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Edell ARP, Cohen EJ. Herpes simplex and herpes zoster eye disease: presentation and management at a city hospital for the underserved in the United States. Eye Contact Lens 2014; 39:311-4. [PMID: 23771014 DOI: 10.1097/icl.0b013e31829a3b47] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To further define the spectrum of clinical disease and treatment among patients with herpes zoster ophthalmicus (HZO) and ocular herpes simplex viral (HSV) infection presenting at a large city hospital for the underserved in the United States. METHODS Retrospective review of medical records of 64 patients (40 HZO and 24 ocular HSV infection) presenting to the Bellevue Hospital Emergency Department for the management of herpetic eye disease for which an ophthalmologic consultation was obtained from January 1, 2006, to December 31, 2011. RESULTS The mean age of patients with HZO was 51 ± 15 years (n=40) versus 33 ± 16 years for patients with ocular HSV infection (n=24; P<0.0001). Overall, 73% of patients with HZO were aged <60 years (n=29 of 40), of whom, 90% (26 of 29) were immunocompetent. The most common decade of onset of HZO was 50 to 59 years (11 of 40, 28%). Four patients with HZO were immunocompromised (n=4 of 40; 10%), with 3 aged <60 years attributable to human immunodeficiency virus (n=3 of 29, 10%). The study included 12 patients eligible to receive the herpes zoster vaccine. None of these patients had a history of vaccination. Of the 24 patients with ocular HSV infection, corneal stromal disease was present in 7 patients and infectious epithelial keratitis in 10 patients. No patients were treated with long-term oral antiviral prophylaxis. CONCLUSIONS Acute HZO was seen more commonly than ocular HSV infection. Patients with HZO were significantly older than those with ocular HSV infection. Available prevention modalities, such as the vaccine against herpes zoster and long-term oral antiviral therapy to reduce ocular HSV infection recurrence, were underused.
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Affiliation(s)
- Aimée R P Edell
- Department of Ophthalmology, New York University School of Medicine, New York, NY, USA
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202
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Hales CM, Harpaz R, Joesoef MR, Bialek SR. Examination of links between herpes zoster incidence and childhood varicella vaccination. Ann Intern Med 2013; 159:739-45. [PMID: 24297190 PMCID: PMC5719886 DOI: 10.7326/0003-4819-159-11-201312030-00006] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Introduction of a universal varicella vaccine program for U.S. children in 1996 sparked concern that less-frequent exposure to varicella would decrease external boosting of immunity to varicella zoster virus and thereby increase incidence of herpes zoster (HZ). OBJECTIVE To determine whether the varicella vaccination program has influenced trends in HZ incidence in the U.S. population older than 65 years. DESIGN Retrospective study of Medicare claims. SETTING Medicare, 1992 through 2010. PARTICIPANTS 2 848 765 beneficiaries older than 65 years. MEASUREMENTS Annual HZ incidence from 1992 through 2010; rate ratios (RRs) for HZ incidence by age, sex, and race or ethnicity; and state-level varicella vaccination coverage. RESULTS 281 317 incident cases of HZ occurred. Age- and sex-standardized HZ incidence increased 39% from 10.0 per 1000 person-years in 1992 to 13.9 per 1000 person-years in 2010 with no evidence of a statistically significant change in the rate of increase after introduction of the varicella vaccination program. Before introduction of this program, HZ incidence was higher in women (RR, 1.21 [95% CI, 1.19 to 1.24]) than men and was lower in black persons (RR, 0.51 [CI, 0.48 to 0.53]) and Hispanic persons (RR, 0.76 [CI, 0.72 to 0.81]) than white persons. In a model adjusted for sex, age, and calendar year from 1997 to 2010, HZ incidence did not vary by state varicella vaccination coverage (RR, 0.9998 [CI, 0.9993 to 1.0003]). LIMITATION Uncertain level and consistency of health-seeking behavior and access and uncertain accuracy of disease coding. CONCLUSION Age-specific HZ incidence increased in the U.S. population older than 65 years even before implementation of the childhood varicella vaccination program. Introduction and widespread use of the vaccine did not seem to affect this increase. This information is reassuring for countries considering universal varicella vaccination. PRIMARY FUNDING SOURCE None.
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203
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Ultsch B, Köster I, Reinhold T, Siedler A, Krause G, Icks A, Schubert I, Wichmann O. Epidemiology and cost of herpes zoster and postherpetic neuralgia in Germany. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2013; 14:1015-1026. [PMID: 23271349 DOI: 10.1007/s10198-012-0452-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 12/06/2012] [Indexed: 06/01/2023]
Abstract
After acquiring a varicella virus infection, the virus can reactivate and cause herpes zoster (HZ)--a painful skin rash. A complication of HZ is long-term persistence of pain after the rash has resolved (so-called postherpetic neuralgia, PHN). We aimed to describe the epidemiology of HZ/PHN and to estimate HZ/PHN-related costs in the German statutory health insurance (SHI) system (~85% of the total population). Treatment data of one large SHI was utilized, containing data on approximately 240,000 insured and their utilisation of services in 2004-2009. Identification of HZ- and PHN-cases was performed based on 'International Statistical Classification of Diseases' and specific medications using a control-group design. Incidences per 1,000 person-years (PY) and cost-of-illness for 1 year following HZ-onset considering the payer and societal perspective were calculated. All amounts were inflated to 2010 Euros. Population-figures were standardised and extrapolated to the total SHI-population in Germany in 2010. A mean annual incidence of 5.79 HZ-cases per 1,000 PY was observed, translating into an estimated 403,625 HZ-cases per year in the total SHI-population. Approximately 5% of HZ-cases developed PHN. One HZ-case caused on average euro 210 and euro 376 of costs from the payer and societal perspective, respectively. The development of PHN generated additional costs of euro 1,123 (euro 1,645 societal perspective). Total annual HZ/PHN-related costs were estimated at euro 182 million (euro 105 million) to society (payer). HZ and PHN place a considerable burden on the German SHI-system. Since HZ-vaccines will soon be available, a health-economic evaluation of these vaccines should be conducted.
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Affiliation(s)
- Bernhard Ultsch
- Immunisation Unit, Department for Infectious Disease Epidemiology, Robert Koch Institute, DGZ-Ring 1, 13086, Berlin, Germany,
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Esteban-Vasallo MD, Gil-Prieto R, Domínguez-Berjón MF, Astray-Mochales J, Gil de Miguel A. Temporal trends in incidence rates of herpes zoster among patients treated in primary care centers in Madrid (Spain), 2005-2012. J Infect 2013; 68:378-86. [PMID: 24247069 DOI: 10.1016/j.jinf.2013.09.035] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 09/13/2013] [Accepted: 09/30/2013] [Indexed: 01/31/2023]
Abstract
OBJECTIVES This study aimed to estimate total and age-specific incidence rates of HZ with data from electronic clinical records in primary care (ECRPC) and to analyze trends by sex and age. METHODS Descriptive cross-sectional study covering the incident HZ episodes registered in the ECRPC of the Madrid Regional Public Health System in 2005-2012. Annual crude and age-adjusted incidence rates were calculated. Differences by sex and age were assessed by poisson regression. The annual percentage of change (APC) of incidence rates and 'breakthrough points' of the time trends were determined with the Joinpoint Regression Program. RESULTS 211,650 episodes of HZ were identified (60.6% women, 52.2% > 55 years). The incidence rate increased from 363.21 to 481.92 per 100,000 person-year in 2005-2012. Rates were higher among women and increased with age. The APC for the period was 3.59% in men and 3.67% in women (p < 0.05). Age-specific rates increased in patients over 14 years. The APC in the 25-44 age group was 7.4% since 2007. The incidence rate ratio (women/men) was highest in this group. CONCLUSIONS The incidence of HZ presents an upward trend in 2005-2012 in adults and the elderly. Monitoring the incidence and age-specific rates, will help to detect changes in trends.
