Oral Valaciclovir Research Articles

Acute gastric dilatation with segmented abdominal paresis as a rare manifestation of herpes zoster: a case report and review of the literature

BackgroundHerpes zoster is a common disease that can affect men and women at any age. Sensory neuropathy is the most common complication while motor neuropathy of the abdominal muscles is rare complication appearing in ~ 0.7% of patients. Furthermore, visceral nerve involvement causing gastroparesis is an extremely rare postherpetic complication. We present an extremely rare case of acute gastric dilatation with segmented abdominal paresis as a rare manifestation of herpes zoster infection.Case presentationA 91-year-old Asian man was admitted to hospital with 2-day history of vomiting and left abdominal protrusion. He was previously treated for a rash on the left abdominal wall as herpes zoster infection with oral valaciclovir 2 weeks prior. On physical examination, characteristic herpes zoster rash scars and an ipsilateral abdominal bulge were observed on the left side. Computed tomography revealed no abdominal wall defect, mass, or stenosis. Remarkable distension of the stomach, asymmetrical left flank wall bulge, and a thinner abdominal wall on the left compared with the right side were shown. He was diagnosed as acute gastric dilatation owing to gastroparesis and segmental paresis of the abdominal musculature associated with herpes zoster infection. The patient showed significant improvement in symptoms and abdominal paresis within a month of conservative treatment, including nasogastric tube decompression and mosapride administration.ConclusionAcute gastric dilatation with abdominal paresis is an extremely rare complication of herpes zoster infection, and to date there have been no reports in the literature. It alerts us that, when examining patients with abdominal bulge, we should be conscious of this rare pathology for the optical diagnosis, avoiding unnecessary invasive examination or surgical exploration.

Shingles without hutchinson sign developing herpes zoster ophthalmicus and preseptal cellulitis

A previously healthy 69-year-old man presented to an emergency room with a vesicular rash on his right forehead in line with shingles (herpes zoster) secondary to varicella-zoster virus. The patient was negative for the Hutchinson sign, a rash involving the tip of the nose or nasal ridge, which indicates an increased risk of herpes zoster ophthalmicus (HZO). Only around 10-20% of shingles cases develop HZO, which is an emergent vision-threatening disease [1]. The patient reports history of chickenpox and denies any immunocompromising conditions [2]. He was sent home on a course of oral valaciclovir. Four days later he was brought to the emergency room with an enlarged, crusting rash encompassing the right side of his forehead to the eyelid with blurry vision and severe eyelid edema (Figure 1A). The rash was spread along the ophthalmic distribution of the trigeminal nerve completely within the V1 dermatome, indicating HZO.

A Network Meta-Analysis of Randomized Clinical Trials to Assess the Efficacy and Safety of Antiviral Agents for Immunocompetent Patients with Herpes Zoster-Associated Pain

BACKGROUND: The most refractory symptom of herpes zoster (HZ) is pain. Approximately 90% of people who have HZ suffer from pain. Early use of antiviral medications has been found to reduce pain across all stages of the disease. Although many antiviral agents via oral or intravenous administration were recommended by clinical practice, the best approach to prevent HZ-associated pain remains uncertain. OBJECTIVES: The purpose of this study was to compare the efficacy and adverse events of various antiviral agents used for the treatment of HZ-associated pain through a network meta-analysis. STUDY DESIGN: A systematic review and meta-analysis. SETTING: The Cochrane Register of Controlled Trials, Embase, and PubMed were searched from inception to Feb 2020. METHODS: Randomized clinical trials evaluating antiviral agents currently available for treating HZ-associated pain were included. We extracted data in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and conducted network meta-analyses with random-effects models. The primary outcome was the presence of acute pain at the end of anti-virus treatment, and the secondary outcomes included the presence of pain at 28-30 days after the onset of the acute herpetic rash, the presence of postherpetic neuralgia (PHN), and any other adverse events. RESULTS: A total of 17 randomized control trials with 5,579 participants were included in this study. According to the results of the network meta-analysis, for the treatment of acute pain, there was no significant difference between oral acyclovir and intravenous acyclovir. Furthermore, oral famciclovir was the most effective treatment concerning both the odds ratio (OR) (superior to placebo OR = 0.25; 95% CI: 0.13~0.48) and the surface under the cumulative ranking curve (SUCRA) values of 0.84 for the treatment of acute pain among all the oral antiviral agents. For the presence of pain at 28-30 days, no significant difference was observed in efficacy between all antiviral treatments and placebo concerning the OR; however, oral valaciclovir ranked first (SUCRA values of 0.96). For the presence of NPH, oral famciclovir was determined to be the most effective (SUCRA values of 0.77) treatment with an efficacy of 0.42 (95% CI: 0.18~0.99) versus placebo. For adverse events, there was no significant difference between oral antivirals and placebo; however, intravenous acyclovir ranked last with a score of OR 4.31 (95% CI: 1.26~14.75) versus placebo. LIMITATIONS: The distribution of severity of pain was different in various studies; then, the lack of availability of individual data prevented us from analyzing the effects of the risk factors. CONCLUSIONS: For the treatment of acute pain and PHN, oral famciclovir was the most effective treatment among all the oral antiviral agents. For alleviating pain after 28-30 days, oral valaciclovir appeared to be the most effective among all antiviral agents. Additionally, all oral antiviral agents were well tolerated. Clinical Trial Registration Information: PROSPERO under the identification CRD42020212834 KEY WORDS: Herpes zoster, antiviral agents, acyclovir, famciclovir, valaciclovir, efficacy, pain, network meta-analysis Given the intrinsic nature of the secondary literature analysis in this study, the Ethics Committee of Chongqing Medical University’s Second Hospital waived the ethical approval.

