Varicella Zoster Reactivation Research Articles

Tofacitinib in Steroid-Refractory Acute Severe Ulcerative Colitis: A Retrospective Analysis.

Steroid-refractory acute severe ulcerative colitis (ASUC) patients are at the highest risk of colectomy. Among the available options, cyclosporine and infliximab have similar efficacy but infliximab is a costly drug and cyclosporine has multiple side effects like kidney injury, neurotoxicity, and dyselectrolytemia.Surgical management is often associated with higher morbidity. Newer oral small molecules like Janus kinase inhibitors are the ideal molecules to bridge the gap. Tofacitinib has already been extensively evaluated in patients with moderate to severe UC; however, data on ASUC treated by tofacitinib are limited. We retrospectively analyzed the data of patients with ASUC who were admitted to our hospital's luminal gastroenterology unit between January 2021 and July 2023. Patients with ASUC who were managed with tofacitinib were included in the study. Eight patients with ASUC were identified who did not respond to intravenous hydrocortisone and were treated with tofacitinib.The mean age was 39 ± 15 years and 87.5% were female. The median duration of illness was 24 months (interquartile range (IQR): 12-120 months).Seven of eight patients (87.5%) responded to oral tofacitinib 10 mg twice a day by the fifth day of treatment. The median follow-up period was six months (IQR: 1-12 months). One patient required colectomy and one patient had varicella zoster reactivation requiring treatment discontinuation. Tofacitinib is an attractive alternative to the currently available salvage therapy for steroid-refractory ASUC;however, long-term efficacy and risk remain to be explored.

Pole-to-pole involvement of varicella zoster virus reactivation following COVID-19 vaccination.

The aim of this study is to report the clinical features, imaging findings including confocal imaging, corneal nerve fiber analysis, and management outcomes in a series of three cases of varicella zoster virus (VZV) reactivation following one dose of coronavirus disease 2019 (COVID-19) vaccination. This was a retrospective and observational study. All the patients who developed uveitis post-vaccination were pooled together. Patients who had VZV reactivation were included. Two cases had polymerase chain reaction positive for VZV from aqueous humor. At the time of presentation, IgG and IgM spike protein antibodies for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) were tested. Out of this pool, three patients with classical features to describe pole-to-pole manifestations were chosen. A 36-year-old lady with post-vaccination sclerokeratouveitis associated with reactivation of herpes zoster ophthalmicus, a 56-year-old lady with post-vaccination acute anterior uveitis associated with herpes zoster ophthalmicus, and a 43-year-old gentleman with post-vaccination acute retinal necrosis were included. We present a possible link between anti-SARS-CoV-2 virus vaccination and varicella zoster reactivation in these patients and also describe the clinical features, imaging findings including confocal imaging, corneal nerve fiber analysis, and management with detailed discussion.

Four-Parameter FluoroSpot Assay Reveals That the Varicella Zoster Virus Elicits a Robust Memory T Cell IL-10 Response throughout Childhood.

