of cell-mediated immunity as age advances, resulting in herpes zoster. We report the case of a 61-year lady presenting with dorsal cord longitudinally extending transverse myelitis following herpes zoster infection that resolved with immunomodulation and antivirals.

Clinical investigation of segmental zoster paresis: A case of rare motor complications of herpes zoster

Introduction: Motor involvement is a rare complication of herpes zoster (HZ) infection, which is referred to as segmental zoster paresis (SZP). Case Report: We evaluated the clinical course of a rare case of motor complications of HZ. A 77-year-old man showed limb paresis, considered as SZP of the limb, of which one also had hemidiaphragmatic paralysis. The time between onset and start of antiviral drug administration was 29 days. An almost complete recovery from motor complications was achieved nine months after onset. Conclusion: Segmental zoster paresis was found in an old patient aged ≥75 years. In addition to age, it was suggested that a delay in antiviral drug initiation may have caused SZP. However, further large prospective cohort studies are required. The patient has recovered from motor paralysis slowly over half a year, which is consistent with the prognosis of conventional SZP.

Chronic Respiratory Diseases as a Risk Factor for Herpes Zoster Infection

IntroductionHerpes zoster (HZ) is a condition that results from the reactivation of the varicella zoster virus (VZV). Several diseases have been reported to increase the risk of developing HZ and postherpetic neuralgia (PHN). The objective of this study is to analyze the prevalence and risk factors for HZ and PHN in the most frequent chronic respiratory diseases, which are chronic obstructive pulmonary disease (COPD), asthma, lung cancer and obstructive sleep apnea (OSA). MethodsWe conducted an observational, retrospective, non-interventional study between January 2012 and December 2020 based on data from the Castilla-La Mancha Regional Health System in Spain. We used the Savana Manager 3.0 artificial intelligence-enabled system to collect information from electronic medical records. Results31765 subjects presented a diagnosis of HZ. Mean age was 64.5 years (95%CI 64.3–64.7), and 58.2% were women. The prevalence of HZ showed an increasing trend in patients over the age of 50. A risk analysis adjusted for sex and comorbidities in COPD, asthma, lung cancer and OSA presented a higher risk of developing HZ in the first three (OR 1.16 [95%CI 1.13–1.19], 1.67 [1.63–1.71], 1.68 [1.60–1.76], respectively), which further increased in all three when associated with comorbidities. Regarding postherpetic neuralgia, an increased risk was only observed related to COPD and lung cancer (OR 1.24 [95%CI 1.23–1.25], 1.14 [1.13–1.16], respectively), further increasing when associated with comorbidities. ConclusionsIn a standard clinical practice setting, the most prevalent respiratory diseases (asthma, COPD and lung cancer) are related to a higher risk of HZ and PHN. These data are fundamental to assess the potential impact of vaccination in this population.

Herpes Zoster Infections in Solid-Organ Transplant Recipients.

Herpes zoster infections can be complicated and mortal in solid-organ transplant recipients. In our study, we investigated herpes zoster infections in solid-organ transplant recipients. UntilJune 2022, our center has performed 3342 kidney, 708 liver, and 148 heart transplants.Herpes zosterinfections were investigated in 1050 adult solid-organ transplant recipients from January 1, 2011, to June 31, 2022. We studied 44 patients diagnosed with herpes zoster infections. Of the 44 patients with herpes zoster, 32 had kidney, 7 had heart, and 5 had liver transplant procedures. Crude incidence rate was 5.2%.,with 9.7% being heart, 5.1% being kidney, and 3.9% being liver transplant recipients; 72.7% were male patients. The median age was 47.5 years, and 61% of patients were aged >45 years. Postherpetic neuralgia was significantly higher in patients older than 45 years (P = .006). The median duration to infection posttransplant was 16.5 months. The dermatomes of patients were 43.2% thoracic. Sacral dermatome involvement was significantly higher in heart transplant patients than in other transplant recipients (P = .015). We reviewed specific findings of the Tzanck test in 36.4% of the patients. There was concomitant infection in 15.9% of the patients, and 6.8% had pneumonia. Acute neuritis was more common in kidney transplant recipients (65.6%). The mean duration of acute neuritis/neuralgia was longest in liver transplant recipients (13.5 months; P = .047). Postherpetic neuralgia was detected as high as 24%. Early specific and supportive treatmentis important for transplant recipients with herpes zoster infections. Appropriate antiviral prophylaxis regimens and vaccination strategies for varicella zoster (chickenpox) and herpes zoster infections should be implemented in the vaccination schedule of solidorgan transplant candidates to prevent herpes zoster infections and complications.

Formulation Optimization and Evaluation of Nanocochleate Gel of Famciclovir for the Treatment of Herpes Zoster.

