Varicella Zoster Infection Research Articles

Risk factors for complicated varicella infection in pediatric oncology patients at a tertiary health care facility in Pakistan

Varicella zoster infection (VZI) is well recognized as a potential cause of morbidity and mortality in immunocompromised pediatric oncology patients (POP). The purpose of this study was to describe the clinical profile and risk factors for complications and outcomes of VZI in POP treated with acyclovir. Medical records of all POP with a discharge diagnosis of VZI over a period of seven years (2005-2011) were reviewed. The demographic features, underlying malignancy, risk factors for VZI, complications, and outcomes were recorded. Thirty-six POP with VZI were identified. Leukemia was the most common underlying malignancy (n = 20, 58.8%), followed by lymphoma (n = 7, 20.6%) and solid organ tumors (n = 7, 20.6%). Most of the cases (41%) were observed in children under five. All patients were treated with acyclovir. Varicella-related complications developed in 10 (29%) patients. The most frequent complication was bloodstream infection (n = 3, 8.8%), followed by pneumonia (n = 2, 5.9%), skin infection (n = 2, 5.9%), hepatitis, renal failure, and encephalitis. Independent risk factors associated with complications were age < five years, weight for age < fifth percentile, delay in seeking care (> seven days after onset of symptoms) and severe neutropenia (ANC < 500/cm). One child died secondary to varicella encephalitis. Our data suggests that young age, poor health-seeking behavior, severe neutropenia, and being underweight are the major risk factors for the development of varicella-related complications in POP in developing countries. These complications could be favorably modified through active immunization of immunocompetent children.

Which dermatological conditions present to an emergency department in australia?

Background/Objectives. There is minimal data available on the types of dermatological conditions which present to tertiary emergency departments (ED). We analysed demographic and clinical features of dermatological presentations to an Australian adult ED. Methods. The St. Vincent's Hospital Melbourne (SVHM) ED database was searched for dermatological presentations between 1 January 2009 and 31 December 2011 by keywords and ICD-10 diagnosis codes. The lists were merged, and the ICD-10 codes were grouped into 55 categories for analysis. Demographic and clinical data for these presentations were then analysed. Results. 123 345 people presented to SVHM ED during the 3-year period. 4817 (3.9%) presented for a primarily dermatological complaint. The most common conditions by ICD-10 diagnosis code were cellulitis (n = 1741, 36.1%), allergy with skin involvement (n = 939, 19.5%), boils/furuncles/pilonidal sinuses (n = 526, 11.1%), eczema/dermatitis (n = 274, 5.7%), and varicella zoster infection (n = 161, 3.3%). Conclusion. The burden of dermatological disease presenting to ED is small but not insignificant. This information may assist in designing dermatological curricula for hospital clinicians and specialty training organisations as well as informing the allocation of dermatological resources to ED.

Aspects of varicella-zoster infection in children

Results Seven children and infants were admitted with a of diagnosis herpes zoster based on clinical judgment. Their ages were between 4 months and 5 years, three of them being infants. None of the children had prior exposure to varicella-zoster virus during gestation or early infancy. One case presented ocular involvement, 6 patients had thoracic form. One of the infants presented a spread of infection to more dermatomes. Two patients presented complications (cardiac and digestive). None of the children were not vaccinated.

Identification of a Receptor for Neuropeptide VGF and Its Role in Neuropathic Pain

VGF (nonacronymic) is a neuropeptide precursor that plays multiple roles in regulation of energy balance, reproduction, hippocampal synaptic plasticity, and pain. Data from a number of pain models showed significant up-regulation of VGF in sensory neurons. TLQP-21, one of the VGF-derived neuropeptides, has been shown to induce a hyperalgesic response when injected subcutaneously into the hind paw of mice. However, the precise role of VGF-derived neuropeptides in neuropathic pain and the molecular identity of the receptor for VGF-derived peptides are yet to be investigated. Here we identified gC1qR, the globular heads of the C1q receptor, as the receptor for TLQP-21 using chemical cross-linking combined with mass spectrometry analysis. TLQP-21 caused an increase in intracellular Ca(2+) levels in rat macrophages and microglia. Inoculation of TLQP-21-stimulated macrophages into rat hind paw caused mechanical hypersensitivity. The increase in intracellular Ca(2+) levels in macrophages was attenuated by either siRNA or neutralizing antibodies against gC1qR. Furthermore, application of the gC1qR-neutralizing antibody to rats with partial sciatic nerve ligation resulted in a delayed onset of nerve injury-associated mechanical hypersensitivity. These results indicate that gC1qR is the receptor for TLQP-21 and plays an important role in chronic pain through activation of macrophages. Because direct association between TLQP-21 and gC1qR is required for activation of macrophages and causes hypersensitivity, disrupting this interaction may be a useful new approach to develop novel analgesics.