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Affiliation(s)
- M D Esteban-Vasallo
- Subdirectorate for Health Promotion and Prevention, Madrid Regional Health Authority, C/San Martín de Porres, 6, 28035 Madrid, Spain.
| | - R Gil-Prieto
- Department of Preventive Medicine and Public Health and Medical Immunology and Microbiology, Rey Juan Carlos University, Avda. de Atenas, s/n, 28922 Alcorcón, Madrid, Spain
| | - M F Domínguez-Berjón
- Subdirectorate for Health Promotion and Prevention, Madrid Regional Health Authority, C/San Martín de Porres, 6, 28035 Madrid, Spain
| | - J Astray-Mochales
- Subdirectorate for Health Promotion and Prevention, Madrid Regional Health Authority, C/San Martín de Porres, 6, 28035 Madrid, Spain
| | - A Gil de Miguel
- Department of Preventive Medicine and Public Health and Medical Immunology and Microbiology, Rey Juan Carlos University, Avda. de Atenas, s/n, 28922 Alcorcón, Madrid, Spain
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205
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Chen SY, Suaya JA, Li Q, Galindo CM, Misurski D, Burstin S, Levin MJ. Incidence of herpes zoster in patients with altered immune function. Infection 2013; 42:325-34. [PMID: 24214127 PMCID: PMC3968442 DOI: 10.1007/s15010-013-0550-8] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 10/26/2013] [Indexed: 12/05/2022]
Abstract
Purpose To estimate the incidence of herpes zoster (HZ) and rates of post-zoster pain in both the total study population and separately in patients with selected conditions/treatments associated with altered immune function. Methods The health administrative claims databases for commercially insured, Medicare, and Medicaid populations, together accounting for approximately 51 million insured individuals, were analyzed between 2005 and 2009 in a retrospective cohort study. Incidence of HZ episodes per 1,000 person-years (PY) was estimated in all study populations as well as within nine potentially immune-altering conditions. Among patients with HZ, the 6-month rate of persistent post-zoster pain was estimated. Results Analysis of 90.2 million PY at risk revealed that the incidence of HZ in the total study population was 4.82/1,000 PY. The incidence of HZ was highest among patients with bone marrow or stem cell transplant (43.03 %) followed by solid organ transplant, human immunodeficiency virus infection, and systemic lupus erythematosus [95 % confidence interval (CI) 15.19–17.41 %]. HZ incidence rates were higher among persons on immunosuppressants/chemotherapy than among non-users. In the total study population, HZ incidence increased with age (18–49 years: 3.37/1,000 PY; 65+ years: 8.43/1,000 PY; P < 0.01) and female gender (incidence ratio vs. male 1.39, 95 % CI 1.38–1.40 %). The 6-month rate of persistent post-zoster pain was 4.29 % (95 % CI 4.22–4.36 %), which was higher in patients with the selected conditions. Conclusions Despite providing a relatively small fraction of overall HZ cases, persons with immune function-altering conditions make a large contribution to the societal healthcare burden because they have a higher risk of developing HZ and persistent post-zoster pain. These risk factors should be considered in HZ prevention efforts.
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206
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Cho SI, Lee CH, Park GH, Park CW, Kim HO. Use of S-LANSS, a tool for screening neuropathic pain, for predicting postherpetic neuralgia in patients after acute herpes zoster events: a single-center, 12-month, prospective cohort study. THE JOURNAL OF PAIN 2013; 15:149-56. [PMID: 24342706 DOI: 10.1016/j.jpain.2013.10.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 10/10/2013] [Accepted: 10/17/2013] [Indexed: 10/26/2022]
Abstract
UNLABELLED Postherpetic neuralgia (PHN) is one of the most severe sequelae of herpes zoster events. Several risk factors have been reported for PHN, including old age, severe skin rash, and intense pain. This study therefore aims to evaluate the usefulness of the Self-completed Leeds Assessment of Neuropathic Symptoms and Signs pain scale (S-LANSS) in conjunction with previously reported risk factors for predicting PHN. A group of herpes zoster patients (N = 305) were included in the cohort study. Subjects were asked for their demographic information, clinical symptoms and signs, intensity of pain by visual analog scale (VAS), and S-LANSS. They were followed up in clinical visits or via telephone for 12 months. Nineteen patients (6.2%) suffered from PHN in this study. Using logistic regression, 3 risk factors for PHN were identified: age ≥70 years, high VAS scores, and high S-LANSS scores. Prediction of PHN using VAS (≥8) and S-LANSS (≥15) criteria achieved a sensitivity of 78.9% and specificity of 78.0%. Prediction of PHN in elderly patients (≥70 years), using the criteria of VAS (≥6) and S-LANSS (≥15) as well, achieved 100% sensitivity and 57.1% specificity. S-LANSS could be a useful prediction tool for PHN, particularly if combined with previously well-known risk factors and VAS. PERSPECTIVE Among acute herpes zoster patients, subjects with characteristics of neuropathic pain showed high frequency of PHN. The tools for screening neuropathic pain like S-LANSS could be helpful for predicting PHN and enabling early intervention of pain management.
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Affiliation(s)
- Soo Ick Cho
- Department of Dermatology, Kangnam Sacred Heart Hospital, College of Medicine, Hallym University, Seoul, Korea
| | - Cheol Heon Lee
- Department of Dermatology, Kangnam Sacred Heart Hospital, College of Medicine, Hallym University, Seoul, Korea
| | - Gyeong-Hun Park
- Department of Dermatology, Dongtan Sacred Heart Hospital, College of Medicine, Hallym University, Hwaseong, Korea
| | - Chun Wook Park
- Department of Dermatology, Kangnam Sacred Heart Hospital, College of Medicine, Hallym University, Seoul, Korea
| | - Hye One Kim
- Department of Dermatology, Kangnam Sacred Heart Hospital, College of Medicine, Hallym University, Seoul, Korea.
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207
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Koo S, Gagne LS, Lee P, Pratibhu PP, James LM, Givertz MM, Marty FM. Incidence and risk factors for herpes zoster following heart transplantation. Transpl Infect Dis 2013; 16:17-25. [PMID: 24147978 DOI: 10.1111/tid.12149] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 02/26/2013] [Accepted: 04/21/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Data on the incidence, timing, and risk factors for herpes zoster (HZ) in heart transplant (HT) recipients are limited. METHODS We determined HZ incidence rates and actuarial estimates of time to first HZ episode in 314 HT recipients at our institution from 1995 to 2010. We developed Cox models to assess potential risk factors for HZ in HT. RESULTS Median age at HT was 54 (range, 17-71) years; 237 (76%) were male. There were 60 episodes of HZ in 51 patients, with an overall incidence rate of 31.6 cases (95% confidence interval [CI], 23.5-41.6)/1000 person-years. Although most cases occurred during the first post-HT year, cumulative HZ incidence was 0.078 at 1, 0.15 at 5, and 0.20 at 10 years. Many patients had substantial HZ morbidity, including 14% with HZ ophthalmicus and 45% with post-herpetic neuralgia. Adjusting for age, gender, and acute cellular rejection episodes, exposure to mycophenolate mofetil (MMF) was an independent risk factor for HZ (adjusted hazard ratio [HR] 2.18; 95% CI, 1.20-3.96; P = 0.01), while ganciclovir-based cytomegalovirus prophylaxis reduced HZ risk (adjusted HR 0.09; 95% CI, 0.01-0.71; P = 0.02). Although age and female gender increased HZ risk, the magnitude of their effect was not statistically significant in Cox models. CONCLUSIONS HZ is common and morbid after HT, particularly with MMF exposure. Ganciclovir prophylaxis is effective in reducing the short-term risk of HZ, but the steady incidence of cases for years post HT makes long-term HZ prevention challenging. Augmenting varicella zoster virus immunity post HT with vaccines warrants further exploration.