BG08 Successful treatment of recalcitrant Darier disease with ustekinumab

Abstract Darier disease (DD) is a genodermatosis characterized by hyperkeratotic greasy papules in a seborrhoeic distribution. DD is caused by dominant mutations in ATP2A2, responsible for encoding the SERCA2 calcium pump. Currently, there are no licensed treatments for DD, but there is emerging evidence for the role of dysfunctional inflammation in DD. Our patient was a 49-year-old White woman with a history of recalcitrant DD involving extensive sheets of raw eroded skin. There was a strong family history of DD; her mother and maternal uncle had both died from sepsis related to DD. She suffered from recurrent superimposed skin infections, including methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas species and herpes simplex virus. Between 2019 and 2021, she required eight prolonged hospital admissions (average duration of stay 21 days; range 4–44) for intensive topical treatments (including potent topical steroids, emollients, topical antimicrobial agents and topical anaesthetic agents) and microbiology-guided systemic antimicrobial therapy [including oral co-amoxiclav, intravenous (IV) flucloxacillin, IV piperacillin–tazobactam, oral linezolid, IV daptomycin and oral valaciclovir]. She routinely required admission to the high-dependency unit for sepsis management, with multidisciplinary input from specialists in internal medicine, pain management, psychiatry and physiotherapy to enhance her recovery and optimize her associated comorbidities. Repeat biopsies were performed to confirm her diagnosis and rule out secondary viral infection or malignancy. Multiple systemic agents were trialled unsuccessfully, including acitretin, isotretinoin, alitretinoin, dapsone, ciclosporin and apremilast. Owing to the inflammatory presentation of her dermatosis and emerging evidence on the role of T helper 2-mediated inflammation in DD, the anti-interleukin (IL)-12/IL-23 agent ustekinumab was added to her regular treatment regimen. This successfully resulted in inducing disease remission within 5 months, with no further requirements for acute hospital admission or IV antimicrobial therapy in the year since initiation. Ustekinumab has never previously been reported for the treatment of DD in the literature. There have been individual reports of other inflammation-targeted agents such as IV methylprednisolone, immunoglobulin and ciclosporin, but treatment was poorly tolerated and relapse occurred following discontinuation. Penicillamine, doxycycline, oral contraceptive agents and oral magnesium have also been examined as potential therapeutic agents. Proinflammatory cytokines, in particular tumour necrosis factor-α and IL-6, have been associated with viral superinfection in DD, suggesting that systemic inflammation may closely relate to skin infections and disease activity in DD. In addition, cultured keratinocytes treated with IL-6 demonstrate reduced expression of ATP2A2. Ustekinumab may be a promising choice as a systemic immunomodulatory agent for DD. Future studies should examine the immune profile of patients with DD to inform therapeutic strategies.