Masseteric nerve for reanimation of the smile in short-term facial paralysis

Our aim was to describe our experience with the masseteric nerve in the reanimation of short term facial paralysis. We present our outcomes using a quantitative measurement system and discuss its advantages and disadvantages. Between 2000 and 2012, 23 patients had their facial paralysis reanimated by masseteric-facial coaptation. All patients are presented with complete unilateral paralysis. Their background, the aetiology of the paralysis, and the surgical details were recorded. A retrospective study of movement analysis was made using an automatic optical system (Facial Clima). Commissural excursion and commissural contraction velocity were also recorded. The mean age at reanimation was 43(8) years. The aetiology of the facial paralysis included acoustic neurinoma, fracture of the skull base, schwannoma of the facial nerve, resection of a cholesteatoma, and varicella zoster infection. The mean time duration of facial paralysis was 16(5) months. Follow-up was more than 2 years in all patients except 1 in whom it was 12 months. The mean duration to recovery of tone (as reported by the patient) was 67(11) days. Postoperative commissural excursion was 8(4)mm for the reanimated side and 8(3)mm for the healthy side (p=0.4). Likewise, commissural contraction velocity was 38(10)mm/s for the reanimated side and 43(12)mm/s for the healthy side (p=0.23). Mean percentage of recovery was 92(5)mm for commissural excursion and 79(15)mm/s for commissural contraction velocity. Masseteric nerve transposition is a reliable and reproducible option for the reanimation of short term facial paralysis with reduced donor site morbidity and good symmetry with the opposite healthy side.

Acyclovir-induced nephro- and neurotoxicity: A case report

Introduction: Acyclovir is a highly effective antiviral agent available for treatment of herpes simplex virus and varicella zoster infections. Although acyclovir therapy is usually well tolerated; serious adverse effects such as acute renal failure and neurotoxicity have been reported usually following parenteral administration.

Initiating oral fingolimod treatment in patients with multiple sclerosis

Fingolimod, the first oral disease-modifying therapy (DMT) approved for the treatment of multiple sclerosis (MS) and the only sphingosine 1-phosphate receptor modulator approved for any disease state, represents an important addition to the expanding DMT options for patients with MS. In three large phase III clinical trials, fingolimod 0.5 mg reduced relapses by approximately half compared with either placebo or weekly intramuscular interferon β1a. The risks associated with the use of fingolimod include first-dose bradycardia, macular edema, and elevation of liver enzymes; fingolimod may increase the risk of infections, some serious in nature, and potentially cause fetal harm. Breakthrough disease or intolerance of injectable medications may be factors that influence the initiation of fingolimod. Identification of potential patients suitable for fingolimod treatment requires a thorough understanding of the potential risks and the particular fingolimod indication of the national authority. To minimize risk, recommended baseline assessments that should be made prior to fingolimod initiation include complete blood count, liver transaminase levels, total bilirubin levels, electrocardiogram (ECG), ophthalmologic examination, varicella zoster infection status, and for women, childbearing potential. First-dose observation is required for all patients for at least 6 h, with hourly pulse and blood pressure measurements and ECG before and 6 h after the first dose. In the European Union, continuous telemetry monitoring is recommended. Healthcare providers should be aware of the potential for symptomatic bradycardia and the need for continuous overnight ECG monitoring for those at higher risk for bradycardia. With experience in over 63,000 patients and over 73,000 patient-years of exposure in clinical trials and postmarketing use, the benefits and full safety profile of fingolimod continue to become better elucidated. This information will enable healthcare providers to initiate fingolimod in appropriately selected and screened patients with MS.

Correlated infections: quantifying individual heterogeneity in the spread of infectious diseases.

