Varicella Zoster Infection Research Articles

Síndrome de necrosis retiniana aguda tras primoinfección por varicela

A 34-year-old male patient developed acute retinal necrosis in his left eye about three weeks after the onset of chickenpox. Systemic antiviral treatment with intravenous acyclovir (10 mg/kg/8 hours) and systemic corticosteroids (1 mg/kg/day) controlled the retinitis and the patient suffered no loss of visual acuity. Acute retinal necrosis is an unusual complication of chickenpox. A mild form of this entity has been described during the course of primary varicella-zoster infection. Adequate and early therapy during the acute phase of the disease with intravenous acyclovir and systemic corticosteroids is recommended to achieve a satisfactory visual acuity and prevent complications.

Prevalence of varicella‐zoster antibodies in pregnant women in Catalonia (Spain). Rationale for varicella vaccination of women of childbearing age

The objective of this study was to determine the prevalence of antibodies against varicella-zoster virus (VZV) in pregnant women in Catalonia (Spain). The prevalence of antibodies against VZV was assessed in a representative sample (n = 1522) of pregnant women of Catalonia obtained in 2003. The sample was obtained including all women attended for childbirth, during 2 months of 2003, in 27 randomly selected hospitals with maternity clinics. Varicella-zoster antibodies were determined using the enzyme-linked immunosorbent assay test. The total number of women included in the study was 1522, corresponding to a participation rate of 83%. The prevalence of varicella-zoster antibodies in pregnant women was 96.1% (95% CI 95.1-97.1). The prevalence of antibodies was 94% in pregnant women aged 15-24 years, 95% in those aged 25-29 years and >95% in those aged 30-49 years. The prevalence of antibodies was not associated to the place of birth, place of residence (urban or rural), educational level and social class. The study showed that 6% of pregnant women aged 15-24 years and 5% of those aged 25-29 years were susceptible to varicella-zoster infections in Catalonia (Spain). The study showed that a varicella-zoster vaccination programme aimed at women of childbearing age could be necessary in Catalonia to prevent all varicella-zoster infections during pregnancy.

Rituximab-induced viral infections in lymphoma patients

18509 Background: Recently, a chimeric mouse human monoclonal antibody, rituximab, has been used successfully to treat cases of B-cell non-Hodgkin’s lymphoma (NHL) and some autoimmune diseases. However, several viral infections related to rituximab have been reported in literature, but not well characterized. Methods: To further investigate this topic, relevant English language studies were identified through Medline. For our search we used the generic name rituximab, and the key phrases virus/virus infection. The references from the identified articles were reviewed for additional sources. Results: There were 64 previously reported cases (26 male, 23 female, and 15 gender not reported) that had experienced serious viral infection after rituximab treatment. The median age of the cases was 61 years (range; 21–79 years). The median time period from the start of rituximab treatment to viral infection diagnosis was 5.0 months (range, 1–20). Most frequently experienced viral infections were hepatitis B virus infection in 25 (39.1%) cases, Cytomegalovirus infection in 15 (23.4%) cases, varicella zoster infection in 6 (9.4%) cases, and other viral infections in 18 (28.1%) cases. Thirteen (52.0%) of the patients with hepatitis B virus infection died due to hepatic failure. Thirty-nine of the cases had viral infections other than HBV and 13 of them died due to these specific infections. Conclusions: Viral infections after the rituximab treatment in lymphoma patients are important to recognize and treat early because of their association with substantial morbidity and mortality. In these case series, about 40% of these viral infections resulted in death. Close monitoring for viral infections in patients receiving rituximab is necessary. [Table: see text] No significant financial relationships to disclose.