Valaciclovir: Its Antiviral Activity, Pharmacokinetic Properties and Therapeutic Efficacy in Herpesvirus Infections: An Review

Valaciclovir, the L-valyl ester of aciclovir (acyclovir), is an oral prodrug that undergoes rapid and extensive first-pass metabolism to yield aciclovir and the essential amino acid L-valine. Aciclovir, the active antiviral component of valaciclovir, shows good in vitro activity against the herpesviruses herpes simplex virus (HSV)-1, HSV-2 and varicella zoster virus. The bio availability of aciclovir from oral valaciclovir is considerably greater than that achieved after oral acyclovir administration. Valaciclovir is an effective treatment for herpes zoster in immunocompetent adults. Valaciclovir was also effective in suppressing recurrent episodes of genital herpes and significantly prolonged the time to a recurrent episode of infection compared with placebo

Coin-shaped corneal endothelial scar in herpes zoster ophthalmicus: a case report

BackgroundHerpes zoster ophthalmicus includes a wide spectrum of lesions at the ocular surface, including epithelial, stromal, endothelial keratitis, and uveitis. Thus far, the occurrence of corneal endothelial disorder in herpes zoster ophthalmicus and the causative virus have not been confirmed, and the differential diagnosis and establishment of therapeutic strategies are challenging. Corneal endothelial coin-shaped lesions are well known to occur in cytomegalovirus-related corneal endotheliitis but have not been reported in patients with herpes zoster ophthalmicus.Case presentationA 39-year-old Asian female was referred to our ophthalmology department with recurrent anterior uveitis accompanied by coin-shaped corneal endothelial scar-like lesions that appeared after right facial herpes zoster. Diffuse corneal stromal haziness was mostly limited in the anterior stroma. The coin-shaped corneal endothelial lesions were separate from stromal lesions and showed a high-reflective scar-like line in sections of anterior segment optical coherence tomography. Anterior uveitis recurred each time she discontinued oral antiviral drug treatment for 12 months after the first event, but was remitted by the maintenance medications of combined topical ganciclovir gel with oral valaciclovir, at a dose lower than the usual adult dose, for acute or recurrent zoster-associated anterior uveitis. Corneal endothelial function remained normal and corneal endothelial and stromal lesions were unchanged throughout the treatment and follow-up period.ConclusionsIn patients with a history of facial herpes zoster with coin-shaped corneal endothelial scar accompanying recurrent anterior uveitis, suspicion for active varicella-zoster virus is warranted, and prolonged intake of oral antiviral agents is required despite varicella-zoster virus DNA not being detected in aqueous humor.

Varicella-zoster virus (VZV) acute retinal necrosis and recombinant zoster vaccine

Varicella zoster virus (VZV) is responsible for chickenpox. Like all herpes viruses, after primary infection it enters into latency and can be reactivated afterwards. Many forms of symptomatic reactivation of VZV exist including acute retinal necrosis (ARN), an ophthalmic emergency which can lead to blindness. ARN is treated starting with high-dose intravenous acyclovir then with oral valaciclovir for a total duration of up to 3 months. Symptomatic reactivations of VZV are public health issues. The new Swiss 2022 vaccination plan includes the recombinant vaccine Shingrix. It effectively prevents VZV symptomatic reactivations even in elderly and immuno suppressed patients.

Anterior segment involvement in Epstein-Barr virus: a review.

The aim of this study is to describe the involvement of Epstein-Barr Virus (EBV) in the diseases of the ocular anterior segment. This is a narrative review designed using the PUBMED, SCOPE and Web of Science databases, searching for reported literature on findings in the anterior ocular segment related to EBV between 1990 and 2020. Epstein-Barr Virus (EBV) is implicated in the development of salmon-coloured conjunctival masses in the context of acute mononucleosis and lymphoproliferative disorders. Moreover, EBV can cause haemorrhagic conjunctivitis and its corneal implications appear as different types of keratitis patterns. The involvement of EBV in the pathogenesis of anterior segment inflammation is not well-defined. Current evidence regarding anterior segment disease caused by EBV infection has been proved by positive viral detection through polymerase chain reaction test in eyes with lymphoproliferative disorders known to be caused by EBV, as B- and NK/T-cell lymphoid tumours. Antiviral treatment (oral Aciclovir or Valaciclovir) in anterior segment disease caused by EBV remains controversial.