During childhood, the composition and function of the T cell compartment undergoes significant changes. In healthy individuals, primary infection with herpesviruses is followed by latency, and occasional subclinical reactivation ensures transmission and contributes to an emerging pool of memory T cells. In immunocompromised individuals, herpesviruses can be life threatening. However, knowledge about the spectrum of virus-specific cytokine responses is limited. Here, we investigated peripheral blood mononuclear cells (PBMCs) from children with differential carrier statuses for cytomegalovirus (CMV), Epstein-Barr virus (EBV), and varicella zoster virus (VZV) (n = 32, age 1 to 17 years). We examined memory T cell subsets as well as IFN-γ-, IL-10-, IL-17A-, and IL-22-producing T cells after polyclonal activation or stimulation with viral peptides using flow cytometry and a 4-parameter FluoroSpot assay. Age and herpesvirus carriage influenced the size of the memory T cell subsets. A positive association between age and the number of IFN-γ-, IL-17A- and IL-22-producing T cells was found following polyclonal activation. For CMV, age was positively associated with IL-17A spot-forming cells (SFC), while for VZV, age was negatively associated with IL-22 and positively associated with IFN-γ SFC. Upon activation with CMV, VZV, and EBV peptides, IFN-γ SFCs dominated. Notably, VZV responses were characterized by a higher IL-10 SFC population compared to both CMV and EBV. Our findings suggest that cytokine responses vary across herpesvirus-type-specific memory T cells and may more adequately reflect their composition. An observed deviation between polyclonal and herpesvirus-specific T cell cytokine responses in children needs to be considered when interpreting the associations between herpesvirus carrier status and bulk T cell reactivity. In summary, these findings may have implications for the treatment of immunocompromised patients. IMPORTANCE Infection with herpesviruses accounts for 35 to 40 billion human cases worldwide. Despite this, little is known about how herpesviruses shape the immune system in the asymptomatic carrier. Particularly in children, primary infection is connected to no or mild symptoms ahead of latency for life. Most research on cellular responses against herpesviruses focuses on inflammatory cytokines associated with antiproliferative and antitumor mechanisms and not the spectrum of cytokine responses in healthy humans. This study investigated four divergent cytokine-producing T cell responses to herpesviruses, reflecting different immunological functions. Three common childhood herpesviruses were selected: Epstein-Barr virus, cytomegalovirus, and varicella-zoster virus. Curiously, not all viruses induced the same pattern of cytokines. Varicella-zoster responses were characterized by IL-10, which is considered regulatory. Besides broadening understanding of responses to herpesviruses, our results raise the possibility that reactivation of varicella-zoster may be counterproductive in cancer treatment through the action of IL-10-producing T-cells.

“HERPES ZOSTER – CASE REPORT”

Herpes zoster (HZ) commonly referred as shingles is reactivation of varicella zoster. Herpes zoster is usually seen in older age group whereas varicella zoster is seen in younger age group. Reactivation of varicella zoster from dorsal root of ganglion results in HZ. The clinical features include painful vesicular rash along the affected dermatome and pain may persist even after skin lesions heal. Complication of HZ are Post Herpetic Neuralgia, Ramsay hunt syndrome. Antiviral drugs are the main treatment of choice. We report a case of Herpes zoster in a 65-year-old female patient and highlights on clinical features complications and various treatment modalities.

Evidence-Based Homoeopathic Treatment of Acute Herpes Zoster (Shingles): A Case Report

AbstractHerpes zoster (HZ), also known as shingles, occurs due to reactivation of varicella zoster. It is manifested by unilateral, painful, vesicular rashes following a dermatome. Homoeopathy is well known for its tremendous results in chronic cases. This article presents the evidence-based significant result of single homoeopathic remedy in an acute case of HZ within a short time period without any post-herpetic neuralgia which usually follows the HZ for months. Three to four doses of Hypericum 30 CH provided significant relief within a day and complete recovery within 10 days. Modified Naranjo score is 9, indicating definite causal attribution. This case proves that by selecting appropriate similimum, promising and positive results are achieved by homoeopathy, be it acute or chronic cases in a safe and gentle way. No such existing homoeopathic literature provides any characteristic information particularly related to HZ in Hypericum. So, future research and clinical trials could be beneficial for better validation of Hypericum as a therapeutic for HZ.

Herpes Zoster associated With COVID-19 in an immunocompetent male

Severe acute respiratory syndrome coronavirus (SARS-COV-2) presented with pulmonary symptoms and various extra pulmonary manifestations including dermatological manifestations like urticarial, acralvascular lesion erythematous maculopapular rash, and vesicular rash. Herpes zoster is a painful vesicular rash resulting from reactivation of varicella-zoster (VZ) virus that also a causative agent of chickenpox. The incidence of HZ infection (HZI) more prevalent in older ages and various immunosuppressive conditions. Coronavirus disease in 2019(Covid19) causing immune exhaustion and VZ virus reactivation, which is commonly presented as HZ in middle-aged adults. Here we report a case of HZ infection in association with COVID 19 positive 60 years male. Update Dent. Coll. j: 2021; 11(2): 35-37

Reactivation of varicella zoster infection presenting as acute retinal necrosis post COVID 19 vaccination in an Asian Indian male.