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Affiliation(s)
- S Koo
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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208
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Al-Sardar H. A case of almost painless herpes zoster presenting with symptoms of cystitis, penile numbness, and acute vestibular failure. Case Rep Dermatol Med 2013; 2013:738579. [PMID: 24251046 PMCID: PMC3819820 DOI: 10.1155/2013/738579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 09/04/2013] [Indexed: 11/23/2022] Open
Abstract
Herpes zoster (shingles) is an acute, painful, vesicular, and cutaneous eruption caused by varicella zoster virus, the same virus which causes chicken pox. It is due to the reactivation of the virus which remains dormant in sensory ganglions following chicken pox. It is usually confined to a single dermatome but may involve 2-3 dermatomes. Typically, it is a unilateral lesion which can affect both cranial and peripheral nerves. It is usually a self-limiting disease; however, it may cause significant morbidity especially in the elderly. It is more common in older people and individuals with immunocompromised conditions. Antiviral drugs can shorten the duration and the severity of the illness and need to be started as soon as possible after the appearance of the rash. Gabapentin and tricyclic antidepressant are effective in postherpetic neuralgia. Vaccine can reduce the risk of infection and its associated pain. Typically, it occurs once in a lifetime, but some individuals may have more than one episode.
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Affiliation(s)
- Hussain Al-Sardar
- Department of Medicine, Southend University Hospital, Prittlewell Chase, Westcliff-on-Sea, Essex SS0 0RY, UK
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209
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Ogunjimi B, Theeten H, Hens N, Beutels P. Serology indicates cytomegalovirus infection is associated with varicella-zoster virus reactivation. J Med Virol 2013; 86:812-9. [DOI: 10.1002/jmv.23749] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2013] [Indexed: 12/19/2022]
Affiliation(s)
- Benson Ogunjimi
- Centre for Health Economics Research and Modeling Infectious Diseases; Vaccine & Infectious Disease Institute; University of Antwerp; Antwerp Belgium
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics; Hasselt University; Hasselt Belgium
| | - Heidi Theeten
- Centre for the Evaluation of Vaccination; Vaccine & Infectious Disease Institute; University of Antwerp; Antwerp Belgium
| | - Niel Hens
- Centre for Health Economics Research and Modeling Infectious Diseases; Vaccine & Infectious Disease Institute; University of Antwerp; Antwerp Belgium
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics; Hasselt University; Hasselt Belgium
| | - Philippe Beutels
- Centre for Health Economics Research and Modeling Infectious Diseases; Vaccine & Infectious Disease Institute; University of Antwerp; Antwerp Belgium
- School of Public Health and Community Medicine; University of New South Wales; Sydney Australia
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210
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Hechter RC, Tartof SY, Jacobsen SJ, Smith N, Tseng HF. Trends and disparity in zoster vaccine uptake in a managed care population. Vaccine 2013; 31:4564-8. [DOI: 10.1016/j.vaccine.2013.07.053] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 07/17/2013] [Accepted: 07/25/2013] [Indexed: 10/26/2022]
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211
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Doan HQ, Ung B, Ramirez-Fort MK, Khan F, Tyring SK. Zostavax : a subcutaneous vaccine for the prevention of herpes zoster. Expert Opin Biol Ther 2013; 13:1467-77. [PMID: 23984934 DOI: 10.1517/14712598.2013.830101] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Herpes zoster (HZ) occurs as a reactivation of dormant varicella zoster virus (VZV), and occurs more frequently in the aging population or the immunocompromised due to waning cell-mediated immunity. Up to 1 million cases of HZ are reported annually in the USA with an estimated 10 - 30% of the population being affected by shingles in their lifetime. HZ is a debilitating illness, and while mortality is low, morbidity remains a significant cause for concern with prevention efforts aimed at reducing VZV reactivation and its complications. The HZ vaccine was approved by the US Food and Drug Administration for individuals aged 50-years or older. However, the Center for Disease Control and Prevention's Advisory Committee for Immunization Practices recommends the vaccine in individuals aged 60-years or older. AREAS COVERED Recent literature investigating the efficacy and indications of live attenuated zoster vaccine. EXPERT OPINION Live attenuated zoster vaccine is safe and efficacious in preventing HZ and decreasing the morbidity associated with postherpetic neuralgia. The vaccine is FDA approved in individuals aged 50-years or older but further studies are warranted to investigate the vaccine's efficacy in immunosuppressed and immunocompromised patients.
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Affiliation(s)
- Hung Q Doan
- The University of Texas Medical Branch, School of Medicine , 301 University Blvd, Galveston, TX 77555 , USA
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212
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Genome-wide analysis of T cell responses during acute and latent simian varicella virus infections in rhesus macaques. J Virol 2013; 87:11751-61. [PMID: 23986583 DOI: 10.1128/jvi.01809-13] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Varicella zoster virus (VZV) is the etiological agent of varicella (chickenpox) and herpes zoster (HZ [shingles]). Clinical observations suggest that VZV-specific T cell immunity plays a more critical role than humoral immunity in the prevention of VZV reactivation and development of herpes zoster. Although numerous studies have characterized T cell responses directed against select VZV open reading frames (ORFs), a comprehensive analysis of the T cell response to the entire VZV genome has not yet been conducted. We have recently shown that intrabronchial inoculation of young rhesus macaques with simian varicella virus (SVV), a homolog of VZV, recapitulates the hallmarks of acute and latent VZV infection in humans. In this study, we characterized the specificity of T cell responses during acute and latent SVV infection. Animals generated a robust and broad T cell response directed against both structural and nonstructural viral proteins during acute infection in bronchoalveolar lavage (BAL) fluid and peripheral blood. During latency, T cell responses were detected only in the BAL fluid and were lower and more restricted than those observed during acute infection. Interestingly, we identified a small set of ORFs that were immunogenic during both acute and latent infection in the BAL fluid. Given the close genome relatedness of SVV and VZV, our studies highlight immunogenic ORFs that may be further investigated as potential components of novel VZV vaccines that specifically boost T cell immunity.
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Abstract
OPINION STATEMENT Varicella zoster virus (VZV) is an exclusively human neurotropic alphaherpesvirus. Primary infection causes varicella (chickenpox), after which virus becomes latent in ganglionic neurons along the entire neuraxis. With advancing age or immunosuppression, cell-mediated immunity to VZV declines and virus reactivates to cause zoster (shingles), which can occur anywhere on the body. Skin lesions resolve within 1-2 weeks, while complete cessation of pain usually takes 4-6 weeks. Zoster can be followed by chronic pain (postherpetic neuralgia), cranial nerve palsies, zoster paresis, meningoencephalitis, cerebellitis, myelopathy, multiple ocular disorders and vasculopathy that can mimic giant cell arteritis. All of the neurological and ocular disorders listed above may also develop without rash. Diagnosis of VZV-induced neurological disease may require examination of cerebrospinal fluid (CSF), serum and/ or ocular fluids. In the absence of rash in a patient with neurological disease potentially due to VZV, CSF should be examined for VZV DNA by PCR and for anti-VZV IgG and IgM. Detection of VZV IgG antibody in CSF is superior to detection of VZV DNA in CSF to diagnose vasculopathy, recurrent myelopathy, and brainstem encephalitis. Oral antiviral drugs speed healing of rash and shorten acute pain. Immunocompromised patients require intravenous acyclovir. First-line treatments for post-herpetic neuralgia include tricyclic antidepressants, gabapentin, pregabalin, and topical lidocaine patches. VZV vasculopathy, meningoencephalitis, and myelitis are all treated with intravenous acyclovir.