Cholesterol Dependence of Varicella-Zoster Virion Entry into Target Cells

The entry of inhaled virions into airway cells is presumably the initiating step of varicella-zoster infection. In order to characterize viral entry, we studied the relative roles played by lipid rafts and clathrin-mediated transport. Virus and target cells were pretreated with agents designed to perturb selected aspects of endocytosis and membrane composition, and the effects of these perturbations on infectious focus formation were monitored. Infectivity was exquisitely sensitive to methyl-beta-cyclodextrin (M beta CD) and nystatin, which disrupt lipid rafts by removing cholesterol. These agents inhibited infection by enveloped, but not cell-associated, varicella-zoster virus (VZV) in a dose-dependent manner and exerted these effects on both target cell and viral membranes. Inhibition by M beta CD, which could be reversed by cholesterol replenishment, rapidly declined as a function of time after exposure of target cells to VZV, suggesting that an early step in viral infection requires cholesterol. No effect of cholesterol depletion, however, was seen on viral binding; moreover, there was no reduction in the surface expression or internalization of mannose 6-phosphate receptors, which are required for VZV entry. Viral entry was energy dependent and showed concentration-dependent inhibition by chlorpromazine, which, among other actions, blocks clathrin-mediated endocytosis. These data suggest that both membrane lipid composition and clathrin-mediated transport are critical for VZV entry. Lipid rafts are likely to contribute directly to viral envelope integrity and, in the host membrane, may influence endocytosis, evoke downstream signaling, and/or facilitate membrane fusion.

Managing varicella zoster infection in pregnancy.

Varicella zoster virus (VZV) infection can be serious for pregnant women and their babies, although it is rare. The implications of primary VZV infection vary with the gestational age at infection. For the mother, the risk of severe illness is greatest after mid-pregnancy, when she is relatively immunocompromised. For the fetus, the risk of congenital infection is greatest when maternal infection occurs in the first or second trimester. Maternal infection is preventable by preconception vaccination.

Quantification of Circulating Varicella-Zoster Virus DNA for Follow-up in a Case of Visceral Varicella-Zoster Infection Ameliorated with Intravenous Acyclovir

We describe a patient with acute lymphocytic leukemia (ALL) who developed visceral varicella-zoster virus (VZV) infection following cord blood stem cell transplantation (CBSCT) and was successfully treated with intravenous acyclovir (ACV). A 24-year-old woman with ALL developed severe epigastric pain 168 days after CBSCT, followed by blistering eruptions 2 days later. A diagnosis of visceral varicella-zoster disease was made, and early intravenous ACV therapy successfully alleviated the epigastric pain and skin lesions within 2 weeks. Polymerase chain reaction analysis of the serum showed dramatic decreases in the viral DNA copy number and revealed large viral concentrations prior to the skin manifestations. The viral DNA copy number in whole blood remained positive, however, but was reduced. Further treatment with intravenous ACV led to VZV DNA becoming undetectable in whole blood, a result not achieved with oral valacyclovir.

Surveillance of varicella and herpes zoster in Slovenia, 1996 – 2005

In Slovenia, varicella and herpes zoster infections are case-based mandatorily notifiable diseases. We present surveillance data for a period of ten years (1996 - 2005). Incidences of varicella ranged from 456 to 777 per 100 000 population in all age groups. As many as 75% of varicella cases reported were in pre-school children, with children aged three and four years being most affected. The incidence of varicella increased between October and January and was lowest in August and September; the seasonal pattern matches patterns in the school calendar. Herpes zoster was declared a reportable disease in 1995. In 2005, 1627 cases were notified (81.3/100 000). Female cases outnumbered male. The highest incidence of herpes zoster was noted in elderly individuals over 70 years of age. Complications, such as zoster meningitis and meningoencephalitis, were rarely reported (3.05/1 000 000).

Famciclovir or valaciclovir in the management of herpes simplex and varicella zoster infections: an attitudinal survey of clinician perceptions of differential activity