To present the clinical features of a rare case of varicella zoster infection following one dose of Coronavirus Disease 2019 (COVID-19) vaccination in an elderly Asian Indian male. Retrospective observational case report. A 71-year-old gentleman presented to us with complaints of reduced vision associated with redness and pain in his right eye for 1 week. On examination he revealed a right eye pan uveitis picture with circumcorneal congestion, multiple fine keratic precipitates, anterior chamber cells and flare, vitritis and widespread areas of acute retinal necrosis. His left eye was within normal limits. Ten days prior to the presentation he had received the first dose of COVID-19 vaccine following which he had developed fever for 2 days that preceded the red eye. The patient's aqueous sample tested positive for varicella zoster virus (VZV) by nested polymerase chain reaction (PCR) method. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in reverse transcriptase polymerase chain reaction (RT-PCR) assay from the aqueous and also from the nasopharyngeal swab was negative. To the best of our knowledge this is the earliest description of a case that has a viral reactivation following COVID-19 vaccination. Elderly people with pre-existing comorbidities, may be at a risk of both primary coronavirus infection and unconceivable risk of aberrant immune reactions leading to a different virus infection or reactivation need to be kept in mind. We present a possible link between SARS-CoV-2 virus vaccination and varicella zoster reactivation in this patient.

B-Cell Lymphoma Patients Have a 10% Risk of Shingles, 7% in Cutaneous T-Cell Lymphoma

Background: Patients with lymphoma can be immunosuppressed from the disease, treatment or both. One indicator of cellular mediated immunity is reactivation of Varicella Zoster (VZV), a painful viral infection estimated to occur to 30% of U.S. population during a lifetime and associated with a particularly morbid post-herpetic neuralgia. Bortezomib and dexamethasone have been shown to be correlated with increased rates of varicella zoster and other viral infections (Kim SJ et al, Clinical lymphoma & myeloma, 2008). Autologous stem cell transplant depletes cellular- and humoral-immunity (Kamber C et al, BMT, 2015). While the main risk factor for VZV reactivation is age (Harpaz R, MMWR Recomm Rep, 2008), the underlying malignancy might play a large role in the risk of VZV reactivation. There is little data comparing the proportion of VZV in multiple myeloma (MM) with other indolent B and T-cell lymphomas. The purpose of this study is to compare varicella infection in MM patients with chronic lymphocytic leukemia (CLL), cutaneous T-cell lymphoma (CTCL), and follicular lymphoma (FL). Given that VZV is a relatively common infection in patients with MM, we hypothesized that varicella reactivation in MM patients occurs at a higher rate than in patients with CLL, CTCL, or FL.Methods: A retrospective chart review of 3,765 patients was conducted. Patients were eligible if they had been diagnosed with 1 of 4 malignancies - MM (1,210), CLL (2,520), CTCL (434), or FL (809). Patients diagnosed with other malignancies i.e. mantle cell lymphoma were excluded, as were patients with multiple malignancies i.e. MM and FL. All patients had been seen at the Ohio State University Wexner Medical Center during their treatment. For each patient, information on age, gender, length of survival, age at diagnosis of hematologic malignancy, and proportion of patients with shingles was collected. Only patients who were diagnosed with shingles after hematologic cancer diagnosis were included as positive. Associations between malignancy type and development of shingles were analyzed by a chi-square test, and logistic regression was used to calculate odds ratios for shingles between MM and the other malignancies, controlling for age as a possible confounder. Median survival time was calculated in years using the Kaplan-Meier method, calculated as the time from cancer diagnosis to date of last contact if alive, or date of death if deceased. Seven patients were excluded from survival analysis due to having the same date of diagnosis as date of last contact. This study was approved by the cancer institutional review board.Results: Patient demographic information is found in Table 1. Of the 1,210 MM patients, 127 developed shingles after diagnosis (10.5%); of 2520 CLL patients, 326 were positive (12.9%); of 434 CTCL patients, 33 were positive (7.6%); of 809 FL patients, 78 were positive (9.6%). At a significance level of a=0.05, there was a significant association between cancer type and shingles (χ2=15.59, df=3, p-value=0.0014). Odds ratios comparing MM to each of the other lymphomas were not found to be significant. The median survival time in years was 8.8 for MM, 20.7 for CLL, 25.1 for CTCL, and 24.6 for FL (Figure 1).Conclusion: Patients with MM had the lowest median survival (8.8 years), and a significant association between cancer type and shingle incidence was found, with CTCL patients having the lowest incidence of shingles (7.6%) within the retrospective period. However, the odds ratios comparing MM to the other 3 lymphomas was not significant, showing that the MM patients did not have significantly higher rates of shingles as originally hypothesized. These results demonstrate the differences in viral infection incidence and disease course between hematologic malignancies, and that antiviral strategies more specialized to T and B cell lymphomas may be important in reducing the risk of viral infection. [Display omitted] DisclosuresHofmeister:Celgene: Research Funding; Adaptive Biotechnologies: Honoraria, Membership on an entity's Board of Directors or advisory committees; Karyopharm: Research Funding; Takeda: Research Funding; Thrassos: Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Research Funding; Bristol-Myers Squibb: Research Funding; Roche: Research Funding.

