A controlled trial of acyclovir for chickenpox in normal children

Impact of herpesvirus infections in the future

Numerous diverse, often opposing, trends will determine the frequency (and severity) of herpesvirus infections in the future. A major factor is the growing population of iatrogenically immunocompromised patients, accruing especially from large increases in organ and autologous bone marrow transplantation. Of even greater importance is the immense number of human immunodeficiency virus (HIV)-infected patients for whom herpesviruses may: (1) have been a cofactor in acquisition of HIV infection; (2) contribute to in vivo activation of HIV; (3) cause severe infections. Another factor influencing severe herpesvirus infections is the aging of populations in developed countries; this will be associated with a greater prevalence, and more morbid manifestations, of herpes zoster. Sociologic changes will also be important. The consequences of these, such as attempts to influence sexual practices, will be difficult to predict. Other changes, such as more frequent use of early child care facilities, will predictably lead to early acquisition of most herpesviruses, thereby decreasing the incidence of severe disease in adulthood. Factors that will reduce the incidence and/or severity of herpesvirus infections include vaccines (varicella, herpes simplex, cytomegalovirus); prophylactic strategies for immunocompromised hosts (passive immunization, antiviral drugs, blood product selection); more rapid and sensitive diagnostic methods; and suppressive or early antiviral therapy for common infections, such as genital herpes simplex and varicella.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of varicella in the immunocompetent adult

Varicella in the immunocompetent adult is an infrequent but potentially serious infection. Previous studies in immunocompetent hosts and normal adults have demonstrated the value of intravenous acyclovir in the treatment of varicella-zoster virus infections. Oral acyclovir has also shown efficacy in both normal adults with zoster (shingles) and immunocompetent children with varicella. A recently completed double-blind placebo-controlled study of oral acyclovir in immunocompetent adults with uncomplicated varicella also demonstrated efficacy. Therapy within the first day reduced the time to 100% crusting of skin lesions from 7.4 to 5.6 days, and reduced the duration of fever by one-half day. Symptoms were also diminished. These benefits were observed only when therapy was initiated within 24 hours of the appearance of the rash. Adults with complicated varicella (usually symptomatic varicella pneumonia) should receive intravenous acyclovir. Several new agents for varicella-zoster therapy are being evaluated; brovavir is a new agent currently being compared to placebo in the treatment of adult varicella.

Acyclovir therapy for varicella in otherwise healthy children and adolescents

Acyclovir has been approved in the United States and elsewhere as antiviral therapy for otherwise healthy children and adolescents with varicella. This development arose from multicentre placebo-controlled trials of acyclovir in normal patients, 2-18 years of age, which showed that the drug accelerated cutaneous healing, and reduced fever and related constitutional symptoms without harmful side effects. Acyclovir did not, however, decrease transmission of chickenpox within the household, nor was there any demonstrable effect of antiviral therapy on varicella complications. In this article, the background and rationale for the multicentre studies of acyclovir in normal paediatric patients with chickenpox is reviewed. The evidence for and against its routine administration within 24 hours of the eruption of skin rash is also discussed.

Costs of pharmaceutical care: can the profession do anything?

OBJECTIVE

To review some of the factors that influence the cost of pharmaceuticals and the delivery of pharmaceutical care as well as some possible measures for decreasing these costs.

DATA SYNTHESIS

Clinical studies have been selected to illustrate factors that may add to the overall cost of pharmaceutical care.

CONCLUSIONS

Because of the perceived problems resulting from the introduction of new, expensive pharmaceuticals, possible means of controlling the costs of individual products are discussed. In addition, recommendations for achieving cooperation between pharmaceutical manufacturers and pharmacy practitioners in demonstrating the cost-effectiveness of new products are provided.

Current dermatologic therapy

This article reviews therapeutic advances reported in the English-language literature during 1991. Readers should review the original article in full before attempting any experimental or controversial therapy.