Linear Endotheliitis Following Posterior Chamber Phakic Intraocular Lens Implantation

PURPOSE: To describe a case of linear corneal endotheliitis in a healthy patient with no previous relevant ophthalmic history other than high myopia, who unilaterally developed this disease during the early postoperative period after Implantable Collamer Lens (ICL; STAAR Surgical) phakic intraocular lens (IOL) implantation. METHODS: Case report. RESULTS: An ICL was uneventfully implanted in the right eye of a 42-year-old woman. After normal examination results at 24 hours postoperatively, sudden loss of vision occurred 48 hours postoperatively due to a moderate focal stromal and epithelial edema at half of the cornea, with a sharp transition between the edematous and the healthy cornea delimited by a fine line of keratic precipitates, associated ocular hypertension, and fine anterior chamber cellular activity. Results of a polymerase chain reaction test of the aqueous humor for herpes virus were negative, but the patient reported a previous history of herpes labialis. Diagnosis of linear endotheliitis was established, and empirical treatment with oral valaciclovir, topical hypotensive drugs, and intense topical steroid was started. Complete resolution of the corneal edema and cellular activity occurred after 2 weeks of treatment. Although visual potential was fully restored, endothelial cell density decreased to less than 1,000 cells/mm 2 , and recurrent episodes of mild hypertensive iritis with difficult intraocular pressure control resulted in explantation of the ICL 2 months after surgery. CONCLUSIONS: This is the first case reported of linear endotheliitis after phakic IOL implantation. The observation of severe focal corneal edema after any uneventful intraocular surgery should lead to the suspicion of this rare disease, where an early diagnosis and intensive empirical treatment are essential for a successful outcome. [ Journal of Refractive Surgery Case Reports. 2021;1(2):e19–e22.]

Prevention strategies for congenital cytomegalovirus infection.

Cytomegalovirus (CMV) is the most common viral cause of congenital infection, occurring in approximately 1-2% of live births worldwide. Given our increasing knowledge of risk, advances in the identification of maternal infection, and the extremely limited options for the treatment of fetal infection, the prevention is a promising direction for research efforts. Recently, there have been several exciting studies assessing different ways of preventing congenital infection in the fetus and one in particular has focused on the use of valaciclovir. A recent study reported a 71% reduction in vertical transmission of CMV with the use of oral valaciclovir following maternal primary CMV infection early in pregnancy. The clinical impact of this study could be enormous and it has particular implications for considerations around maternal serological screening in the first trimester of pregnancy. Further research assessing behaviour modifications during early pregnancy could also provide evidence for an effective primary prevention technique. Prevention of congenital CMV infection, whether primary, secondary or tertiary, is possible, however, there are barriers to its utilisation in a clinical setting. The main limitation is the requirement for early, effective and large-scale serological screening of mothers to detect asymptomatic primary infection.

Recurrent facial palsy and fissured tongue

A 28-year old Chinese man presented with right facial paralysis for 8 days. He felt that for first 3-days, his right face was swollen that subsided after starting oral valaciclovir and prednisolone by his general practitioner. He did not have any pain or swelling of the parotid gland and denied any ear symptom. He had developed right facial paralysis 7-years ago and left facial paralysis 2-years ago, which recovered considerably within a month on both occasions. He did not have any cardiovascular risk factors or immunocompromised state.

Erythema multiform-like Lesions in a Patient Infected With SARS-CoV-2: A Case Report

Background: SARS-CoV-2, is followed by several manifestations, such as fever, cough, respiratory distress syndrome and mucocutaneous lesions such as papules, urticaria, vasculitic purpura and erythema multiform. Case: A 22-year old woman was diagnosed with COVID-19. Considering the skin and oral lesions, erythema multiform was suggested as the most likely diagnosis. Oral valaciclovir was administered. Discussion: Erythema multiforme were reported in some patients with COVID-19. Its pathophysiology is not yet completely understood, but it seems there is a lymphocyte-mediated hypersensitivity reaction to SARS-CoV-2 antigens presenting in the skin. Conclusion: Mucocutaneous and oral lesions might be the first manifestations of COVID-19. Therefore, during the pandemic, it is prudent to consider this virus as a differential diagnosis once we encounter oral ulceration.