Herpes zoster in chronic lymphocytic leukemia: Effect of vaccination and treatment.

7527 Background: Patients with Chronic Lymphocytic Leukemia (CLL) are susceptible to infections due to impaired humoral immunity as a complication of the disease, treatments received and age at diagnosis. Herpes zoster (HZ) is a painful, vesicular rash from reactivation of varicella-zoster virus that is common in immunocompromised patients. While HZ vaccines can reduce both varicella-zoster reactivation and post-herpetic neuralgia, vaccination rates are low. The aim of this study is to determine the effect of vaccination on rates of HZ infection in patients with CLL. Methods: We identified patients diagnosed with CLL between September 1999 and October 2015 using Veterans Administration Central Cancer Registry (VACCR). Pharmacy records were used to identify patients who received treatment for CLL and HZ. HZ events were defined as patients with International Classification of Diseases 9th Revision (ICD-9) codes for HZ infection (053) or prescriptions of acyclovir or valacyclovir at a dose of 1500 mg/day or higher or famciclovir at a dose of 1000 mg/day or higher without a diagnosis of Herpes simplex or Bell’s palsy, or an ICD-9 code and prescription above. Cox proportional hazards regression model was used to assess the association between vaccination as a time-varying exposure and developing HZ while controlling age at CLL diagnosis, co-morbidity score, and receipt of first and second line chemotherapy. The study was approved by the St. Louis VA Medical Center institutional review board. Results: A cohort of 7155 patients with CLL was identified using VACCR. 2640 patients (36.9%) and 1161 patients (16.2%) received first and second line chemotherapy respectively. Mean age at first chemotherapy was 69.5 years. We detected 1115 cases of HZ (15.6%) using ICD-9 codes, prescriptions or both. 615 patients (8.6%) received HZ vaccinations. Patients with HZ were younger (mean 68.0 vs. 69.8 years, p < 0.001), had similar co-morbidities, and were more likely to get treatment for CLL (58.1% vs. 33.0%, p < 0.001). Using a time-varying analysis, there was a trend for HZ vaccine to decrease the risk of developing HZ (HR 0.71, 95% CI 0.49-1.04, p = 0.082). When adjusting for age and co-morbidity, patients with CLL treated with first line chemotherapy had a higher risk of HZ (HR 2.34, 95% CI 2.02-2.71, p < 0.001) compared to those never receiving therapy. Second line chemotherapy increased risk of HZ (HR 1.32, 95% CI 1.13-1.55, p < 0.001) beyond first line treatment. Conclusions: HZ is prevalent in patients with CLL and affects younger patients who require chemotherapy. The risk of developing HZ increases in recipients of first and second line chemotherapy. In the time-varying analysis, there was a trend towards decreased infection in patients who received HZ vaccination. Further studies in a more modern cohort that assess infection risk using a larger vaccinated group with the newer and more effective HZ vaccine are warranted.

Varicella Zoster Reactivation Following mRNA Vaccination: Two Case Reports and a Review of Cutaneous Adverse Events of COVID-19 Vaccines

Cutaneous reactions following the COVID-19 vaccination, in particular mRNA vaccines, have been increasingly reported in literature. The most common morphologies were delayed large local reactions, local injection site reactions, urticaria, and morbilliform reaction. The purpose of this report is to review the cutaneous manifestations of COVID-19 vaccines and to report two cases of COVID-19 mRNA vaccine-induced varicella zoster reactivation along with the possible pathogenesis. These two cases are of an 80-year-old female patient with multiple comorbidities and a previously healthy 57-year-old male patient who experienced varicella zoster reactivation post-COVID-19 mRNA vaccine (Pfizer, New York City, New York, USA) following the first and second dose

Safety of Janus Kinase Inhibitors in Older Patients: A Focus on the Thromboembolic Risk.

