Varicella Zoster Infection Research Articles

Case of varicella zoster infection in adult: A disease with increasing incidence

Case of varicella zoster infection in adult: A disease with increasing incidence

Hip Pain as Initial Presentation for Varicella-Zoster Infection in an Adolescent Male

Hip pain and varicella infections are common diagnoses affecting children and adolescents. Hip pain in childhood can be a challenging presenting complaint for the pediatrician or orthopedic physician. The differential diagnosis is broad, and ranges from benign conditions, such as transient synovitis and muscle strains, to more serious infections or malignancies. Acute hip pain is usually referred to an orthopedic surgeon, and the principal concern is to distinguish infection of the hip joint or pelvis from an irritable hip or musculoskeletal pain. The Varicella-zoster virus, a member of the herpes virus family, often presents as a generalized, pruritic, vesicular rash. The primary infection is commonly known as chickenpox. The prevalence of varicella infections has decreased significantly over the past decade with use of the varicella vaccine. Reactivation of varicella infection, or herpes zoster, in patients younger than 20 years is seen in only 68 per 100,000 people. Hip pain as the presenting symptom for onset of a herpes zoster infection is rare. This article presents a case of herpes zoster infection with initial presentation of hip pain in a 13-year-old boy. This case highlights the difficulty in diagnosing atraumatic joint pain in the pediatric population. The clinical importance of a thoughtful differential diagnosis, and the necessity of close follow-up by a pediatrician and/or orthopedic surgeon until there is a confirmed diagnosis cannot be overstated.

Varicella Zoster Infection in Renal Transplant Recipients: Prevalence, Complications and Outcome

Varicella zoster virus (VZV) is an important pathogen after renal transplantation. In the present study, we examined the prevalence, clinical presentation and outcome of VZV infections in renal transplant recipients. Charts and medical records of adult renal allotransplant recipients were investigated to find patients with VZV infection. From December 1972 until July 2010, 1,139 patients received kidney allograft at our institution. VZV infection was diagnosed in 40 patients (3.51%). 28 patients (70%) had intensified immunosuppression prior to VZV infection occurrence. Median time of onset was 2.13 years after transplantation (range 9 days to 19.2 years). 35 patients developed VZV during the first post-transplant year (median 0.61 years). Four patients developed VZV infection more than 12 years after transplantation. 33 patients (82.5%) had dermatomal distribution, 5 (12.5%) disseminated herpes zoster (HZ), and 2 patients (5%) who were VZV IgG-negative before transplantation, developed chickenpox. Immunosuppression was reduced and patients received acyclovir. Cutaneous scarring was recorded in 7 cases (17.5%). Two patients developed post-herpetic neuralgia, which was accompanied by scarring and skin depigmentation in 1 of them. Five patients (12.5%) experienced relapse of HZ. Timely initiation of therapy may prevent development of complications and the visceral form of disease. Based on our experience with development of chickenpox, we suggest active immunization for all seronegative patients before organ transplantation.

Visceral leishmaniasis reactivation in transplant patients: a minireview with report of a new case

An updated review of cases of reactivated visceral leishmaniasis (VL) in transplant patients is presented, with a new report of a kidney transplant patient who had VL caused by reactivation of a dormant infection contracted 21 years previously. Close to the time of disease reactivation, the patient had a primary varicella-zoster infection.

Disseminated Cutaneous Varicella Zoster Virus Infections During Infliximab Therapy for Crohn’s Disease: Case Report of Two Pediatric Patients at One Institution

Infliximab is a monoclonal antibody against tumor necrosis factor-a (TNF-a) that has been approved for the treatment of rheumatoid arthritis and Crohn’s disease. It is used in steroid-sparing regimens for patients who have had an inadequate response to conventional therapy. There are a number of studies that have shown an increased risk of infections with bacteria, fungi, mycobacterium, and more recently, chronic viral infections in patients receiving TNF-a antagonists. We report 2 cases of pediatric patients on infliximab therapy for Crohn’s disease who presented with disseminated cutaneous varicella zoster and primary varicella infections. Despite prompt and appropriate antiviral therapy both patients continued to manifest clinical findings of varicella zoster virus (VZV) infection and ultimately required hospitalization.