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Affiliation(s)
- Maria A. Nagel
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Don Gilden
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Microbiology, University of Colorado School of Medicine, Aurora, CO, USA
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215
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Weitzman D, Shavit O, Stein M, Cohen R, Chodick G, Shalev V. A population based study of the epidemiology of Herpes Zoster and its complications. J Infect 2013; 67:463-9. [PMID: 23872209 DOI: 10.1016/j.jinf.2013.06.016] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Revised: 06/13/2013] [Accepted: 06/19/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To assess the incidence of Herpes Zoster (HZ) and its complications in the Israeli general population and specifically in immune-compromised individuals, and to identify risk factors for developing HZ and post-herpetic neuralgia (PHN). METHODS A retrospective database search for newly diagnosed cases of HZ and of PHN during 2006-2010 was conducted using the comprehensive longitudinal database of Maccabi Health Services. Cox-proportional hazards models were used to assess associations between risk factors and HZ and PHN. RESULTS During 2006-2010 there were 28,977 newly diagnosed cases of HZ and 1508 newly diagnosed cases of PHN. Incidence density rate of HZ was 3.46 per 1000 person-years in the total population and 12.8 per 1000 person-years in immune-compromised patients. HZ and PHN incidence increased sharply with age. 12.4% and 3.1% of elderly HZ patients (≥ 65 years) developed PHN or ophthalmic complications, respectively. In multivariable analyses, HZ and PHN were associated with female sex, higher socioeconomic status, diabetes mellitus, cancer history, and HIV treatment. CONCLUSIONS Extrapolating to the entire Israeli population, we estimate over 24,000 new cases of HZ and 1250 new cases of PHN each year. Cost-effectiveness analysis should be performed to determine the threshold age for vaccination against HZ.
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Affiliation(s)
- Dahlia Weitzman
- Maccabi Healthcare Services, Medical Division, Tel Aviv, Israel.
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216
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Studying Physician Knowledge, Attitudes, and Practices Regarding the Herpes Zoster Vaccine to Address Perceived Barriers to Vaccination. Cornea 2013; 32:976-81. [DOI: 10.1097/ico.0b013e318283453a] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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217
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Beukelman T, Xie F, Baddley JW, Chen L, Delzell E, Grijalva CG, Mannion ML, Patkar NM, Saag KG, Winthrop KL, Curtis JR. Brief report: incidence of selected opportunistic infections among children with juvenile idiopathic arthritis. ACTA ACUST UNITED AC 2013; 65:1384-9. [PMID: 23460423 DOI: 10.1002/art.37866] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Accepted: 01/08/2013] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To compare incidence rates of selected opportunistic infections among children with and children without juvenile idiopathic arthritis (JIA). METHODS Using U.S. national Medicaid administrative claims data from 2000 through 2005, we identified a cohort of children with JIA based on physician diagnosis codes and dispensed medications. We also identified a non-JIA comparator cohort of children diagnosed as having attention deficit hyperactivity disorder (ADHD). We defined 15 types of opportunistic infection using physician diagnosis or hospital discharge codes; criteria for 7 of these types also included evidence of treatment with specific antimicrobial agents. We calculated infection incidence rates. The rates in the ADHD comparator cohort were standardized to the age, sex, and race distribution of the JIA cohort. We calculated incidence rate ratios (IRRs) with 95% confidence intervals (95% CIs) to compare infection rates. RESULTS The JIA cohort included 8,503 children with 13,990 person-years of followup. The ADHD comparator cohort included 360,362 children with 477,050 person-years of followup. When all opportunistic infections were considered together as a single outcome, there were 42 infections in the JIA cohort (incidence rate 300 per 100,000 person-years; IRR 2.4 [95% CI 1.7-3.3] versus ADHD). The most common opportunistic infections among children with JIA were 3 cases of Coccidioides (incidence rate 21 per 100,000 person-years; IRR 101 [95% CI 8.1-5,319] versus ADHD), 5 cases of Salmonella (incidence rate 35 per 100,000 person-years; IRR 3.8 [95% CI 1.2-9.5]), and 32 cases of herpes zoster (incidence rate 225 per 100,000 person-years; IRR 2.1 [95% CI 1.4-3.0]). CONCLUSION Opportunistic infections are rare among children with JIA. Nevertheless, children with JIA had a higher rate of opportunistic infections, including an increased rate of Coccidioides, Salmonella, and herpes zoster compared to children with ADHD.
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Affiliation(s)
- Timothy Beukelman
- University of Alabama at Birmingham, Division of Pediatric Rheumatology, Birmingham, AL 35233-1711, USA.
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218
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Addison B, Harvey M. Herpes zoster-induced acute urinary retention. Emerg Med Australas 2013; 25:279-81. [DOI: 10.1111/1742-6723.12079] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Ben Addison
- Department of General Surgery; North Shore Hospital; Auckland; New Zealand
| | - Martyn Harvey
- Department of Emergency Medicine; Waikato Hospital; Hamilton; New Zealand
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219
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Cogman AR, Chakravarty EF. The case for Zostavax vaccination in systemic lupus erythematosus. Vaccine 2013; 31:3640-3. [PMID: 23742992 DOI: 10.1016/j.vaccine.2013.05.085] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 05/15/2013] [Accepted: 05/21/2013] [Indexed: 11/16/2022]
Affiliation(s)
- Abigail R Cogman
- Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, 825 NE 13th Street, Oklahoma City, OK 73104, USA.
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220
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Haberthur K, Messaoudi I. Animal models of varicella zoster virus infection. Pathogens 2013; 2:364-82. [PMID: 25437040 PMCID: PMC4235715 DOI: 10.3390/pathogens2020364] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 04/16/2013] [Accepted: 05/01/2013] [Indexed: 11/16/2022] Open
Abstract
Primary infection with varicella zoster virus (VZV) results in varicella (chickenpox) followed by the establishment of latency in sensory ganglia. Declining T cell immunity due to aging or immune suppressive treatments can lead to VZV reactivation and the development of herpes zoster (HZ, shingles). HZ is often associated with significant morbidity and occasionally mortality in elderly and immune compromised patients. There are currently two FDA-approved vaccines for the prevention of VZV: Varivax® (for varicella) and Zostavax® (for HZ). Both vaccines contain the live-attenuated Oka strain of VZV. Although highly immunogenic, a two-dose regimen is required to achieve a 99% seroconversion rate. Zostavax vaccination reduces the incidence of HZ by 51% within a 3-year period, but a significant reduction in vaccine-induced immunity is observed within the first year after vaccination. Developing more efficacious vaccines and therapeutics requires a better understanding of the host response to VZV. These studies have been hampered by the scarcity of animal models that recapitulate all aspects of VZV infections in humans. In this review, we describe different animal models of VZV infection as well as an alternative animal model that leverages the infection of Old World macaques with the highly related simian varicella virus (SVV) and discuss their contributions to our understanding of pathogenesis and immunity during VZV infection.
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Affiliation(s)
- Kristen Haberthur
- Department of Microbiology and Molecular Immunology, Oregon Health and Science University, Portland, OR 97239, USA.
| | - Ilhem Messaoudi
- Department of Microbiology and Molecular Immunology, Oregon Health and Science University, Portland, OR 97239, USA.
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Kang SH, Song HK, Jang Y. Zoster-associated segmental paresis in a patient with cervical spinal stenosis. J Int Med Res 2013; 41:907-13. [PMID: 23628922 DOI: 10.1177/0300060513478084] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Segmental zoster paresis is a rare complication of herpes zoster, characterized by focal motor weakness that does not always present simultaneously with skin lesions. Zoster paresis can be easily confused with other neuromuscular or spinal diseases. This case report describes the case of a 72-year-old woman with herpes zoster and cervical spinal stenosis at the same spinal level, where it was difficult to distinguish segmental zoster paresis from cervical radiculopathy combined with motor neuropathy. Although segmental zoster paresis in the upper extremity is rare, it should be included in the differential diagnosis of segmental pain and weakness in the extremities, especially in older or immunocompromised patients. Correct diagnosis is required, to avoid unnecessary surgery and allow timely antiviral treatment.