The Janus kinase (JAK)–signal transducer and activator of transcription (STAT) pathway is a membrane-to-nucleus signaling cascade that effects activation of gene transcription. JAK inhibitors have demonstrated effectiveness in autoimmune diseases such as rheumatoid arthritis. An increased risk of infection, mainly varicella-zoster reactivation, with these new agents is of concern. Comorbid conditions, along with pharmacokinetic variations in drug metabolism in the older population, further increase the risk of adverse outcomes. Newly raised concerns for potential adverse effects such as deep vein thrombosis and pulmonary embolism are essential considerations for clinicians. Older patients are at increased risk because of multiple comorbid conditions and pharmacokinetic changes related to drug metabolism and excretion. Both the US FDA and the European Medicines Agency have issued warnings regarding this risk. These warnings highlight individuals aged > 50 years with concomitant cardiovascular risk factors. Furthermore, the FDA released a black box warning for increased thromboembolic risk associated with JAK inhibitors. As the use of these drugs increases, a solid understanding of adverse effects and risks is critical to those treating older adults.

Evaluating the reactivation of herpesviruses and inflammation as cardiovascular and cerebrovascular risk factors in antiretroviral therapy initiators in an African HIV-infected population (RHICCA): a protocol for a longitudinal cohort study

IntroductionIn Sub-Saharan Africa, the rising rates of cerebrovascular and cardiovascular diseases (CBD/CVD) are intersecting with an ageing HIV-infected population. The widespread use of antiretroviral therapy (ART) may confer an additive...

IMMUNITY AND VACCINE PROPHYLAXIS IN ADULTS WITH INFECTION CAUSED BY VARICELLA ZOSTER VIRUS

Due to the wide spread of herpesvirus infections and the increase in the number of diseases that inhibit the immune system, the modern course of infection caused by Varicella zoster has features. If earlier herpes zoster was considered a disease of the age of 60 years or more, now they are increasingly ill persons under 60 years. The article shows that groups of people with secondary immunodeficiency have a higher risk of reactivation of Varicella zoster. Patients with HIV infection, myeloma and other immunocompromising diseases are more likely to be affected by herpes zoster. The data of own researches confirming the existing data that the chronic pathology directly or indirectly influencing cellular immunity, in particular, on T-lymphocytes, is also risk of occurrence at the age of 60 years are given. Due to the fact that the infection caused by Varicella zoster, against the background of secondary immunodeficiency occurs in a more severe form than in persons who do not suffer from immunodeficiency, the prevention of relapses of the disease by vaccination and chemoprophylaxis are discussed. In accordance with the existing views, the indications for specific prevention in HIV-infected and cancer patients are described. Important criteria are indicators of CD4 levels of lymphocytes, the stage of the underlying disease and the time elapsed after the last course of chemotherapy. Since all registered vaccines against Varicella zoster are live attenuated - this increases the risk of adverse events. Prospects of creation and ways of increase of the combined immunopreparations are discussed.

Siponimod versus placebo in secondary progressive multiple sclerosis (EXPAND): a double-blind, randomised, phase 3 study