Novel management of post varicella purpura fulminans owing to severe acquired protein S deficiency

Acquired protein S deficiency is a rare complication of varicella zoster infection often resulting in purpura fulminans, which is a potentially life-threatening syndrome of intravascular thrombosis and haemorrhagic infarction of the skin. Patients are presumed to develop crossreacting autoantibodies to the virus and protein S. There is no consensus on how best to manage these patients but previous recommendations focus on plasmapheresis and plasma exchange. We report the case of a 3-year-old girl with post varicella purpura fulminans owing to protein S deficiency, who was diagnosed promptly and made a full recovery following immediate treatment with anticoagulation and plasma support. This suggests that if anticoagulation is used, plasma exchange is not always necessary. As recovery occurred without plasmapheresis, we were able to track protein S levels. The timing of protein S recovery was consistent with the waning titre of an acquired immunoglobulin G autoantibody.

Primary varicella-zoster infection in patients on biologic therapies for psoriasis

Primary varicella-zoster infection in patients on biologic therapies for psoriasis

Varicella Zoster Virus (VZV) in Solid Organ Transplant Recipients

-herpesvirus family. VZV is presentworldwide and is highly infectious. Primary infection leadsto acute varicella or ‘chickenpox,’ usually from exposureeither through direct contact with a skin lesion or throughairborne spread from respiratory droplets (1,2). After initialinfection, VZV establishes lifelong latency in cranial nerveanddorsalrootganglia,andcanreactivateyearstodecadeslater as herpes zoster (HZ) or ‘shingles’ (3). More than90% of adults in the United States acquired the disease inchildhood, while the majority of children and young adultshave been vaccinated with the live virus vaccine (2,4).Primary varicella typically presents with fever, constitu-tional symptoms and a vesicular, pruritic, widely dissem-inated rash that primarily involves the trunk and face (5).Thesymptomsusuallyresolvewithin7–10days,butinrarecases primary varicella leads to more severe disease andvisceral invasion. Complications, such as hepatitis, pancre-atitis, pneumonitis and encephalitis are infrequent but canbelife-threatening;adultsandveryyoungchildrenaremorelikely to develop such complications from primary infection(6,7). Rates of hospitalization and mortality due to varicellahave dropped with the institution of routine childhood vari-cella vaccination (8,9).Nearly all patients with HZ develop an exanthem of vesic-ular lesions in a dermatomal distribution. The annual inci-dence of HZ in the general population is 1.5–3.0 cases per1000 persons (2), and is estimated to occur in up to 20%of individuals during their lifetime (10). Secondary compli-cations such as bacterial superinfection and postherpeticneuralgia (PHN), or chronic neuropathic pain at the site ofHZ, lead to increased morbidity (11).Over 90% of adult solid organ transplant (SOT) recipientswill be seropositive for VZV. Rates are lower in pediatrictransplants(12,13),butimmunitywillincreaseasuptakeofvaricella vaccine improves. Varicella is rare in adult SOT re-cipients,butcanbedevastating,withvisceralinvolvement,severe skin disease, and disseminated intravascular coag-ulation (14–19). HZ is a frequent infectious complication inSOT recipients with an incidence of approximately 8–11%during the first 4 years posttransplant (20–22). Invasive dis-ease and dissemination similar to that seen in primary VZVinfection are uncommon but have been reported in SOTand other immunocompromised populations, and level ofimmunosuppression may alter the risk of developing thesecomplications (17,23,24). Rates of PHN in SOT recipi-ents may also be higher than in immunocompetent popu-lations (22).

Laryngeal Mass with Multiple Cranial Neuropathies as a Presenting Sign for Varicella Zoster Infection

The most common presentation of varicella zoster virus (VZV) infection is unilateral distribution of herpetic eruptions and neuralgia. Laryngeal involvement is considered very rare.

Necrosis of nose skin after varicella zoster infection: A case report

Varicella zoster virus (VZV) is the causal agent of varicella (chickenpox) and herpes zoster (shingles). Primary VZV infection is a common childhood disease, but elderly patients and those having a compromised immune system are also at risk. We present the case of progressive necrosis of the nose skin in a patient with a compromised immune system and a generalised VZV infection. During the course of his hospital stay and follow-up, the lesion gradually improved with conservative treatment.

Disseminated varicella zoster infection in a patient with rheumatoid arthritis treated with methotrexate

Conflict of interest: none declared. Methotrexate is among the most commonly used systemic agents in dermatology and rheumatology. It was first introduced approximately 50 years ago for the treatment of psoriasis.1 As with other immunosuppressants, a major concern about the use of methotrexate is the occurrence of potentially life‐threatening side‐effects. We report a case of disseminated varicella zoster virus (VZV) infection in a patient with rheumatoid arthritis (RA) treated with methotrexate. A 58‐year‐old woman with RA presented with a rash on the right forehead and a 17‐day history of right‐sided scalp pain radiating to the right jawline. She had been started on oral antibiotics for presumed cellulitis by her general practitioner and subsequently changed over to aciclovir 800 mg five times a day for herpes zoster virus (HZV) infection. She had been diagnosed with early rheumatoid arthritis 5 months before presentation to us and had been started on methotrexate at a dose of 10 mg/week, which had led to an improvement in her RA.