Herpes virus infections impose considerable morbidity in immunocompetent patients, with 22% of adults in developed countries having been infected with herpes simplex virus 2 (HSV-2) and four cases per 1000 individuals of symptomatic varicella zoster virus (VZV) infections estimated per year.1,2 Symptoms from both HSV and VZV can be effectively reduced with acyclovir therapy. More recently valaciclovir (GlaxoSmithKline, Brentford, London, UK) and famciclovir (Novartis, Basel, Switzerland) have shown similar efficacy in these conditions, with more favourable dosing schedules than acyclovir.3–6 The usage of these two drugs imposes a considerable financial burden on the public healthcare system, with initial treatment courses for HSV costing $A104.51 for valaciclovir and $A135.79 for famciclovir compared to $A89.31 for acyclovir – see http://www.pbs.gov. au/html/healthpro/search/ (accessed 26 April 2007). The Australian Health Insurance Commission spent $A27 816 155 and $A41 761 426 on famciclovir and valaciclovir respectively in the last financial year for HVS-2 and VZV management – see http://www.medicareaustralia.gov.au/statistics/ (accessed 26 April 2007). We therefore sought to determine if there was a perception of differential efficacy between these two commonly prescribed drugs and to determine which clinical characteristics might influence prescribing. In September 2003, an attitudinal survey was undertaken involving 632 metropolitan based primary care clinicians across Australia. The survey questions were prepared by the authors based on published clinical variables that might influence treatment responses, with the survey delivered to clinicians by product representatives from Novartis. The following research questions were asked: ‘Did the clinician believe that either famciclovir or valaciclovir had greater efficacy in certain patients?’ and ‘If so, what patient characteristics were thought to account for this difference (e.g. age, gender, number of episodes, severity or others)?’ This question was asked separately for patients with genital herpes and herpes zoster. Responses were collected by the product representatives within the following 2 weeks and forwarded to the authors for analysis.

Immune Reconstitution Syndrome Presenting With Cerebral Varicella Zoster Vasculitis in HIV-1-Infected Patient: A Case Report

Neurologic dysfunction complicating HIV infection may occur in up to 70% of AIDS patients. The advent of highly active antiretroviral therapy has reduced central nervous system opportunistic infections. Immune reconstitutions after highly active antiretroviral therapy also lead to atypical presentations of neurologic opportunistic infections. We report a man who developed an encephalitic illness 10 months after institution of highly active antiretroviral therapy and improvement in his CD4 count. Varicella zoster vasculitis involving the brain was suspected. Acyclovir therapy resulted in complete clinical and radiologic recovery. Symptomatic reactivation of varicella zoster infection within the encephalon during therapeutic immunologic reconstitution is rare and should be suspected, especially in patients with neurologic syndrome consistent with encephalitis with recent history of herpes zoster and multiple, discrete areas of infarct or demyelination on brain magnetic resonance imaging. The clinical and neuroradiologic features of this condition and its relevance to the immune reconstitution syndrome are discussed.

Constant Pain Following Treatment of Herpes Esophagitis

HSV esophagitis, first reported in 1940, is typically caused by herpes simplex virus type-I (HSV-I) and less frequently by HSV-II. It usually occurs in immunocomprimised hosts such as patients on immunosuppressive therapy, patients with hematological malignancies or patients with AIDs. However, it has also been reported in immnunocompetent hosts and is usually self-limiting. Although approximately 10 to 15 percent of all patients with herpes zoster will develop postherpetic neuralgia (PHN), the phenomenon has never been reported in the literature following HSV esophagitis. Case: A 46-year-old male physician with gastroesophageal reflux disease (GERD) and pharyngeal pemphigus vulgaris on immunosuppressive therapy consisting of 45 mg of prednisone per day presented to the emergency room with one week of epigastric pain which increased in intensity after food consumption. The pain was sharp, constant, with no radiation, not relieved by esomeprazole, sucralfate and antacids. Odynophagia and dysphagia secondary to oropharyngeal pemphigus vulgaris had not changed from baseline. Upper endoscopy revealed multiple erosions with exudates at the vocal cord area and aryepiglottic folds, consistent with pemphigus vulgaris. Two irregular but sharply demarcated ulcers with white exudates were seen in the distal esophagus, the adjacent mucosa appeared normal. Biopsy of the ulcers showed severe acute herpes esophagitis with ulceration. Immunostain was positive for HSV I/II. The patient was treated with acyclovir 400mg orally 5 times a day without significant relief of pain. He was then switched to famciclovir. Two weeks later, due to continued reports of pain with oral intake, a repeat upper endoscopy revealed a normal esophagus and biopsies taken at the time of the procedure were free of infection. Additional work-up for other causes of pain were unrevealing. The patient's pain continued for 5 months before regression and improvement. PHN has traditionally been defined as the persistence of pain for more than one month after the disappearance of rash or lesions associated with varicella zoster infection. Based on our patient's persistence of pain despite treatment and visual resolution of herpetic lesions, we feel that this case represents the first report of postherpetic neuralgia following herpes esophagitis.