No treatment has consistently shown efficacy in slowing disability progression in patients with secondary progressive multiple sclerosis (SPMS). We assessed the effect of siponimod, a selective sphingosine 1-phosphate (S1P) receptor1,5 modulator, on disability progression in patients with SPMS. This event-driven and exposure-driven, double-blind, phase 3 trial was done at 292 hospital clinics and specialised multiple sclerosis centres in 31 countries. Using interactive response technology to assign numbers linked to treatment arms, patients (age 18-60 years) with SPMS and an Expanded Disability Status Scale score of 3·0-6·5 were randomly assigned (2:1) to once daily oral siponimod 2 mg or placebo for up to 3 years or until the occurrence of a prespecified number of confirmed disability progression (CDP) events. The primary endpoint was time to 3-month CDP. Efficacy was assessed for the full analysis set (ie, all randomly assigned and treated patients); safety was assessed for the safety set. This trial is registered with ClinicalTrials.gov, number NCT01665144. 1651 patients were randomly assigned between Feb 5, 2013, and June 2, 2015 (1105 to the siponimod group, and 546 to the placebo group). One patient did not sign the consent form, and five patients did not receive study drug, all of whom were in the siponimod group. 1645 patients were included in the analyses (1099 in the siponimod group and 546 in the placebo). At baseline, the mean time since first multiple sclerosis symptoms was 16·8 years (SD 8·3), and the mean time since conversion to SPMS was 3·8 years (SD 3·5); 1055 (64%) patients had not relapsed in the previous 2 years, and 918 (56%) of 1651 needed walking assistance. 903 (82%) patients receiving siponimod and 424 (78%) patients receiving placebo completed the study. 288 (26%) of 1096 patients receiving siponimod and 173 (32%) of 545 patients receiving placebo had 3-month CDP (hazard ratio 0·79, 95% CI 0·65-0·95; relative risk reduction 21%; p=0·013). Adverse events occurred in 975 (89%) of 1099 patients receiving siponimod versus 445 (82%) of 546 patients receiving placebo; serious adverse events were reported for 197 (18%) patients in the siponimod group versus 83 (15%) patients in the placebo group. Lymphopenia, increased liver transaminase concentration, bradycardia and bradyarrhythmia at treatment initiation, macular oedema, hypertension, varicella zoster reactivation, and convulsions occurred more frequently with siponimod than with placebo. Initial dose titration mitigated cardiac first-dose effects. Frequencies of infections, malignancies, and fatalities did not differ between groups. Siponimod reduced the risk of disability progression with a safety profile similar to that of other S1P modulators and is likely to be a useful treatment for SPMS. Novartis Pharma AG.

544 - Combination Strategy with Low-Dose Acyclovir and Vaccination Against Varicella Zoster Reactivation after Hematopoietic Stem Cell Transplantation

544 - Combination Strategy with Low-Dose Acyclovir and Vaccination Against Varicella Zoster Reactivation after Hematopoietic Stem Cell Transplantation

Infectious diseases causing autonomic dysfunction.

To review infectious diseases that may cause autonomic dysfunction. Review of published papers indexed in medline/embase. Autonomic dysfunction has been reported in retrovirus (human immunodeficiency virus (HIV), human T-lymphotropic virus), herpes viruses, flavivirus, enterovirus 71 and lyssavirus infections. Autonomic dysfunction is relatively common in HIV-infected patients and heart rate variability is reduced even in early stages of infection. Orthostatic hypotension, urinary dysfunction and hypohidrosis have been described in tropical spastic paraparesis patients. Varicella zoster reactivation from autonomic ganglia may be involved in visceral disease and chronic intestinal pseudo-obstruction. Autonomic and peripheral nervous system dysfunction may happen in acute tick-borne encephalitis virus infections. Hydrophobia, hypersalivation, dyspnea, photophobia, and piloerection are frequently observed in human rabies. Autonomic dysfunction and vagal denervation is common in Chagas disease. Neuronal depopulation occurs mainly in chagasic heart disease and myenteric plexus, and megacolon, megaesophagus and cardiomyopathy are common complications in the chronic stage of Chagas disease. Parasympathetic autonomic dysfunction precedes left ventricle systolic dysfunction in Chagas disease. A high prevalence of subclinical autonomic neuropathy in leprosy patients has been reported, and autonomic nerve dysfunction may be an early manifestation of the disease. Autonomic dysfunction features in leprosy include anhidrosis, impaired sweating function, localised alopecia ,and reduced heart rate variability. Urinary retention and intestinal pseudo-obstruction have been described in Lyme disease. Diphtheritic polyneuropathy, tetanus and botulism are examples of bacterial infections releasing toxins that affect the autonomic nervous system. Autonomic dysfunction may be responsible for additional morbidity in some infectious diseases.