Immunoelectron microscopy for rapid diagnosis of varicella-zoster virus in a complicated case of human T-cell lymphotropic virus type 1 infection

Rapid techniques for the detection of herpes simplex virus (HSV) and varicella-zoster virus (VZV) are needed for optimal therapeutic management. VZV infection poses a serious threat, especially to seriously ill patients, for instance, immunocompromised patients. We report a case of human T-cell lymphotropic virus type 1-positive leukemia complicated by atypical multidermatomal herpes zoster. Viral culture and standard serological tests failed to prove VZV infection. Herpesvirus infection was confirmed by cytodiagnosis (Tzanck test). The final diagnosis of VZV was made by immunoelectron microscopy (IEM), which can differentiate between HSV and VZV. Immunoglobulin M antibodies in serum directed against VZV were detected by IEM but not by immunofluorescence. Because IEM was able to identify virus and analyze sera in only 2 h, it is considered a valuable additional tool for the rapid diagnosis of HSV and VZV infections.

Systemic antiviral drugs used in ophthalmology

Over the past two decades, the recognition of viral enzymes and proteins that can serve as molecular targets of drugs has revolutionized the treatment of viral infections. Beginning with acyclovir, a number of systemically administered agents which are both relatively safe and effective for the treatment of herpetic infections and human immunodeficiency virus (HIV) infections have become widely available. Because of increased numbers of herpes virus infections, as well as the rising epidemic of HIV infections, the ophthalmologist is, more likely than ever before to be involved in the treatment of severe and frequent ocular infections caused by herpes viruses. In addition, the acute retinal necrosis (ARN) syndrome has been demonstrated to be caused by herpes viruses and a once rare retinal infection caused by cytomegalovirus is common in patients with the acquired immunodeficiency syndrome (AIDS). In this article, four systemic antiviral drugs (Vidarabine, Acyclovir, Ganciclovir, and Foscarnet) that have demonstrated usefulness in the treatment of ophthalmic disease are reviewed in detail with regard to their mechanisms, applications, effectiveness, and side effects.

Acyclovir treatment of varicella in otherwise healthy adolescents. The Collaborative Acyclovir Varicella Study Group

STUDY OBJECTIVE

To determine whether orally administered acyclovir is of therapeutic benefit for varicella in otherwise healthy adolescents, and to compare the severity of the disease in adolescents with that in younger children.

DESIGN

Multicenter, randomized, placebo-controlled, double-blind trial.

SETTING

Patients' homes and university hospital clinics.

PATIENTS

Sixty-eight adolescents between 13 and 18 years of age with varicella entered the study. Of the 62 adolescents with laboratory-confirmed varicella who were included in the final analysis, 31 received acyclovir and 31 received placebo.

INTERVENTIONS

Placebo or an 800 mg acyclovir tablet was given orally four times daily for 5 days, beginning within 24 hours of onset of rash.

MEASUREMENTS AND MAIN RESULTS

Acyclovir recipients had significant reductions in times to cessation of new lesion formation (p less than 0.001), maximum number of lesions (p = 0.019), and defervescence (p = 0.045). Mean constitutional illness score was significantly reduced on day 4 (0.5 vs 1.5, p = 0.05), as was the mean number of residual hypopigmented lesions present on 28-day follow-up examination (22.7 vs 92.7, p = 0.018). Two complications, both bacterial superinfections, occurred in placebo recipients. Adverse experiences and varicella-zoster virus antibody titers measured 28 days after enrollment were similar in both treatment groups. Comparison of placebo recipients with children 2 to 12 years of age participating in a companion study indicated that varicella is more severe in adolescents: mean maximum total lesions (421 vs 347, p = 0.003), mean maximum constitutional illness score (3.1 vs 2.2, p = 0.032), and mean number of residual lesions (92.7 vs 33.2, p = 0.01) were all greater in the adolescent population.

CONCLUSIONS

Oral acyclovir therapy is safe and effective for treatment of varicella in otherwise healthy adolescents; this may be an appropriate subgroup for treatment with antiviral drugs because the disease is more severe in them than in younger children.