Herpes zoster is a viral infection triggered due to the reactivation of the varicella- zoster virus in the posterior dorsal root ganglion. Herpes zoster infections occur mostly in the facial, cervical and thoracic regions of the body, beginning with pain and resulting in the vesicular eruption. Recently, this infection was observed during the COVID-19 pandemic and also after the induction of mRNA-based vaccine for coronavirus at an extended level. Nanocochleates are cylindrical (cigarshape) microstructure lipid-based versatile carriers for drug delivery systems. Famciclovir is an antiviral agent employed for the treatment of Herpes zoster infections. The current research patent aims to develop a novel nanocochleate gel of Famciclovir for the treatment of herpes zoster infections with higher efficacy. The interaction studies using FTIR were carried out and indicated no such interactions between the drug and lipids. The nanocochleates were developed using hydrogel, trapping, liposome before cochleate dialysis, direct calcium dialysis and binary aqueous-aqueous emulsion methods, respectively. The 32 Box-Behnken design was applied by considering the concentration of lipids (phosphatidylcholine and cholesterol) and speed of rotation as independent factors, whereas particle size and entrapment efficiency as dependable factors. The developed nanocochleates were estimated for the particle size (276.3 nm), zeta potential (-16.7 mV), polydispersity index (0.241), entrapment efficiency (73.87±0.19%) and in vitro diffusion release (>98.8% in 10 h). The optimized batch was further converted into the topical gel using carbopol 940 as a gelling agent. The prepared gel was smooth, rapidly spreadable with a viscosity (5998.72 cp), drug content (95.3%) and remained stable during stability studies. A novel nanocochleate gel of Famciclovir was successfully developed for the treatment of infections associated with Herpes Zoster with sustained release action.

Case Report: Post herpes zoster comedones: A new entity under Wolf’s isotopic response

The emergence of a completely new skin condition at the precise location of a different, unrelated and previously healed skin disease is referred to as a "Wolf's isotopic response". It is also referred as post-herpetic isotopic response because it typically manifests after contracting the varicella-zoster virus causing herpes zoster. Wolf’s isotopic response is a rare, unique and widely accepted phenomenon. In this study, we discuss the various theories proposed behind its etiology. Further studies can help us understand the pathomechanism behind the localization of skin diseases thereby, helping us manage the condition effectively. Here, we describe a case of a 36-year-old male who presented in the outpatient department with multiple open and closed comedones distributed along the site of T2 dermatome previously infected by herpes zoster infection. Dermoscopic examination revealed multiple, round, brown-colored follicular keratinous plugs with peri-lesional erythema. Histopathological analysis showed a large dilated follicular canal containing orthokeratotic stratum corneum consistent with closed comedone formation. The patient was diagnosed with post-herpetic zosteriform comedones and was prescribed oral isotretinoin 20 mg, topical tretinoin 0.05% cream with a moisturizer and asked to follow up regularly. The lesions gradually healed over a five-month period. In our case, timely medical intervention helped preventing the further progression of the disease. However, further studies involving large sample sizes can help us identify the underlying mechanism behind this phenomenon.

High CD4+:CD8+ ratios with herpes zoster infections in patients with multiple sclerosis on dimethyl fumarate

Background: Dimethyl fumarate (DMF) depletes CD8+ and CD4+ T cells, and cases of herpes zoster (HZ) in patients with multiple sclerosis (MS) on DMF have been documented. Objectives: To evaluate lymphocyte subsets in patients with MS who developed HZ on DMF (Tecfidera) compared to matched controls who did not develop HZ. Methods: We used linear mixed-effects models to test for differences in white blood cell count, lymphocyte percentage, absolute lymphocyte count, CD3+ percentage, absolute CD3+ count, CD4+ percentage, absolute CD4+ count, CD8+ percentage, absolute CD8+ count, and CD4+:CD8+ ratio over time in HZ and non-HZ groups. Results: Eighteen patients developed HZ while on DMF. The linear mixed-effects model for CD4+:CD8+ ratio showed a significant difference between the HZ and non-HZ groups (p = 0.033). CD4+:CD8+ ratio decreased over time in the HZ group and increased over time in the non-HZ group. Conclusion: Patients with MS who develop HZ while on DMF have high CD4+:CD8+ ratios, suggesting an imbalance of CD4+ and CD8+ cells that may put a patient at risk for developing HZ while on DMF. This result emphasizes the need for lymphocyte subset monitoring (including CD4+:CD8+ ratios) on DMF, as well as vaccination prior to DMF initiation.