Outcomes of Patients with Herpes Simplex Keratitis Before and After the Implementation of a New Treatment Guideline in Sydney, Australia.

Outcomes of Patients with Herpes Simplex Keratitis Before and After the Implementation of a New Treatment Guideline in Sydney, Australia.

Different dosages of valaciclovir for the treatment of herpes zoster in adults: A randomized clinical study.

The dosages of valaciclovir used for herpes zoster treatment recommended by Chinese pharmaceutical companies can differ considerably from those reported in the literature. This randomized clinical study compares the efficacy and safety of different oral valaciclovir doses for the treatment of herpes zoster in adults. A total of 214 patients with herpes zoster were enrolled and randomized into two groups according to age: 98 patients in the 18-44-year group (younger patients) and 116 patients in the 45-74-year group (middle-aged and elderly patients). Patients in the two age groups were then prescribed different doses of valaciclovir. The high-dose group was administered 900mg of valaciclovir, three times daily for 10days, whereas the low-dose group was administered 300mg of valaciclovir, two times daily for 10days. The efficacy and side effects of these regimens were recorded on days 6, 11 and 30. In total, 207 (of 214 enrolled) patients completed the study. Of the seven patients who discontinued the study, five discontinued because their follow-up time was not fixed and two withdrew after moving to other cities. At the 11th day after treatment, the clinical effect of high-dose valaciclovir groups were significantly better than that of the low-dose valaciclovir groups in middle-aged and elderly patients (p<0.05). The difference in visual analog scale (VAS) pain scores between the two dose groups was statistically significant in middle-aged and elderly patients at the 6th day(p<0.05), whereas there was no difference in younger patients (p>0.05). The VAS scores were significantly lower in high-dose group than in low-dose group at day 11 in both groups of patients(p<0.05).There was no statistically significant difference in the time to skin scab improvement between the two different dose groups in younger patients (p>0.05). Among middle-aged and elderly patients, the incidence of postherpetic neuralgia (PHN) was significantly lower in the high-dose group than in the low-dose group (p<0.05). The difference in the incidence of adverse reactions between the high-dose and low-dose groups was not statistically significant (p>0.05). Overall, the main side effect was headache. The present study indicates that early treatment with high-dose valaciclovir can significantly reduce pain in patients, especially in elderly patients, in whom it can also reduce the incidence of PHN. In terms of safety, no significant difference was noted in the incidence of adverse reactions between high- and low-dose groups.

Herpes zoster of the trigeminal nerve with multi-dermatomal involvement: a case report of an unusual presentation

BackgroundHerpes zoster, also known as shingles, results from reactivation of the varicella-zoster virus. It commonly presents with burning pain and vesicular lesions with unilateral distribution and affects the thoracic and cervical sites in up to 60 and 20% of cases, respectively. The branches of the trigeminal nerves are affected in up to 20% of cases. Multidermatomal involvement of the trigeminal nerves has been only anecdotally described in immunocompetent subjects.Case presentationA 71-year-old previously healthy male presented with grouped vesicular and impetiginized lesions with crusts on the left half of the face of two-weeks duration. The lesions first developed on the left nasal tip and progressively worsened with unilateral appearance of vesicular lesions on the left forehead, face, ala nasi, nasal vestibulum and columella, as well as on the left side of hard and soft palate. The affected edematous erythematous areas corresponded to the distribution of the left ophthalmic (V1) and maxillary (V2) branches of the trigeminal nerve, including the infraorbital and nasopalatine nerves of the maxillary branch responsible for the oral cavity involvement. Viral DNA amplification by polymerase chain reaction confirmed the presence of Varicella zoster virus. The patient was started on oral valaciclovir with rapid recovery.ConclusionsAmong immunocompetent patients, herpes zoster is considered a self-limited localized infection. Our observation provides a rare but paradigmatic example of herpes zoster with involvement of both the ophthalmic and maxillary divisions of the trigeminal nerve in an immunocompetent patient. Immunocompetence status and age-specific screening should be warranted in case of atypical involvement and according to the patient’s history, while treatment with antiviral drugs should be rapidily initiated in patients at risk.