Fatal outcome of varicella zoster sepsis in a 22-year old patient

ZusammenfassungEine Infektion mit dem Herpesvirus Varizella-Zoster betrifft vor allem Kinder bis zum 15. Lebensjahr und ist hier mit einem in der Regel harmlosen Verlauf vergesellschaftet. Wir berichten in dieser Kasuistik über eine Varizella-Zoster-Infektion bei einem 22-jährigen Mann, die einen fatalen Verlauf nahm. Der Patient entwickelte eine schwere Hepatitis mit akutem Leberversagen sowie ein akutes Lungenversagen (ARDS). Neben einer Übersicht über die Erkrankung im Allgemeinen werden der Krankheitsverlauf sowie die dargestellten Behandlungsmethoden im Zusammenhang mit einer Literaturdarstellung diskutiert.

Varicella vaccines and measles, mumps, rubella, and varicella vaccine

To present an up-to-date review of studies investigating the efficacy, adverse events and vaccination regimens of the varicella vaccine and the new presentation combined with the vaccine for measles, mumps and rubella. Bibliographic review of the MEDLINE and LILACS databases covering the period 1999 to 2006. The varicella vaccine protects 70 to 90% of immunized children against any form of varicella zoster infection, but the efficacy against severe forms is higher (95 to 98%). This is a well-tolerated vaccine that causes few reactions. Since the vaccine was licensed, there have been three confirmed cases of transmission of the vaccine virus by domestic contacts to previously healthy people, who went on to develop mild disease. Despite evidence that the protection offered by this vaccine can wane over a number of years, it is not yet possible to state that a second dose is warranted, bearing in mind exposure to wild virus. After universal vaccination the chances of natural stimulation should drop and it is very probable that booster doses will become necessary. A measles, mumps, rubella, and varicella vaccine has recently been licensed that combines vaccines for measles, mumps, rubella and varicella in a single product with high rates of seroconversion. The Brazilian Society of Pediatrics recommends the varicella vaccine for children from 1 year on. We hope that the measles, mumps, rubella, and varicella vaccine will soon be available in Brazil, since combined vaccines facilitate wider vaccination coverage.

Delayed facial nerve palsy following tympano-mastoid surgery: incidence, aetiology and prognosis

To establish the frequency of occurrence of delayed facial nerve paralysis following tympano-mastoid surgery in our department and to determine the aetiological factors and long term prognosis. Tertiary care academic centre. A retrospective review of all patients who had undergone tympano-mastoid surgery in our department over the previous five years was carried out. A total of 219 patients were included in the study. Only two patients were identified as having delayed onset facial nerve palsy over this period of time. The patients' medical records were reviewed and the patients clinically assessed. The frequency of delayed onset facial nerve palsy following tympano-mastoid surgery in our series was 0.91 per cent. Facial weakness set in on day eight and day 14 in the two patients. Serological investigations in both patients revealed raised titres of immunoglobulin (Ig) M and IgG to varicella-zoster virus, confirming the presence of varicella-zoster infection. In our experience, the combined use of prednisone and acyclovir was an effective form of treatment for both patients, whose facial nerve function fully recovered within six months of onset. The incidence of delayed facial nerve palsy following tympano-mastoid surgery is low. It can occur up to two weeks after the surgery. Our two cases confirm viral reactivation to be an important aetiological factor in the development of delayed onset facial nerve palsy. The overall prognosis for delayed facial nerve palsy following tympano-mastoid surgery appears to be good.

Rituximab long-term maintenance therapy after autologous stem cell transplantation in patients with B-cell non-Hodgkin’s lymphoma