A case of colonic mantle cell lymphoma: new insights in a rare disease

An 82-year-old man was referred to our outpatient clinic because of a change in bowel habits and involuntary weight loss. His medical history consisted of atrial fibrillation. A few weeks before presentation he had suffered a varicella zoster infection of his face. A colonoscopy was performed to rule out colorectal carcinoma. Dozens of small sessile polyps, varying in size, were found in the entire colon ([Fig. 1]). The mucosa in the rectosigmoid region was diffusely swollen and polypous with multiple superficial ulcerations ([Fig. 2]). Biopsies of proximal and distal lesions revealed a mononuclear infiltration between muscularis mucosae and otherwise normal-appearing crypts. Lymphocytes showed nuclear irregularity. Immunohistochemistry showed positivity for CD5, CD20, CD43, CD79a, Bcl-2, and cyclin-D1 ([Fig. 3]). Stainings for CD10, CD15, CD30, CD138, IgA, IgG, and IgM were negative. This profile supports the diagnosis of a mantle cell lymphoma (MCL). Unfortunately, the patient suffered an ischemic cerebrovascular accident (CVA) the day after colonoscopy, 6 days after stopping anticoagulants temporarily, leaving him hemiplegic and bedridden. For this reason, it was decided to refrain from starting systemic chemotherapy. His recent varicella zoster infection was considered a paraneoplastic phenomenon. The patient died 6 weeks after diagnosis of complications of his CVA.

Acute pancreatitis associated with varicella infection in an immunocompetent child

Acute pancreatitis associated with varicella-zoster infection is a rare event, particularly in immunocompetent children. We report on a case of acute pancreatitis in a 6-year old girl presenting with acute abdominal pain less than 72 hours after the onset of a typical vesicular rash. The diagnosis was confirmed through hyperamylasaemia, ultrasonographic findings of oedematous pancreatitis and acute seroconversion to varicella-zoster virus, after excluding more common causes of acute pancreatitis. Conservative treatment was initiated, with complete resolution of symptoms and absence of local or systemic complications on follow up. A review of the literature revealed only three previously reported cases, with very different outcomes, highlighting the need to consider this potentially fatal complication in every child presenting with acute abdominal pain during the course of varicella disease.

Bilateral Retrobulbar Neuritis Due to Varicella Zoster Preceding Retinal Necrosis in a Patient with AIDS

Objective: The purpose of this study is to describe a case report of varicella zoster (VZV) infection presenting as bilateral retrobulbar neuritis affecting optic tracts, chiasm, and bilateral optic nerves preceding bilateral progressive outer retinal necrosis in a single patient with AIDS.Methods:The clinical course of a single patient with confirmed VZV infection will be described including presentation, diagnosis, and treatment.Results:The affected patient presented with acute, bilateral vision loss, and headache. The patient’s history was devoid of past, concurrent, or subsequent development of herpes zoster dermatitis. The patient lacked signs of meningeal irritation or infection. Diagnosis of VZV arachnoiditis and retrobulbar optic neuritis were confirmed by radiological and CSF examination and preceded the clinical identification of retinal involvement. Despite early, aggressive treatment with intravenous antiviral and steroids, as well as intravitreal antiviral therapy, complete bilateral visual loss resulted.Conclusion: Varicella zoster continues to present uniquely in patients with acquired immune deficiency syndrome. Absence of retinal involvement doesn’t rule out retrobulbar visual pathways involvement by VZV. The astute clinician should be aware of this presentation and suspect the involvement of varicella zoster in immunocompromised patients presenting with retrobulbar optic neuritis and meningeal involvement with normal fundus exam.