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Affiliation(s)
- Sung-Hee Kang
- Department of Anaesthesia and Pain Medicine, The Catholic University of Korea, College of Medicine, Incheon St Mary's Hospital, Republic of Korea
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222
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Feng AC, Hsieh CB, Fan HL. Ramsay Hunt syndrome with an unusual clinical presentation in a liver transplant recipient: a case report and literature review. Transpl Int 2013; 26:e77-8. [PMID: 23621703 DOI: 10.1111/tri.12106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Widdifield J, Bernatsky S, Paterson JM, Gunraj N, Thorne JC, Pope J, Cividino A, Bombardier C. Serious infections in a population-based cohort of 86,039 seniors with rheumatoid arthritis. Arthritis Care Res (Hoboken) 2013; 65:353-61. [PMID: 22833532 DOI: 10.1002/acr.21812] [Citation(s) in RCA: 149] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 07/10/2012] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To assess risk and risk factors for serious infections in seniors with rheumatoid arthritis (RA) using a case-control study nested within an RA cohort. METHODS We assembled a retrospective RA cohort age ≥66 years from Ontario health administrative data across 1992-2010. Nested case-control analyses were done, comparing RA patients with a primary diagnosis of infection (based on hospital or emergency department records) to matched RA controls. We assessed independent effects of drugs, adjusting for demographics, comorbidity, and markers of RA severity. RESULTS A total of 86,039 seniors with RA experienced 20,575 infections, for a rate of 46.4 events/1,000 person-years. The most frequently occurring events included respiratory infections, herpes zoster, and skin/soft tissue infections. Factors associated with infection included higher comorbidity, rural residence, markers of disease severity, and history of previous infection. In addition, anti-tumor necrosis factor agents and disease-modifying antirheumatic drugs were associated with a several-fold increase in infections, with an adjusted odds ratio (OR) ranging from 1.2-3.5. The drug category with the greatest effect estimate was glucocorticoids, which exhibited a clear dose response with an OR ranging from 4.0 at low doses to 7.6 at high doses. CONCLUSION Seniors with RA have significant morbidity related to serious infections, which exceeds previous reports among younger RA populations. Rural residence, higher comorbidity, markers of disease severity, and previous infection were associated with serious infections in seniors with RA. Our results emphasize that many RA drugs may increase the risk of infection, but glucocorticoids appear to confer a particular risk.
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Chaudhry R, Schietel SM, North F, Dejesus R, Kesman RL, Stroebel RJ. Improving rates of herpes zoster vaccination with a clinical decision support system in a primary care practice. J Eval Clin Pract 2013; 19:263-6. [PMID: 22304668 DOI: 10.1111/j.1365-2753.2011.01814.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
RATIONALE Herpes zoster (shingles) is a localized neurocutaneous eruption of blisters caused by reactivation of the varicella zoster virus. The cost of care for herpes zoster and its complications is estimated at $1.1 billion. The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommends a one-time dose of the vaccine for adults aged 60 years or older. Despite that recommendation, utilization of the vaccine is very low. One way to boost the delivery of preventive services such as vaccinations is with a computerized clinical decision support system. Our study found that the herpes zoster vaccination rate increased significantly after the implementation of such a system. AIMS To study utilization of herpes zoster vaccine before and after the implementation of a web-based clinical decision support software solution in a primary care practice. METHODS Billing data was utilized to determine number of herpes zoster vaccination administered to patients for a 12-month period during the implementation of the software solution. RESULTS The utilization of vaccinations improved from 63 to 117 (53.8% increase) for one primary care practice and from 54 to 127 (42.5% increase) in the other primary care practice. CONCLUSION Herpes zoster vaccination rate significantly improved with implementation of a web-based clinical decision support system.
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Affiliation(s)
- Rajeev Chaudhry
- Department of Medicine, Division of Primary Care Internal Medicine and Mayo Clinic, Rochester, MN 55905, USA.
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Abstract
Herpes zoster and its sequela post-herpetic neuralgia (PHN) are conditions with significant morbidity. PHN is a chronic, debilitating neuropathic pain that can persist long beyond resolution of visible cutaneous manifestations. This paper provides practical guidelines for management of herpes zoster and PHN. For herpes zoster, antivirals should be started, preferably within 72 h of onset, to reduce the severity and duration of the eruptive phase and to reduce the intensity of acute pain. PHN can be treated with either topical or systemic agents. Topical lidocaine and capsaicin are effective. For patients with more severe pain, the following systemic agents can be considered (in decreasing order of recommendation): the anticonvulsants gabapentin and pregabalin, the tricyclic antidepressants amitriptyline, nortriptyline, and desipramine, and, lastly, the opioid analgesics tramadol, morphine, oxycodone, and methadone. For patients at high risk of developing PHN, early initiation of gabapentin or amitriptyline after the onset of herpes zoster is suggested. The new zoster vaccine has been shown to be effective in reducing the incidence of herpes zoster and PHN.
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226
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Khalafallah AA, Woodgate M, Koshy K, Patrick A. Ophthalmic manifestations of herpes zoster virus in patients with multiple myeloma following bone marrow transplantation. BMJ Case Rep 2013; 2013:bcr2012007625. [PMID: 23429015 PMCID: PMC3603998 DOI: 10.1136/bcr-2012-007625] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report three patients with ophthalmic herpes zoster (HZ) manifestations on the background diagnosis of multiple myeloma (MM). It seems that immunocompromised status has caused reactivation of the varicella zoster virus (VZV) producing a well-characterised neurological syndrome and subsequent postherpetic neuralgia in two patients. One patient experienced lymphocytic leptomeningitis resulting in unilateral optic neuritis. All patients received similar myeloma disease-specific treatment prior to HZ reactivation. All patients were treated with thalidomide and steroids, and they thereafter underwent autologous stem cell transplantation. Prior to HZ reactivation they received new immunomodulatory drugs in the form of thalidomide in addition to bortezomib (2 patients) and lenalidomide (1 patient). Immediate specific antiviral therapy was successfully applied with intravenous acyclovir for 10 days, followed by long-term oral famciclovir maintenance. Two patients progressed to have chronic HZ ophthalmicus and postherpetic neuralgia requiring ongoing antiviral therapy and neuroepileptic medications for the neuropathic pain.
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Irwin MR, Levin MJ, Laudenslager ML, Olmstead R, Lucko A, Lang N, Carrillo C, Stanley HA, Caulfield MJ, Weinberg A, Chan ISF, Clair J, Smith JG, Marchese RD, Williams HM, Beck DJ, McCook PT, Zhang JH, Johnson G, Oxman MN. Varicella zoster virus-specific immune responses to a herpes zoster vaccine in elderly recipients with major depression and the impact of antidepressant medications. Clin Infect Dis 2013; 56:1085-93. [PMID: 23413415 DOI: 10.1093/cid/cis1208] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Depression Substudy of the Shingles Prevention Study (SPS) was designed to evaluate the association between major depression and immune responses to a high-titer live attenuated varicella zoster virus (VZV) vaccine (zoster vaccine), which boosts cell-mediated immunity (CMI) to VZV and decreases the incidence and severity of herpes zoster (HZ). The Depression Substudy was a 2-year longitudinal cohort study in 92 community-dwelling adults≥60 years of age who were enrolled in the SPS, a large, double-blind, placebo-controlled Veterans Affairs Cooperative zoster vaccine efficacy study. METHODS Forty subjects with major depressive disorder, stratified by use of antidepressant medications, and 52 age- and sex-matched controls with no history of depression or other mental illness had their VZV-CMI measured prior to vaccination with zoster vaccine or placebo and at 6 weeks, 1 year, and 2 years postvaccination. RESULTS Depressed subjects who were not treated with antidepressant medications had lower levels of VZV-CMI following administration of zoster vaccine than nondepressed controls or depressed subjects receiving antidepressants even when antidepressant medications failed to alter depressive symptom severity (P<.005). Similar results were obtained taking into account the time-varying status of depression and use of antidepressant medications, as well as changes in depressive symptoms, during the postvaccination period. CONCLUSIONS Depressed patients have diminished VZV-CMI responses to zoster vaccine, and treatment with antidepressant medication is associated with normalization of these responses. Because higher levels of VZV-CMI correlate with lower risk and severity of HZ, untreated depression may increase the risk and severity of HZ and reduce the efficacy of zoster vaccine.