Treatment of B-cell non-Hodgkin's lymphomas (NHL) with either Rituximab alone or in combination with cytotoxic chemotherapy has been effective without major side effects. Thus, Rituximab maintenance therapy after autologous peripheral blood stem cell transplantation (PBSCT) might represent an improvement in NHL therapy. We therefore retrospectively analyzed the efficacy and side effects of monthly long-term Rituximab maintenance therapy after PBSCT in 27 patients with NHL. In median 10 infusions of Rituximab were given after PBSCT in time intervals of 1 month. Molecular monitoring of t(14;18) was performed using nested as well as quantitative real time polymerase chain reaction (RT-PCR) based on the LightCycler technology. Side effects according to common toxicity criteria (CTC) > II did mainly affect the hematopoietic system. In total, 10 patients (37%) suffered form grade III-IV hematotoxicity. Except for two patients with cutaneous Varicella-Zoster infection no serious infectious complications (CTC grade III/IV) occurred. No patient died because of treatment-related causes. This adverse event data compared favorably to the published data. Three patients had t(14;18) nested RT-PCR positive results before Rituximab therapy and converted to negativity after Rituximab therapy. We conclude that a prolonged Rituximab maintenance therapy after PBSCT with monthly administration is reliable and safe.

Acquired intestinal aganglionosis after a lytic infection with varicella-zoster virus

Background and Purpose In this report, we present the first case of an immunologically impaired child surviving a lytic varicella-zoster virus infection affecting the enteric nervous system. In histological findings, myenteric and submucous enteric ganglia were nearly completely absent owing to virus infection. Methods A 3-year-old girl with acute lymphoblastic leukemia and generalized varicella-zoster infection developed an ileus. She underwent multiple laparotomies in which histological sections of the entire small intestine could be obtained. Results The histological evaluation of these samples showed a generalized aganglionosis with inflammatory residuals. A more detailed immunohistochemical analysis using neuronal (PGP, enolase), glial (S100), and lymphocytic (LCA) antibodies demonstrated a nearly complete neuronal loss. Conclusion To our knowledge, this is the first case of a secondary intestinal aganglionosis after varicella-zoster virus infection.

Remission of rheumatoid arthritis after acute disseminated varicella-zoster infection

A 65-year-old immunocompetent male presented with symmetric polyarthritis of 12 weeks and paresthesias in the distribution of the left median nerve distribution of 4 weeks duration. He had tender joint count of 20 and swollen joint count of 12. He was positive for rheumatoid factor and his erythrocyte sedimentation rate was 52 mm. Nerve conduction study demonstrated polyneuropathy. Radiographs showed severe juxta articular osteopenia at the wrist and the metacarpophalangeal joints. He received methotrexate of 10 mg/week and prednisolone of 0.15 mg/kg/day along with nonsteroidal antiinflammatory drugs (NSAIDs) with a diagnosis of seropositive rheumatoid arthritis (RA). Thirteen weeks after therapy, he presented to the outpatient clinic with disseminated vesicular eruptions all over his body with erythematous base and pneumonia involving the left upper lobe. Tzanck smear from the lesions and serology (IgG) for varicella-virus infection were positive. A diagnosis of acute disseminated varicella zoster with pneumonia was made. The patient improved on parenteral acyclovir and broad-spectrum antibiotics. With the improvement in rash and pneumonia after 2 weeks, the patient noticed a marked improvement in the joint symptoms. Arthritis remained in remission without the need for any disease-modifying drug or NSAID for next the 24 months and continued to be so until the last follow-up. Our case presents a unique phenomenon of RA remission after disseminated varicella-zoster infection in an immunocompetent individual.

Necrotizing Scleritis due to Varicella Zoster Infection: A Case Report

Purpose: To report a case with necrotizing scleritis due to varicella-zoster infection. Methods: The patient records were evaluated. The present literature was investigated using MEDLINE. A six-year-old boy with varicella infection was admitted to our clinic with redness, pain, and lid edema on the right eye. Slit lamp examination revealed lid edema, purulent secretion, conjunctival injection and chemosis, and inferotemporal scleral necrosis. Sclera was avascular and the conjunctiva was spontaneously detached from sclera in the necrotic region. Results: Systemic and topical acyclovir treatment was started and a rapid improvement achieved in signs and symptoms. Conclusions: Ophthalmic manifestations of varicella infection are potentially blinding especially in the absence of appropriate diagnosis and medical intervention. Distinctive skin eruptions are specifically helpful in the early diagnosis of the disease.