In this paper, we propose new methods for investigating the extent of heterogeneity in effective contact rates relevant to the transmission of infections. These methods exploit the correlations between ages at infection for different infections within individuals. The methods are developed for serological surveys, which provide accessible individual data on several infections, and are applied to a wide range of infections. We find that childhood infections are often highly correlated within individuals in early childhood, with the correlations persisting into adulthood only for infections sharing a transmission route. We discuss 2 applications of the methods: 1) to making inferences about routes of transmission when these are unknown or uncertain and 2) to estimating epidemiologic parameters such as the basic reproduction number and the critical immunization threshold. Two examples of such applications are presented: elucidating the transmission route of polyomaviruses BK and JC and estimating the basic reproduction number and critical immunization coverage of varicella-zoster infection in Belgium, Italy, Poland, and England and Wales. We speculate that childhood correlations stem from confounding of different transmission routes and represent heterogeneity in childhood circumstances, notably nursery-school attendance. In contrast, it is suggested that correlations in adulthood are route-specific.

Active Shingles Infection as Detected on 18F-FDG PET/CT

We present the case of a 56-year-old male with a history of recurrent follicular lymphoma undergoing chemotherapy with multiple 18F-FDG PET-CT studies at an outside facility. He developed a painful erythematous, pruritic rash in the left back requiring a visit to the emergency room. He was diagnosed and treated for Varicella zoster infection. He then presented to our imaging center 2 months later for a follow up 18F-FDG PET/CT study. Imaging demonstrated a cutaneous band of increased metabolic activity in the upper back following a dermatomal distribution. This was confirmed to be in the same area as the treated Varicella zoster eruption. A subsequent follow up 18F-FDG PET-CT scan 4 months later to confirm tumor resolution demonstrated the abnormal band of uptake in the back had resolved. This case illustrates the significance of being aware of this entity and to distinguish it from metastasis, especially in patients with a known history of malignancy.

Varicella zoster meningitis complicating combined anti-tumor necrosis factor and corticosteroid therapy in Crohn’s disease

Opportunistic viral infections are a well-recognized complication of anti-tumor necrosis factor (TNF) therapy for inflammatory bowel disease (IBD). Cases of severe or atypical varicella zoster virus infection, both primary and latent reactivation, have been described in association with immunosuppression of Crohn's disease (CD) patients. However, central nervous system varicella zoster virus infections have been rarely described, and there are no previous reports of varicella zoster virus meningitis associated with anti-TNF therapy among the CD population. Here, we present the case of a 40-year-old male with severe ileocecal-CD who developed a reactivation of dermatomal herpes zoster after treatment with prednisone and adalimumab. The reactivation presented as debilitating varicella zoster virus meningitis, which was not completely resolved despite aggressive antiviral therapy with prolonged intravenous acyclovir and subsequent oral valacyclovir. This is the first reported case of opportunistic central nervous system varicella zoster infection complicating anti-TNF therapy in the CD population. This paper also reviews the literature on varicella zoster virus infections of immunosuppressed IBD patients and the importance of vaccination prior to initiation of anti-TNF therapy.

Expanding the histologic findings in smallpox‐related post‐vaccinial non‐viral folliculitis

Post-vaccinial non-viral folliculitis has been recognized in the past decade as a new adverse cutaneous reaction to smallpox vaccination. Contrary to more serious smallpox vaccine reactions, post-vaccinial non-viral folliculitis has a benign course and resolves spontaneously within approximately 7 days. We describe additional histopathologic findings associated with post-vaccinial non-viral folliculitis, which has only been described once previously. New findings include the presence of a neutrophilic or lymphohistiocytic infiltrate that is concentrated around the hair follicles. We compare our findings to the follicular nature of varicella and herpes zoster infections, generating the hypothesis of deposition of vaccinia protein within folliculosebaceous units as a potential pathophysiologic mechanism behind post-vaccinial non-viral folliculitis.