A Retrospective Study on Clinical Experience with Tofacitinib in the Treatment of Rheumatoid Arthritis at a Tertiary Care Center

Abstract Introduction: Tofacitinib is the first oral Janus kinase (JAK) inhibitor approved for the treatment of rheumatoid arthritis (RA). Since the expiry of its patent, the drug has become affordable to patients in India. The present study describes our experience with tofacitinib in patients with RA. Objective: To retrospectively study the 6-month outcome of patients with RA treated with tofacitinib. Methods: We retrieved the records of all consecutive patients with RA who were commenced on tofacitinib in the rheumatology clinic of our tertiary care hospital from December 2020 to December 2021. The drug was prescribed as per recommended indications at a dose of 5 mg twice daily. Age, sex, duration of disease, and prior treatment received were noted. Baseline and 6-month data on the tender joint count, swollen joint count, patient global assessment, and physician global assessment were obtained from the records. Similarly, baseline and 6-month laboratory parameters (CBC, Erythrocyte sedimentation rate, C-reactive protein, LFT, and KFT) were also retrieved. Disease activity was assessed using SDAI at baseline and after 6 months. Adverse effects documented in the records were carefully noted. Results: Seventy-five patients had been commenced on tofacitinib between December 2020 and December 2021. Five patients were lost to follow-up. Twelve patients had stopped the drug after 2–3 months because of inefficacy while 7 had stopped the drug because of adverse effects. Thus, 51 patients (out of 75) had taken tofacitinib for 6 months or more. Of these, 39 achieved EULAR good response (low-disease activity-23, remission-16) and 12 achieved EULAR moderate response. Adverse effects occurred in 27 (36%) patients and included weight gain (8%), cytopenia (6.6%), folliculitis (4%), and alopecia (4%). Others included anxiety, dyspepsia, constipation, chest pain, dyslipidemia, herpes zoster, hypertension, oral thrush, sensory neuropathy, somnolence, and urinary tract infection. Conclusion: Tofacitinib treatment resulted in remission in 16/75 (21%) and LDA in 23/75 (31%) in RA patients who were inadequate responders to conventional synthetic disease-modifying antirheumatic drugs/biological drugs. Adverse effects occurred in 36%.

Safety of Janus Kinase Inhibitors: A Real-World Multicenter Retrospective Cohort Study.

Oral Janus kinase inhibitors (JAKis) represent an effective strategy for rheumatoid arthritis (RA) treatment. A previous study supported that tofacitinib (TOF) is associated with higher incidence of cardiovascular (CV) and neoplastic events compared to tumor necrosis factor inhibitors. Given the apparent discrepancy between these data and real-world experience, we aimed to investigate the safety and efficacy of the available JAKis in a multicenter cohort. We retrospectively evaluated patients with RA who ever received 1 JAKi (TOF, baricitinib [BAR], upadactinib [UPA], filgotinib [FIL]) from 4 tertiary care centers in Milan, Italy. Outcomes related to JAKi safety were recorded, particularly major CV events as well as adverse events of special interest (AESIs), which included serious infections, opportunistic infections, venous thromboembolism, herpes zoster infections, liver injury, malignancies, and deaths; retention rates were also calculated. Further analyses included patients fulfilling the risk factors suggested to influence TOF safety. Six hundred eighty-five patients were included and received BAR (48%), TOF (31%), UPA (14%), or FIL (7%) as first-line innovative treatment prior to a biologic. Of a total of 1137 patient-years of observation, we recorded 1 stroke and 123 (18%) AESIs, including 3 deaths, all a result of severe infections. Among patients with a higher CV risk, we observed a higher frequency of AESIs (23%). Our real-world data confirm that JAKis are effective and carry a low risk of AESIs, especially in patients who do not display CV risk factors at baseline. Our study could not identify differences between JAKis. Different safety profiles should be defined in larger prospective cohorts.

Hospitalization burden related to herpes zoster infection during the COVID-19 pandemic in Spain (2020-2021)

ABSTRACT Varicella-Zoster Virus (VZV) belongs to the family Herpesviridae. Herpes zoster (HZ) is caused by reactivation of latent VZV. It is associated with risk factors such as immunosenescence, immunosuppressive pathologies and pharmacological treatments. Patients with these risk factors are more likely to be hospitalized. Increases in HZ hospitalizations have been reported in many countries in recent years. The objective of this study is to estimate hospitalization rates, mortality rates and costs due to HZ during the worst years of the COVID-19 pandemic in Spain (2020–2021). This is a descriptive study based on an analysis of information from the Minimum Basic Dataset and coded according to the Spanish version of the 10th International Classification of Diseases (ICD-10-CM). Hospitalization, mortality and case-fatality rates, and median length of hospitalization were calculated.. The hospitalization rate was 14.4 cases per 100,000 inhabitants, and the mortality rate was 1.3 cases per 100,000 inhabitants. Both increased considerably with age. In this time period, 92.3% of the registered cases were people over 50 years of age. Nevertheless, during the COVID-19 pandemic period, hospitalization rate decreased and the mortality rate increased from previous years. HZ hospitalization and mortality rates are relevant issues in the public health of older people. It is highly recommended to evaluate new vaccination strategies against VZV to include the HZ vaccine for health care for elderly people, as well as to reduce the disease burden and associated risk factors. The estimation of HZ disease hospitalization costs were €100,433,904.