Valaciclovir to prevent vertical transmission of cytomegalovirus after maternal primary infection during pregnancy: a randomised, double-blind, placebo-controlled trial

Cytomegalovirus is a common congenital infection, with high morbidity after an early primary maternal infection. No effective means exist to prevent viral transmission to the fetus. We aimed to investigate whether valaciclovir can prevent vertical transmission of cytomegalovirus to the fetus in pregnant women with a primary infection acquired early in pregnancy. This prospective, randomised, double-blind, placebo-controlled trial was done at the Infectious Feto-Maternal Clinic of Rabin Medical Center (Petach Tikvah, Israel). Pregnant women aged 18 years or older, with serological evidence of a primary cytomegalovirus infection acquired either periconceptionally or during the first trimester of pregnancy, were randomly assigned to oral valaciclovir (8 g per day, twice daily) or placebo from enrolment until amniocentesis at 21 or 22 gestational weeks. Randomisation was done separately for participants infected periconceptionally or during the first trimester and was done in blocks of four. Patients and researchers were masked to participant allocation throughout the entire study period. The primary endpoint was the rate of vertical transmission of cytomegalovirus. Statistical analyses were done according to per-protocol principles. The study was registered at ClinicalTrials.gov, NCT02351102. Between Nov 15, 2015, and Oct 8, 2018, we enrolled and randomly assigned 100 patients to receive valaciclovir or placebo. Ten patients were excluded, five from each study group; therefore, the final analysis included 45 patients (all singletons) in the valaciclovir group and 45 patients (43 singletons and two sets of twins) in the placebo group. In the valaciclovir group, including both first trimester and periconceptional infections, five (11%) of 45 amniocenteses were positive for cytomegalovirus, compared with 14 (30%) of 47 amniocenteses in the placebo group (p=0·027; odds ratio 0·29, 95% CI 0·09-0·90 for vertical cytomegalovirus transmission). Among participants with a primary cytomegalovirus infection during the first trimester, a positive amniocentesis for cytomegalovirus was significantly less likely in the valaciclovir group (two [11%] of 19 amniocenteses) compared with the placebo group (11 [48%] of 23 amniocenteses; p=0·020. No clinically significant adverse events were reported. Valaciclovir is effective in reducing the rate of fetal cytomegalovirus infection after maternal primary infection acquired early in pregnancy. Early treatment of pregnant women with primary infection might prevent termination of pregnancies or delivery of infants with congenital cytomegalovirus. None.

Clinical diagnostic criteria of efficiency for combined etiopathogenetic therapy in patients with chronic Epstein–Barr virus infection

Treatment of chronic viral infections accompanied by permanent virus persistence in the target epitopes of the oral cavity, skin, urogenital tract is complicated by virtual lack of available drugs exerting combined systemic virulicidal and immunomodulatory effects. Here we demonstrate clinical and immunological efficacy of combined therapy in treatment of Epstein–Barr virus (EBV)-associated chronic infections. The aim of the study was to evaluate the clinical and immunological efficacy of combined etiopathogenetic therapy using the Acegram cosmetic product in patients with EBV-associated chronic infections. Materials and methods. There were enrolled 40 patients monitored before treatment as well as 20 patients followed up after combination therapy (cycle therapy consisted of oral valaciclovir (Valtrex) applied at dose of 500 μg twice a day for 10 days, glucosaminylmuramyldipeptide (Licopid) — 10 mg 2 twice a day for 10 days, topical irrigation for mucous membranes with granulocyte-macrophage colony-stimulating factor active center-derived peptide (Acegram-spray) 3 times a day for 10 days. If necessary, treatment courses were repeated 20 days after the onset. All patients were examined for the presence of EBV genomes in the oral fluid and blood using the qualitative and quantitative polymerase chain reaction (PCR) using the DNA technology test system (Russia) on a DT-Lite device prior treatment and 30, 60 days post-therapy time points. In addition, serum samples were analyzed for level of class G immunoglobulins specific to the EBV nuclear and capsid antigens by using enzyme immunoassay (test systems manufactured by CJSC Vector Best, Russia) as well as immune status (clinical methods, enu flow cytometry evaluation of the phagocytic activity of neutrophils, ELISA method). Results. Use of single or two course combination therapy in subjects with fully eradicated EBV carriage associated with reversed clinical symptoms was accompanied by recovered immune system status (T and B cells, T-helper cells, CD3+ CD25+ cells, phagocytosis parameters). A non-invasive approach proposed for controlling virus elimination in the oral fluid by using polymerase chain reaction method may serve as to objectively monitor therapeutic efficacy.