Clinical Epidemiology of Chickenpox in Iraq from 2007-2011

Varicella zoster (chickenpox) infection is an acute common disease caused by the varicella zoster virus (VZV). Children are most susceptible to infection. In non-vaccinated populations, primary infection tends to occur at a younger age. In 1998, the World Health Organization (WHO) recommended that routine childhood varicella vaccination be considered in countries where the disease is a relatively important public health and socioeconomic problem, and where high (85 to 90%) and sustained vaccine coverage can be achieved.Aim:1- To determine the trend (occurrence, age and gender distribution, seasonal variation) of registered clinical cases of chickenpox in Iraq from 2007-2011.2- To determine the need for the use of chicken pox vaccine in Iraq and putting a plan for its use accordingly.Methods:Retrospective descriptive study.Results:Frequency of clinical cases shows an obvious rise in the registration of chickenpox cases from 21798 case in 2007 through 59681 in 2008 to 74195 in 2011 with possible outbreaks occurred in 2008 and 2011. Rate of occurrence of clinical chickenpox cases also shows an obvious rise in the occurrence that ranges from 73.41/100000 in 2007 to 222.61/100000 in 2011. The rate in 2008 and 2011 is suggestive of a possible outbreak. Although the total number of chickenpox varies from 2007-2011 but all have shown the same seasonal distribution, being highest in spring (April, May) season. The largest no. recorded was in 2011 (14000 cases in April and May). The lowest no. recorded was in 2007 (4000 cases in April and May).The highest registered number of chickenpox cases was in provinces of Ninawa, Baghdad/russafa, Dihok, Baghdad/karkh, Al-Basrah, As-Sulaymaniyah. Regarding gender distribution there was sustained preponderance for the males over females with nearly the same percentage over the years. Age distribution of the registered cases had shown that most of the cases occurred in those of age 5-14 years (65%), only 1% occur in those >45 years with statistical significance p=0.001.Conclusions:1- There is a rising trend in the registration of clinical chickenpox cases.2- Most cases occur in the age group of less than 15 years. Males are a little bit higher than females.3- The highest frequencies were reported in March, April, and May.4- Most of the cases were registered in Baghdad, Ninawa, Dihok and Al-Basrah.

Pancreas Transplant at Taipei Veterans General Hospital

Background: Insulin-dependent diabetes mellitus (IDDM) or Type 1 diabetes eventually leads to nephropathy, neuropathy, retinopathy and angiopathy after 10 - 30 years. Currently, pancreas transplant is the treatment of choice in tight control of blood sugar for IDDM patients, and further to stabilize, prevent or even to reverse the diabetic complications. According to the International Pancreas Transplant Registry (IPTR) and United Network for Organ Sharing (UNOS), over 25,000 cases of pancreas transplant have been performed worldwide, with an increase of more than 1,600 - 1,800 cases per year, mainly in the USA. The 1-year pancreas graft survival rate is 86.0% and 5-year is 69.8%, very close to those of kidney transplant. Among the whole pancreas transplants, 80% are simultaneous pancreas-kidney transplant (SPK), 15% pancreas after kidney transplant (PAK), and 5% pancreas transplant alone (PTA). Materials: From 2003 to 2011, there were 73 pancreas transplants performed for 69 patients at Taipei Veterans General Hospital, with 27 SPK, 7 PAK, 35 PTA and 4 PBK. Results: The blood sugar usually returned to normal level within 5 hours (median) after revascularization of the pancreas grafts. The fasting blood sugar maintained within normal range thereafter throughout the whole clinical course in most cases. The technical success rate was 95.5%. There were 8 graft loss, due to acute rejection in 1, chronic rejection in 2, technique failure in 3 and 2 died with functioning graft, and 4 of them received another successful re-transplant. All SPK patients are free from dialysis, but 1 primary nonfunction of kidney graft. Post-transplant infection disease included 5 CMV gastroenterocolitis, 1 CMV pneumonia, 4 UTI (urinary Tract Infection), 2 BK virus infection,3 herpes zoster infection, 1 pseudomembraneous colitis, 2 varicella zoster infection, 1 skin infection with MRSA and cryptococcus, 2 bacteria pneumonia, 1 sepsis. Conclusion: Pancreas transplant provided an ideal insulin-free solution for DM, especially IDDM. Pancreas transplant could be performed with similar successful rate of kidney transplant if they were done simultaneously.

Young Boy With Eye Pain

Young Boy With Eye Pain

Diagnosing and managing postherpetic neuralgia.