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Affiliation(s)
- Michael R Irwin
- Cousins Center for Psychoneuroimmunology, UCLA Semel Institute for Neuroscience, University of California, Los Angeles, Los Angeles, CA 90095-7057, USA.
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Long MD, Martin C, Sandler RS, Kappelman MD. Increased risk of herpes zoster among 108 604 patients with inflammatory bowel disease. Aliment Pharmacol Ther 2013; 37:420-9. [PMID: 23240738 PMCID: PMC3886551 DOI: 10.1111/apt.12182] [Citation(s) in RCA: 142] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 10/24/2012] [Accepted: 11/24/2012] [Indexed: 01/02/2023]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) on certain immunosuppressants have increased herpes zoster (HZ) risk. AIM To determine the risk of HZ in IBD and how antitumour necrosis factor-alpha (anti-TNF) agents affect this risk. METHODS We performed a retrospective cohort and nested case-control study using administrative data from IMS LifeLink(®) Information Assets-Health Plan Claims Database. In the cohort, we identified IBD patients <age 64 by diagnosis codes; matched to four individuals without IBD. HZ risk was evaluated by incidence rate ratio (IRR) and adjusted Cox proportional hazards models (HR). In the nested case-control analysis, 2659 IBD patients with HZ were each matched to four IBD patients without HZ. We determined associations between medications and HZ using conditional logistic regression. RESULTS The cohort included 50 932 patients with Crohn's disease (CD), 56 403 patients with ulcerative colitis (UC) and 1269 with unspecified IBD, matched to 434 416 individuals without IBD. The IBD cohort had increased HZ risk compared with non-IBD (IRR: 1.68, 95% CI: 1.60-1.76). After adjustment, IBD patients had a higher risk of HZ than non-IBD (HR: 1.49, 95% CI: 1.42-1.57). In the nested case-control multivariate-adjusted analyses, anti-TNF medications (OR: 1.81, 95% CI: 1.48-2.21), corticosteroids (OR: 1.73, 95% CI: 1.51-1.99) and thiopurines (OR: 1.85, 95% CI: 1.61-2.13) were independently associated with HZ. Risk of HZ was highest with combination anti-TNF and thiopurine therapy (OR: 3.29, 95% CI: 2.33-4.65). CONCLUSIONS Patients with inflammatory bowel disease are at increased risk for herpes zoster. Use of thiopurines, anti-TNF agents, combination therapy and corticosteroids increases herpes zoster risk.
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Affiliation(s)
- Millie D. Long
- University of North Carolina at Chapel Hill, Department of Medicine, Division of Gastroenterology and Hepatology,Center for Gastrointestinal Biology and Disease, Chapel Hill, NC
| | - Christopher Martin
- University of North Carolina at Chapel Hill, Department of Medicine, Division of Gastroenterology and Hepatology,Center for Gastrointestinal Biology and Disease, Chapel Hill, NC
| | - Robert S. Sandler
- University of North Carolina at Chapel Hill, Department of Medicine, Division of Gastroenterology and Hepatology,Center for Gastrointestinal Biology and Disease, Chapel Hill, NC
| | - Michael D. Kappelman
- Center for Gastrointestinal Biology and Disease, Chapel Hill, NC,University of North Carolina at Chapel Hill, Department of Pediatrics, Division of Gastroenterology and Hepatology
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Hasbún T, Chamlin SL. A 3-year-old girl with a painful skin eruption. Pediatr Ann 2013; 42:8-10. [PMID: 23316823 DOI: 10.3928/00904481-20121221-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
CME EDUCATIONAL OBJECTIVES1.Identify clinical lesions of shingles.2.Describe the importance of the attenuated varicella vaccine and its impact on shingles presentation.3.Discuss treatment options for patients with shingles. A 3-year-old, otherwise healthy female, presented to the dermatology clinic for evaluation of a painful eruption on her right arm and back. It had been present for 6 days, and had started as a single blister on her right fourth digit. Over several days, new lesions appeared on her right hand, forearm, arm, and back. All lesions were painful and pruritic. She was afebrile and otherwise felt well. Her vaccinations were all up to date. A review of systems was unremarkable; family history was noncontributory.
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Affiliation(s)
- Trinidad Hasbún
- Division of Pediatric Dermatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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Masuet-Aumatell C, Ramon-Torrell JM, Casanova-Rituerto A, Banqué-Navarro M, Dávalos-Gamboa MDR, Montaño-Rodríguez SL. Seroprevalence of varicella-zoster virus infection in children from Cochabamba: tropical or temperate pattern? Trop Med Int Health 2012; 18:296-302. [PMID: 23279637 DOI: 10.1111/tmi.12040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES To determine the seroprevalence of varicella-zoster viral (VZV) infections in schoolchildren from the Cochabamba region (Bolivia), and its association with socio-demographic variables, socio-economic status and geographical location. METHODS Seroepidemiological survey (n = 436) on VZV of schoolchildren living in the Cochabamba region of Bolivia in 2010. An ELISA test was used to measure varicella antibodies. Parents or guardians completed a questionnaire regarding socio-demographic information (age, gender, living area, parental educational level, presence of siblings and number of family members in the household), and a blood sample was collected from each child to check for VZV antibodies. A descriptive and bivariate analysis was performed. RESULTS The global prevalence of VZV was 78.2% (95% CI 74.3-82.1). It was higher in females (82.1%), pre-adolescents (aged 10.1-13 years: 81.4%) and adolescents (aged >13 years: 80.2%), in children with less well-educated parents (81.3% to 81.6%), in warmer municipalities (81.4% to 82.2%), in rural areas (80.0%), in children with siblings (80.1%), those who although the latter association was not statistically significant. CONCLUSIONS The prevalence of VZV infection in childhood was relatively high for a tropical country, and much closer to that of temperate countries prior to the introduction of varicella vaccine into vaccination programmes.
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Affiliation(s)
- Cristina Masuet-Aumatell
- International Health Center and Travel Medicine Clinic, University Hospital of Bellvitge, Bellvitge, Spain.
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233
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Attenuation of the adaptive immune response in rhesus macaques infected with simian varicella virus lacking open reading frame 61. J Virol 2012; 87:2151-63. [PMID: 23221560 DOI: 10.1128/jvi.02369-12] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Varicella zoster virus (VZV) is a neurotropic alphaherpesvirus that causes chickenpox during primary infection and establishes latency in sensory ganglia. Infection of rhesus macaques (RM) with the homologous simian varicella virus (SVV) recapitulates hallmarks of VZV infection. We have shown that an antisense transcript of SVV open reading frame 61 (ORF61), a viral transactivator, was detected most frequently in latently infected RM sensory ganglia. In this study, we compared disease progression, viral replication, immune response, and the establishment of latency following intrabronchial infection with a recombinant SVV lacking ORF61 (SVVΔORF61) to those following infection with wild-type (WT) SVV. Varicella severity and viral latency within sensory ganglia were comparable in RMs infected with SVVΔORF61 and WT SVV. In contrast, viral loads, B and T cell responses, and plasma inflammatory cytokine levels were decreased in RMs infected with SVVΔORF61. To investigate the mechanisms underlying the reduced adaptive immune response, we compared acute SVV gene expression, frequency and proliferation of dendritic cell (DC) subsets, and the expression of innate antiviral genes in bronchoalveolar lavage (BAL) samples. The abundance of SVV transcripts in all kinetic classes was significantly decreased in RMs infected with SVVΔORF61. In addition, we detected a higher frequency and proliferation of plasmacytoid dendritic cells in BAL fluid at 3 days postinfection in RMs infected with SVVΔORF61, which was accompanied by a slight increase in type I interferon gene expression. Taken together, our data suggest that ORF61 plays an important role in orchestrating viral gene expression in vivo and interferes with the host antiviral interferon response.