Retrospective and prospective evaluation of chickenpox post-exposure prophylaxis (PEP) in at-risk groups before and after the change in PEP guidelines

Background Public Health England (PHE) chickenpox post-exposure prophylaxis (PEP) guidelines were updated in August 2018. Varicella Zoster Immunoglobulin (VZIg) was replaced with oral aciclovir or valaciclovir in specific settings. Method We retrospectively examined issues of VZIg between August 1 2017 and July 31 2018 at a transplantation centre that also had a large maternity service. In addition, since September 2018, information has been collected prospectively. Additional data were collected on exposure incident, patient risk group and any clinical or serological follow up. Results Thirty issues of VZIg were identified retrospectively over 12 months. These included 9 pregnant women and 21 immunosuppressed patients, average age was 7.6 years (median 4.4 years, SD 11.1). Prospective outcome data were collected since September 4 2018 involving 2 pregnant women and 6 immunosuppressed individuals. Clinical follow-up information was available for 2 pregnant women and 16 immunosuppressed patients. One pregnant woman exposed to her own child with chickenpox and 2 immunosuppressed patients developed clinical varicella at an average of 15.3 days post VZIg. Five immunosuppressed patients were VZV IgG negative post-exposure. Follow-up available to date for 2 of 8 exposure incidents after the change in guidance has shown no clinical or serological evidence of varicella infection. Discussion Where follow up information was available, 19 % developed attenuated VZV around 2 weeks after receiving VZIg. Given the new guidance on using aciclovir prophylaxis, prospective outcome data are being collected and no VZV infections have been noted to date.

Efficacy of assisted treatment of thumb-tack acupuncture with surrounding needling method for herpes zoster of stagnated heat in liver meridian

To compare the efficacy difference between thumb-tack acupuncture with surrounding needling method plus medication and medication alone for herpes zoster (HZ) of stagnated heat in liver meridian type. According to random number table method, 60 patients with HZ of stagnated heat in liver meridian type were randomly divided into an observation group and a control group, 30 cases in each one. All the patients were treated with oral valaciclovir hydrochloride dispersible tablets (0.3 g per time, twice per day), mecobalamin tablets (0.5 mg per time, three times a day) and vitamin B1 (10 mg per time, three times a day) for 15 days. In addition, the patients in the observation group were treated with thumb-tack acupuncture at area 1 cm outside the herpes, with an interval of 3 cm between thumb-tack needles. The thumb-tack acupuncture was given once every 3 days, retained for 48 h, with an interval of 1 day between treatments, and totally 5 treatments were given. The index of herpetic evaluation (stopping time of herpes, scarring time, decrustation time), visual analogue scale (VAS), serum immune-related factors (IgG, IgM, IgA) and serum inflammatory factors (IL-4, IL-17, TNF-α, TGF-β1) were observed before and after treatment in the two groups. After treatment, the stopping time of herpes, scarring time, decrustation time in the observation group were shorter than those in the control group (all P<0.05). Compared before treatment, the VAS score in the two groups were reduced after treatment (both P<0.05), and no significant difference was observed between the two groups (P>0.05), but the difference before and after treatment in the observation group was superior to that in the control group (P<0.05). Compared before treatment, the levels of serum immune-related factors IgG, IgM, IgA were increased in the two groups after treatment (all P<0.05), and the levels in the observation group after treatment were higher than those in the control group (all P<0.05). Compared before treatment, the levels of serum inflammatory factors IL-4, IL-17, TNF-α, TGF-β1 were reduced in the two groups after treatment (all P<0.05), and the levels in the observation group after treatment were lower than those in the control group (all P<0.05). The thumb-tack acupuncture with surrounding needling method plus medication have the advantages of rapid onset and analgesic effect for HZ of stagnated heat in liver meridian type, which could also improve serum immune-related factors and reduce inflammatory reaction.

Valaciclovir therapy for herpes encephalitis: caution advised

Recently some authors have suggested that oral valaciclovir 1 g q8h is a valid alternative to intravenous aciclovir for herpes encephalitis. We are concerned about numerous caveats that we think have not been sufficiently addressed to allow such use outside of a controlled research setting.