Postherpetic neuralgia (PHN) represents a potentially debilitating and often undertreated form of neuropathic pain that disproportionately affects vulnerable populations, including the elderly and the immunocompromised. Varicella zoster infection is almost universally prevalent, making prevention of acute herpes zoster (AHZ) infection and prompt diagnosis and aggressive management of PHN of critical importance. Despite the recent development of a herpes zoster vaccine, prevention of AHZ is not yet widespread or discussed in PHN treatment guidelines. Diagnosis of PHN requires consideration of recognized PHN signs and known risk factors, including advanced age, severe prodromal pain, severe rash, and AHZ location on the trigeminal dermatomes or brachial plexus. PHN pain is typically localized, unilateral and chronic, but may be constant, intermittent, spontaneous and/or evoked. PHN is likely to interfere with sleep and daily activities. First-line therapies for PHN include tricyclic antidepressants, gabapentin and pregabalin, and the lidocaine 5 % patch. Second-line therapies include strong and weak opioids and topical capsaicin cream or 8 % patch. Tricyclic antidepressants, gabapentinoids and strong opioids are effective but are also associated with systemic adverse events that may limit their use in many patients, most notably those with significant medical comorbidities or advanced age. Of the topical therapies, the topical lidocaine 5 % patch has proven more effective than capsaicin cream or 8 % patch and has a more rapid onset of action than the other first-line therapies or capsaicin. Given the low systemic drug exposure, adverse events with topical therapies are generally limited to application-site reactions, which are typically mild and transient with lidocaine 5 % patch, but may involve treatment-limiting discomfort with capsaicin cream or 8 % patch. Based on available clinical data, clinicians should consider administering the herpes zoster vaccine to all patients aged 60 years and older. Clinicians treating patients with PHN may consider a trial of lidocaine 5 % patch monotherapy before resorting to a systemic therapy, or alternatively, may consider administering the lidocaine 5 % patch in combination with a tricyclic antidepressant or a gabapentinoid to provide more rapid analgesic response and lower the dose requirement of systemic therapies.

574 Varicella Zoster Infection Complicated by Meningeococcalmeningits, Seosis and Subdural Empyema in an Infant, a Case Report

AimsTo highlight possible and may be fatal complications of Varicella Zoster virus (VZV) infection.MethodWe report a case of an infant with VZV infection who developed meningeococcal sepsi, meningeococcal meningitis, VZV...

Poster 149 Varicella-Zoster Infection Presenting with an Acute Disk Herniation with Radicular Pain: A Case Report

Poster 149 Varicella-Zoster Infection Presenting with an Acute Disk Herniation with Radicular Pain: A Case Report

Use of adalimumab in refractory non-infectious childhood chronic uveitis: efficacy in ocular disease--a case cohort interventional study

To assess the use of adalimumab in the treatment of refractory non-infectious childhood chronic uveitis. A case cohort interventional study was performed on patients with uveitis, who were treated with adalimumab after failure of treatment with a combination of corticosteroids and another immunosuppressant drug. Main outcome measures were (i) stability of vision, (ii) stability of inflammation and (iii) reduction of immunosuppressive load. Adverse events and reasons for stopping adalimumab were noted. Seventeen patients from a single regional centre were included in the study. Nine patients had previously received an anti-TNF agent, and because of inefficacy, all were changed to adalimumab. At 12 months, fewer patients had visual acuity worse than LogMAR 0.4 (18% vs 32% at baseline). Using standardized uveitis nomenclature criteria, at 3 months, 50% of the patients eyes (n = 32) had improved, 16% had stable inflammation and 3% had worsened, whereas 31% were maintained with no anterior chamber cells. Six patients required courses of oral steroids for uveitis. Seven patients received intra- or periocular injections of steroids. Adalimumab treatment was interrupted in one patient because of varicella zoster infection. It was stopped in three patients. Seven (41%) patients reported injection site reactions. In this group of children with refractory uveitis, use of adalimumab was associated with improvement in visual acuity and improving or stable ocular inflammation. However, it did not completely obviate the need for systemic or periocular steroid treatment. Prospective randomized controlled trials are required to help determine which subset of patients may benefit from adalimumab and the duration of treatment.

An unusual case of Henoch-Schönlein purpura associated with varicella zoster infection

Henoch-Schonlein purpura (HSP) is one of the most common vasculitis of childhood which is characterized by nonthrombocytopenic palpable purpura, arthritis, renal and gastrointestinal system (GIS) involvement. The etiology of HSP is mainly unknown and antecedent upper respiratory tract infection, usually viral and Streptococcal origin, drugs, cold, insect bite or some foods are the known triggering factors. HSP is rarely triggered by varicella zoster infection. In this study, we present a case with HSP following varicella infection who was admitted to the hospital because of edema and erythema in the right ankle, palpable purpura in the lower extremities and crusted lesions of varicella in his back. As a result of the case, we believe that consideration of varicella zoster as a causative agent for HSP necessitates the vaccination against it which will prevent the development of many complications of varicella zoster infection including HSP. Key words: Henoch-Schonlein purpura, varicella zoster infection, nonthrombocytopenic purpura.

Foot Drop and Urinary Retention Following Disseminated Varicella Zoster Infection (P02.269)

Foot Drop and Urinary Retention Following Disseminated Varicella Zoster Infection (P02.269)