Case Report Ramsay Hunt Syndrome presenting as “a window’’ to HIV diagnosis in 48 year old African female: A case report

Background: Ramsay Hunt Syndrome in adults is reported in a number of case reports as an uncommon presentation of Varicella zoster Virus infection. Ramsay Hunt Syndrome occurs when there is reactivation of the latent Varicella zoster virus present in the ganglia due to previous varicella infection. Following a breakdown of the immune system, latent Varicella zoster infection can be activated. HIV (Human Immunodeficiency Virus infection), causes immunosuppression and hence reactivation of Varicella zoster. The diagnosis of Ramsay Hunt Syndrome, gives a window of opportunity to investigate for HIV. Here we report our first case of Ramsay Hunt syndrome as a presenting feature of HIV disease in an apparently healthy looking 48 year old black African female who was unaware of her HIV status at the time of presentation.
 This case is reported in order to highlight the need to use Ramsay Hunt Syndrome as a window of opportunity to screen for underlying HIV.
 Case presentation: A 48 year old black African female who was unaware of her HIV status, presented to our outpatients department with a two day history of painful right ear pain, vesicles on the right pinna and inability to completely close her right eye, her mouth was deviated to the left, with a wrinkle free frown. She denied any alteration in taste sensation and hyperacusis. She had a grade IV House-Brackmann facial paralysis.A diagnosis of Ramsay Hunt Syndrome was made and an HIV test was offered, the test was positive for HIV.A subsequent HAART (Highly Active Antiretroviral Therapy) work up, revealed CKD 3B (Chronic Kidney Disease stage 3B) and a CD4 (cluster of differentiation 4) count of 217 cells/µl .She was started on antiretroviral therapy 2 weeks after completing a 10 day regimen of acyclovir. In addition to her drug treatment she received ocular care and physiotherapy. Four months on her facial nerve function has improved modestly.
 Conclusion: An HIV test should be an indispensable part of the Ramsay Hunt syndrome workup, as its diagnosis gives a window of opportunity to diagnose HIV and offer life- saving HAART.

Encephalomyelitis After Varicella Zoster Reactivation in an Immunocompromised Patient.

Encephalomyelitis After Varicella Zoster Reactivation in an Immunocompromised Patient.

Imiquimod triggering varicella zoster reactivation in an immunocompetent patient

Imiquimod is widely used for the treatment of superficial basal cell carcinoma as well as several other dermatologic conditions. While its local immunostimulatory action is well proven, its potential for systemic immunomodulation has been less well described. We report the first case (to our knowledge) of varicella zoster reactivation caused by Imiquimod in an immunocompetent patient.

Folliculocentric Herpes: A Clinicopathological Study of 28 Patients.

The cutaneous manifestations of herpes infection are primarily in the context of active infection and of the post-herpetic zosteriform eruption. The former manifests cytopathic alterations diagnostic of herpes. The latter includes lichen planus-like and granuloma annulare-like eruptions and lymphocytoma cutis. We encountered skin biopsies from 28 patients whose acute or chronic herpetic or post-herpetic zosteriform lesions manifested folliculocentricity. The clinical appearance of the lesions was correlated with the histopathologic and immunohistochemical features of paraffin-embedded skin biopsies to determine the specific viral etiology. A history of underlying medical disease was noted if present. There were 16 men and 12 women with a folliculocentric eruption occurring after a known herpetic eruption or manifesting cytopathic changes and/or immunohistochemical findings compatible with herpes virus in lesional skin biopsies. Underlying immune dysregulatory states were present in most cases, namely, malignancy, anticonvulsant or antidepressant therapy, diabetes mellitus, psoriasis, Crohn disease, and other conditions. All biopsies demonstrated dense lymphohistiocytic infiltrates in or around hair follicles with variable necrosis, while active infections also showed cytopathic and/or immunohistochemical evidence of herpetic alterations, most commonly varicella zoster. Other features included interfollicular interface dermatitis, lymphocytic eccrine hidradenitis, neuritis, and folliculocentric vasculitis. Cutaneous herpetic eruptions can evoke a predominantly folliculocentric mononuclear cell reaction and vasculitis; there is an association with underlying endogenous and/or iatrogenic immune dysregulation. Most cases are secondary to reactivation of varicella zoster. The histomorphology suggests a role for cell-mediated immunity. Antigenic homology of an endogenous 72-kd heat shock protein in follicles with that of a herpetic heat shock protein, in concert with an intrafollicular proliferative response of γ-δ T lymphocytes, may explain the follicular localization and composition of the infiltrate.