Mechanisms Associated with HIV-1 Resistance to Acyclovir by the V75I Mutation in Reverse Transcriptase

It has recently been demonstrated that the anti-herpetic drug acyclovir (ACV) also displays antiviral activity against the human immunodeficiency virus type 1 (HIV-1). The triphosphate form of ACV is accepted by HIV-1 reverse transcriptase (RT), and subsequent incorporation leads to classical chain termination. Like all approved nucleoside analogue RT inhibitors (NRTIs), the selective pressure of ACV is associated with the emergence of resistance. The V75I mutation in HIV-1 RT appears to be dominant in this regard. By itself, this mutation is usually not associated with resistance to currently approved NRTIs. Here we studied the underlying biochemical mechanism. We demonstrate that V75I is also selected under the selective pressure of a monophosphorylated prodrug that was designed to bypass the bottleneck in drug activation to the triphosphate form (ACV-TP). Pre-steady-state kinetics reveal that V75I discriminates against the inhibitor at the level of catalysis, whereas binding of the inhibitor remains largely unaffected. The incorporated ACV-monophosphate (ACV-MP) is vulnerable to excision in the presence of the pyrophosphate donor ATP. V75I compromises binding of the next nucleotide that can otherwise provide a certain degree of protection from excision. Collectively, the results of this study suggest that ACV is sensitive to two different resistance pathways, which warrants further investigation regarding the detailed resistance profile of ACV. Such studies will be crucial in assessing the potential clinical utility of ACV and its derivatives in combination with established NRTIs.

Brachial neuritis caused by varicella-zoster diagnosed by changes in brachial plexus on MRI

Brachial neuritis is a rare disorder affecting the brachial plexus. It is characterized by the acute onset of shoulder and arm pain followed by weakness, sensory loss and atrophy. Diagnosis is essentially clinical with electrophysiological investigations and imaging useful in excluding other differentials and supporting the diagnosis. Magnetic resonance imaging (MRI) usually does not show any pathology in the brachial plexus or spinal cord. We present a case of a patient who had brachial neuritis preceded by varicella zoster infection. This was supported by MRI which showed abnormal signal consistent with inflammatory changes in the brachial plexus.

Adult Varicella Zoster Infection Complicated with Streptococcal Retrosternal Abscess

A 43-year-old lady with type 2 diabetes mellitus and bronchial asthma presented with varicella zoster infection, dyspnea, and neck fullness. An urgent computed tomography scan revealed a mediastinal abscess with superior vena cava thrombus. Blood, mediastinal pus, and swab from a vesiculopustule on the neck cultured group A beta hemolytic Streptococcus. She recovered with a combination of broad spectrum antimicrobials, antivirals, and surgical drainage. This case illustrates the rare occurrence of mediastinal abscess and acute superior vena cava obstruction caused by group A beta hemolytic Streptococcus complicating adult varicella zoster.

Susceptibility of New Entrant University Students in Sri Lanka to Varicella Zoster Infection

To investigate the susceptibility of Sri Lankan new entry university students to varicella zoster virus (VZV) infection, a cross-sectional descriptive study was carried out among new entrant medical and engineering students of the University of Peradeniya, Sri Lanka. Self-reported history of chicken pox was studied first, followed by serological evaluation for VZV IgG antibodies. A total of 451 students participated in the study out of which 189 (41.9%) reported a history of chicken pox. Median age of reported age of acquiring the disease was 14 years with an interquartile range of 10 to 17 years. Only 25% of the population reported history of infection prior to age of 10 years. The seropositive rate of VZV IgG antibodies among undergraduates with a negative history of chicken pox was 10.1% ( 25/247). The present study indicates that nearly half (222/436) of the study population (50.9%, 95% CI 46.2-55.6) was susceptible to VZV infection.

Hepatocellular Carcinoma in 2 Young Adolescents With Chronic Hepatitis C

Hepatocellular Carcinoma in 2 Young Adolescents With Chronic Hepatitis C

Atypical varicella zoster infection associated with hemophagocytic lymphohistiocytosis

Two adolescents, on immunosuppressive therapy for graft-versus-host disease, developed hemophagocytic lymphohistiocytosis (HLH) after varicella zoster virus (VZV) reactivation. In the absence of dermatome restricted characteristic skin lesions, VZV reactivation was not immediately recognized and treatment with acyclovir was delayed. The first patient developed optical neuritis and died 2 months after the VZV episode due to massive intracranial hemorrhage. The second patient presented with severe abdominal pain and pancreatitis, followed by atypical skin eruptions, which prompted a faster diagnosis. Both patients recovered from their HLH, the first patient being successfully treated with immunosuppressive agents and the second with VZV treatment only. These two cases demonstrate the difficulties in recognizing VZV reactivation, and in order to start adequate and timely treatment, the need to consider VZV as a possible cause of HLH in severely immunocompromised patients.