A Case Report of Refractory Postherpetic Neuralgia After Ramsay Hunt Syndrome Treated With Tympanic Nerve Neurectomy.

Ramsay Hunt syndrome is a facial nerve palsy that arises from herpes zoster infection. In rare cases, postherpetic neuralgia is a complication following Ramsay Hunt syndrome. Pain management to address postherpetic neuralgia includes facial nerve blocks, medications such as gabapentin, carbamazepine and botulinum toxin injections, and pulsed radiofrequency. Despite the reported benefits for patients with glossopharyngeal nerve pain, neurectomy as a treatment has rarely been described. A 45-year-old patient visited our ENT clinic for chronic right-sided facial, ear, and jaw pain that persisted for 9 years following the development of Ramsay Hunt syndrome. She trialed multiple medications including gabapentin, carbamazepine, and botulinum toxin injections with minimal relief to her symptoms. The patient underwent a diagnostic myringotomy with topical application of lidocaine to the tympanic nerve. This resulted in temporary relief of her pain until the effects of the lidocaine subsided. The patient was subsequently offered lysis of the right tympanic nerve for more definitive management. The patient experienced significant pain reduction after the right tympanic neurectomy procedure. Chronic postherpetic neuralgia following Ramsay Hunt syndrome can cause significant impairment in a patient's quality of life. For patients with ear pain refractory to conservative management, a tympanic neurectomy can be considered.

Comparative risk of infections between JAK inhibitors versus TNF inhibitors among patients with rheumatoid arthritis: a cohort study

BackgroundTo compare infectious risk between JAK inhibitors (JAKis) versus TNF inhibitors (TNFis) among rheumatoid arthritis (RA) patients in Korea.MethodsUsing 2009–2019 Korea National Health Insurance Service database, we conducted a cohort study on RA patients initiating a JAKi or TNFi. The primary outcomes were herpes zoster (HZ), serious bacterial (SBI), and opportunistic infections (OI). Propensity-score fine-stratification (PSS) and weighting were applied to adjust for > 70 baseline covariates. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox proportional hazard models comparing JAKi versus TNFi users.ResultsWe included 2963 JAKi initiators PSS-weighted on 5169 TNFi initiators. During a follow-up of 1.16 years, the most frequent type of infections was HZ with incidence rate (IR) per 100 person-years of 11.54 and 4.88 in JAKi and TNFi users, respectively. The IR of SBI was 1.39 and 1.32, respectively. The OI was rare with a majority being tuberculosis and showed an IR of 0.11 and 0.49 in JAKi and TNFi users, respectively. The PSS-weighted HR (95% CI) for individual types of infections was 2.37 (2.00–2.80) for HZ, 1.04 (0.71–1.52) for SBI, and 0.25 (0.09–0.73) for OI.ConclusionsThis population-based cohort study on RA patients treated with JAKi or TNFi in Korea showed an exceptionally high IR of HZ in both treatment groups compared to that from Western countries, with an approximately doubled risk associated with JAKi versus TNFi use. The risk of SBI was comparable, but the risk of OI, particularly tuberculosis, was less among JAKi than TNFi initiators.

Herpes Zoster Mandibularis: Dilemma of Diagnosis - A Case Report.

Background: Herpes zoster infection involving the mandibular branch of the trigeminal nerve is rare. It can present with severe pre-eruptive pain along the distribution of the nerve involved. As presented by the patient in this study, this lesion may be mistaken for other painful conditions, leading to misdiagnosis and maltreatment. Post-herpetic neuralgia is the most common and important complication of herpes zoster infection. It is often refractory to treatment and can profoundly affect the patient's quality of life.
 
 Objective: To report an unusual and rare case of herpes zoster mandibularis and the diagnostic dilemma experienced in the management.
 
 Case Report: A 60-year-old female presented with severe intractable pain from the left side of the tongue and floor of the mouth, rashes of the lower lip and cheek, and ulcerations of the oral cavity. After a period of diagnostic puzzle due to confusing presentations, a diagnosis of herpes zoster infection involving the mandibular branch of the trigeminal nerve complicated with postherpetic neuralgia was finally made and the patient was treated accordingly. The peculiarity, management, and treatment outcome of the case are discussed.
 
 Conclusion: Herpes zoster mandibularis as seen in this case can present with clinical features that are confusing and can lead to misdiagnosis and inappropriate treatment. This study aims to raise awareness of the clinical presentation of this rare entity among clinicians in medical and dental practices. It is also advisable to seek dental and orofacial evaluation for patients with a similar presentation from specialists in Oral Medicine and Maxillofacial Surgery.