下位脳神経障害をきたした帯状庖疹の1例

下位脳神経障害をきたした帯状庖疹の1例

Varicella-Zoster Virus Attacked Successfully on Two Fronts

The benefits of varicella immunization were characterized in considerable detail in 2005, and another form of varicella-zoster infection, shingles, was

Improvement of cervico–trunco–brachial segmental dystonia with topiramate

Sirs: Topiramate (Topamax, Ortho-McNeil Pharmaceuticals, Raritan, NJ), a sulfamate-substituted monosaccharide, was approved in 1995 (1996 in the United States) for the treatment of epileptic disorders (including epileptic myoclonus [9]). Since then it was also approved for the prevention of migraine and its off label use has gained popularity as a weight reduction agent, in the treatment bipolar disorder [10], neuropathic pain [4] and in hyperkinetic movement disorders [3]. We report a patient with segmental cervicotrunco-brachial dystonia who experienced symptomatic benefit after treatment with topiramate. A 47-year-old ambidextrous male was initially evaluated in our Movement Disorders clinic (at the age of 40 years) for administration of botulinum toxin injections for his segmental dystonia which started about the age of 8 following a varicella-zoster viral infection. His dystonic symptoms involved the neck and shoulder muscles as well as the trunk and both upper extremities (left > right). His abnormal movements consisted of side-to-side trunk flexion associated with mild-moderate head tremors, shoulder elevation and action-induced upper limb dystonia of moderate intensity, mainly of the extensors of the wrist (left > right). The neck and shoulder dystonia has been highly responsive to botulinum toxin injections (usually about 300 units in both trapezius and splenius capitis and right sternocleidomastoid muscles) which had been given continuously since the age of 35 (every 4 months). The patient has also tried different combinations of lorazepam, clonazepam, propranolol, sodium valproate and baclofen with mild symptomatic benefit. He has a family history in which his sister has laryngeal dystonia and his father suffers from Parkinson’s disease. However, no genetic tests were performed. Neurological examination has consistently revealed trunk flexion movements associated with mild to moderate amplitude head tremors for the most part rotational with a tendency for the head to be mildmoderately rotated to the left, and a moderate left shoulder elevation. When he stretched out the upper extremities, there was mild dystonic posturing of both, left more than right. Sustained postural holding or task performance (writing, eating etc.) elicited dystonic activity of both upper extremities. EEG, brain MRI and copper studies were normal. The patient was gradually started on topiramate (up to 200 mg/day) at the age of 46 and experienced a marked improvement of his trunk and upper limb dystonic component, with marked reduction in trunk flexion and action-induced wrist extension. The patient did not report an improvement of his symptoms at lower doses of topiramate (100 mg–150 mg/day). However, about two months later he started complaining of a significant amount of eye pain associated with eye redness, blurred vision (which was diagnosed as angle closure glaucoma) as well as weight loss and occasional word-finding difficulty. After gradually discontinuing the topiramate all these symptoms (all known side-effects of topiramate [2, 8]) subsided. However, there was considerable deterioration of the dystonic features. There are limited data on the efficacy of topiramate on hyperkinetic movement disorders. It has been found to reduce symptoms of essential [3] and cerebellar tremor [11], and was reported to be effective in single cases of spinal myoclonus [14], Tourette’s syndrome [1] and vascular hemichorea/hemiballism [5]. Furthermore, topiramate has been reported to reduce levodopa-induced dyskinesia (without affecting the antiparkinsonian action of levodopa) in the MPTP-lesioned marmoset model of Parkinson’s disease (PD) [13]. The exact mechanism of action of topiramate in hyperkinetic movement disorders is unknown. It has been postulated that hyperkinetic disorders may be caused by decreased GABAergic transmission in the indirect basal ganglion pathway [7]. Consistent with that theory, it seems reasonable to believe that drugs that increase GABAergic neurotransmission would be beneficial. Topiramate has been proven to enhance GABA activity [12]. Topiramate has also AMPA receptor antagonistic properties [6]. Since overactive AMPA receptormediated transmission has been implicated in the development of hyperkinetic movement disorders (i. e. levodopa-induced dyskinesia) in animal models [13] it could provide a useful treatment for other hyperkinetic movement disorders like dystonia. In summary, there are reports (including the present one) that suggest the possible beneficial role of topiramate in the treatment of hyperkinetic movement disorders. However, one should always be aware of its potential side effects LETTER TO THE EDITORS