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Abstract
PURPOSE To provide a population-based estimate of the incidence of herpes zoster ophthalmicus (HZO) with comparisons across racial, sex, and age groups, as well as to estimate the frequency of postherpetic neuralgia (PHN). DESIGN Retrospective, population-based cohort study. PARTICIPANTS All patients enrolled in the Kaiser Permanente Hawaii health plan during the study period (N = 217 061). METHODS All patient encounters between January 1, 2006, and December 31, 2007, in the electronic medical record of Kaiser Permanente Hawaii were queried for International Classification of Diseases, 9th edition (ICD-9) codes corresponding to HZO. Charts were reviewed to confirm a diagnosis of HZO and to collect information about specific ocular manifestations. Demographic data and information on PHN were collected electronically. Incidence rates were calculated per 100 000 person-years for the entire population and for age-, sex-, and race-specific subgroups. MAIN OUTCOME MEASURES Clinical diagnosis of HZO during the study period. RESULTS A total of 134 cases of HZO were identified in this population of 217 061 people. The overall incidence was 30.9 per 100 000 person-years (95% confidence interval [CI], 25.9-36.6). The incidence rate for the population aged ≥65 years was 104.6 per 100 000 person-years (95% CI, 79.0-135.9), approximately 5 times the remainder of the population (P < 0.001). The most common manifestation of HZO was dermatitis, followed by keratitis and conjunctivitis. The incidence of HZO for Pacific Islanders was 19.0 per 100 000 person-years (95% CI, 12.4-28.3), which was significantly lower than the rate for non-Pacific Islanders (P = 0.007). Twenty-one percent of patients with HZO developed PHN. Older age and HZO with keratitis, conjunctivitis, or uveitis were found to be risk factors for PHN. CONCLUSIONS This study provides a population-based estimate of HZO and highlights differences across various age and racial groups. It also suggests that demographic characteristics may be useful in determining the risk of developing HZO.
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Tyring SK, Plunkett S, Scribner AR, Broker RE, Herrod JN, Handke LT, Wise JM, Martin PA. Valomaciclovir versus valacyclovir for the treatment of acute herpes zoster in immunocompetent adults: a randomized, double-blind, active-controlled trial. J Med Virol 2012; 84:1224-32. [PMID: 22711350 DOI: 10.1002/jmv.23329] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Herpes zoster is a common infectious disease that can result in significant acute and chronic morbidity. The safety and efficacy of once-daily oral valomaciclovir (EPB-348) was evaluated for non-inferiority to 3-times daily valacyclovir, an approved therapy. In this study, 373 immunocompetent adults with onset of a herpes zoster rash within the preceding 72 hr were randomly assigned to receive one of four treatments for 7 days: (1) EPB-348 1,000 mg once-daily; (2) EPB-348 2,000 mg once-daily; (3) EPB-348 3,000 mg once-daily; or (4) valacyclovir 1,000 mg 3-times daily. A 20% margin was the reference for non-inferiority assessment. For the primary efficacy measure of time to complete crusting of the zoster rash by Day 28, non-inferiority criteria were met for once-daily EPB-348 2,000 mg and once-daily EPB-348 3,000 mg compared to 3-times daily valacyclovir. Additionally, EPB-348 3,000 mg significantly shortened the time to complete rash crusting by Day 28 compared to valacyclovir. For secondary efficacy measures, non-inferiority was achieved for the EPB-348 1,000 and 2,000 mg groups compared to the valacyclovir group for time to rash resolution by Day 28. No EPB-348 group was non-inferior to valacyclovir for time to cessation of new lesion formation or time to cessation of pain by Day 120, though no significant differences occurred between treatment groups. Nausea, headache, and vomiting were the most common adverse events. Based on these results, additional studies are warranted to define further EPB-348's potential as an effective and safe therapy for acute herpes zoster.
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Affiliation(s)
- Stephen K Tyring
- Departments of Dermatology, Microbiology and Molecular Genetics, and Internal Medicine, University of Texas Health Science Center, Houston, TX, USA.
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Furst DE, Clarke AE, Fernandes AW, Bancroft T, Greth W, Iorga SR. Incidence and prevalence of adult systemic lupus erythematosus in a large US managed-care population. Lupus 2012; 22:99-105. [DOI: 10.1177/0961203312463110] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective The objective of this paper is to determine the incidence and prevalence of adult systemic lupus erythematosus (SLE) in a large US managed-care population. Methods Subject inclusion in the incidence cohort required a medical claim with an SLE diagnosis and a service date from 2003 to 2008 that satisfied the following criteria: 1) ≥18 years on service date; 2) continuously enrolled for 24 months before and 12 months after service date; 3) in the 12 months after service date, ≥ one inpatient claim or ≥ two office or ER visits with an SLE diagnosis; 4) no SLE diagnosis 24 months prior to service date; and 5) no SLE medications 12 months prior to service date. Prevalence cohort subjects were identified using a similar algorithm and were not required to satisfy criteria 4) and 5). Results A total of 1,557 subjects were included in the incidence cohort, and 15,396 were included in the prevalence cohort. The overall age- and gender-adjusted SLE incidence rate (2003–2008) was 7.22 cases per 100,000 person-years. The annual prevalence of SLE (per 100,000 individuals) varied from 81.07 in 2003 to 102.94 in 2008. Conclusion The SLE incidence in this large managed-care plan with geographic diversity was slightly higher than previous estimates, and the prevalence was within the range of previous estimates.
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Affiliation(s)
- DE Furst
- University of California, Los Angeles, CA, USA
| | - AE Clarke
- McGill University, Montreal, Quebec, Canada
| | | | | | - W Greth
- MedImmune LLC, Gaithersburg, MD, USA
| | - SR Iorga
- OptumInsight, Eden Prairie, MN, USA
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Joesoef RM, Harpaz R, Leung J, Bialek SR. Chronic medical conditions as risk factors for herpes zoster. Mayo Clin Proc 2012; 87:961-7. [PMID: 23036671 PMCID: PMC3538398 DOI: 10.1016/j.mayocp.2012.05.021] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 05/25/2012] [Accepted: 05/30/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To determine the degree to which chronic conditions might contribute to the unexplained burden of herpes zoster. METHODS We conducted a case-control study using MarketScan data from January 1, 2007, through December 31, 2007, to investigate chronic conditions as risk factors for herpes zoster among persons 20 to 64 years old. Cases were enrollees with a herpes zoster diagnosis (International Classification of Diseases, Ninth Revision, Clinical Modification codes 053.xx), and controls were those without a herpes zoster diagnosis, matched by age groups and insurance plan. We selected 10 chronic conditions based on their prevalence in the general population. We calculated the attributable fraction and created a comorbidity composite score by summing the significant coefficient of regression of chronic conditions. We used logistic regression to evaluate the associations between herpes zoster and chronic conditions. RESULTS We identified a total of 59,173 cases and 616,177 controls for the analysis. Risk of herpes zoster was significant for 8 of the 10 study conditions (odds ratios, 1.06-1.52). Herpes zoster risk also increased as a function of comorbidity composite score. The attributable fractions for these 8 significant conditions ranged from 0.24% to 2.89%. CONCLUSION The risk of herpes zoster may be increased in people with chronic conditions. However, this risk may not contribute substantially to the burden of herpes zoster in the population. The causes for most cases of herpes zoster remain unknown.
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Affiliation(s)
| | - Rafael Harpaz
- Correspondence: Address to Rafael Harpaz, MD, MPH, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, MS A-34, Atlanta, GA 30333
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Baxter R, Tran TN, Hansen J, Emery M, Fireman B, Bartlett J, Lewis N, Saddier P. Safety of Zostavax™--a cohort study in a managed care organization. Vaccine 2012; 30:6636-41. [PMID: 22963800 DOI: 10.1016/j.vaccine.2012.08.070] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 08/22/2012] [Accepted: 08/28/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Zostavax™ is a live, attenuated varicella-zoster virus vaccine indicated for the prevention of herpes zoster (shingles). An observational post-licensure (Phase IV) study was conducted at Kaiser Permanente Northern California (KPNC), a US managed care organization, to assess the safety of zoster vaccine in people 60 years of age or older, vaccinated in routine medical care. METHODS We performed a cohort study, comparing rates of clinical events resulting in hospitalizations or emergency department visits in a 42-day risk time period immediately following vaccination with rates in the same cohort in a subsequent comparison time period. The study data were reviewed and interpreted by an external safety review committee of 3 independent experts. RESULTS Approximately 29,000 people ≥ 60 years of age were vaccinated with zoster vaccine from July 2006 to November 2007. Of the 386 comparisons performed for the main analysis, 4 had an increased relative risk with a nominal p-value ≤ 0.05. After medical records review, the timing of these conditions and procedures was found to be often prior to vaccination, and no clear increase in health events was observed in the risk period following vaccination compared to later. Persons receiving zoster vaccine appeared to be in their optimal health at the time of vaccination, which led to an apparent protective effect of the vaccine for some health outcomes, due to the study design. CONCLUSIONS There was no evidence of a safety concern for zoster vaccine.
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Affiliation(s)
- Roger Baxter
- Kaiser Permanente Vaccine Study Center, Oakland, CA, USA.
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Moquete RA, Hartman B, Granstein RD. Herpes Zoster with Cutaneous Dissemination in a Patient 21 Years after Splenectomy for Idiopathic Thrombocytopenic Purpura. J Cutan Med Surg 2012; 16:368-71. [DOI: 10.1177/120347541201600518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: Varicella-zoster virus is a member of the herpes virus family that causes varicella during a primary infection and herpes zoster (HZ) when reactivated. Patients who are immunocompromised often have atypical presentations of HZ and experience complications such as multidermal involvement and dissemination. Objective: We report a case of disseminated HZ in an immunocompetent patient with a history of splenectomy for idiopathic thrombocytopenic purpura (ITP). Our 46-year-old female patient presented with a painful vesiculopapular dermatomal rash with approximately 80 other lesions diffusely spread over her body. She was in good health but had a splenectomy for ITP 21 years earlier and a history of recurrent herpes labialis. The latter led to the tentative diagnosis of a widespread herpes simplex infection. However, laboratory results confirmed a diagnosis of disseminated herpes zoster. A workup of the patient's immune status did not reveal any abnormalities other than the patient's previously noted splenectomy. Conclusions: This case adds to the two reports of patients developing cutaneous disseminated HZ several years after splenectomy. Our case serves as a reminder that patients with a history of splenectomy appear to be at increased risk for cutaneous dissemination of HZ. Renseignements de base: Le virus varicelle-zona est un virus de la famille des Herpesviridae qui cause la varicelle durant une primo-infection, et l'herpès zoster (zona) (HZ) en cas de réactivation. Les patients qui sont immunocompromis ont souvent des présentations atypiques de HZ et affichent des complications telles que la participation et la dissémination multicutanées. Objectif: Nous exposons un cas de zona disséminé chez un patient immunocompétent ayant subi une splénectomie pour traiter un purpura thrombocytopénique idiopathique (PTI). Notre patiente âgée de 46 ans présentait une éruption vésiculo-papuleuse douloureuse localisée dans une zone dermatome avec environ 80 autres lésions diffuses réparties sur son corps. Elle était en bonne santé mais avait subi une splénectomie pour traiter un PTI 21 ans plus tôt et présentait des antécédents d'épisodes récurrents d'herpès labial. Ce dernier a abouti 'a un diagnostic provisoire d'une infection généralisée par le virus herpès simplex. Cependant, les résultats des analyses de laboratoire ont confirmé un diagnostic d'herpès zoster (zona) disséminé. Une investigation de l'état immunitaire de la patiente n'a pas révélé d'anomalies autres que la splénectomie que la patiente a subie antérieurement. Conclusions: Ce cas vient s'ajouter aux deux cas de patients signalés qui ont développé un HZ disséminé plusieurs années après avoir subi une splénectomie. Notre cas sert à rappeler que les patients présentant des antécédents de splénectomie semblent être exposés à un risque accru de dissémination cutanée sous forme de HZ.
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Affiliation(s)
- Rachel A. Moquete
- Departments of Dermatology and Medicine, Weill Cornell Medical College of Cornell University, New York, NY
| | - Barry Hartman
- Departments of Dermatology and Medicine, Weill Cornell Medical College of Cornell University, New York, NY
| | - Richard D. Granstein
- Departments of Dermatology and Medicine, Weill Cornell Medical College of Cornell University, New York, NY
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Leroux-Roels I, Leroux-Roels G, Clement F, Vandepapelière P, Vassilev V, Ledent E, Heineman TC. A phase 1/2 clinical trial evaluating safety and immunogenicity of a varicella zoster glycoprotein e subunit vaccine candidate in young and older adults. J Infect Dis 2012; 206:1280-90. [PMID: 22872734 DOI: 10.1093/infdis/jis497] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND An adjuvanted recombinant varicella zoster virus (VZV) subunit vaccine is being developed for the prevention of herpes zoster and its complications. METHODS In a phase I/II, open-label, randomized, parallel-group study, older adults (50-70 years) received 2 doses 2 months apart of an adjuvanted recombinant glycoprotein E vaccine (HZ/su; n = 45), a live attenuated Oka strain VZV vaccine (OKA; n = 45), or HZ/su and OKA administered concomitantly (n = 45). To evaluate safety prior to administration in older adults, young adults (18-30 years) were vaccinated with 2 doses 2 months apart of HZ/su (n = 10) or OKA (n = 10). Safety and immunogenicity were assessed up to 42 months for older adults immunized with HZ/su and up to 12 months for all others. RESULTS Few grade 3 events and no severe adverse events were reported. Fatigue, myalgia, headache, and injection site pain were the most common solicited reactions for HZ/su and occurred more frequently than with OKA. CD4(+) T-cell and humoral immune responses were much higher with HZ/su than with OKA and remained elevated until 42 months. Addition of OKA to HZ/su did not increase immunogenicity. CONCLUSIONS In this study, HZ/su adjuvanted subunit vaccine was well tolerated and more immunogenic than a live attenuated VZV vaccine. Clinical Trial registration. NCT00492648 and NCT00492648.
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Abstract
Vaccination is the most efficient strategy to prevent infectious disease. The increased vulnerability to infection of the elderly makes them a particularly important target population for vaccination. However, most vaccines are less immunogenic and efficient in the elderly because of age-related changes in the immune system. Vaccination against influenza, Streptococcus pneumoniae and varicella zoster virus is recommended for the elderly in many countries. Various strategies such as the use of adjuvants and novel administration routes are pursued to improve influenza vaccination for the elderly and recent developments in the field of pneumococcal vaccination led to the licensure of protein-conjugated polysaccharide vaccines containing up to 13 serotypes. As antibody titres are generally lower in the elderly and-particularly for inactivated vaccines-decline fast in the elderly, regular booster immunizations, for example against tetanus, diphtheria and, in endemic areas, tick-borne encephalitis, are essential during adulthood to ensure protection of the elderly. With increasing health and travel opportunities in old age the importance of travel vaccines for persons over the age of 60 is growing. However, little is known about immunogenicity and efficacy of travel vaccines in this age group. Despite major advances in the field of vaccinology over the last decades, there are still possibilities for improvement concerning vaccines for the elderly. Novel approaches, such as viral vectors for antigen delivery, DNA-based vaccines and innovative adjuvants, particularly toll-like receptor agonists, will help to achieve optimal protection against infectious diseases in old age.
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Affiliation(s)
- B Weinberger
- Institute for Biomedical Aging Research, Austrian Academy of Sciences, Innsbruck, Austria
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Barton JC, Barton JC, Bertoli LF. Predictors of shingles reports at diagnosis of common variable immunodeficiency and selective immunoglobulin G subclass deficiency in 212 Alabama adults. Infect Dis Rep 2012; 4:e34. [PMID: 24470948 PMCID: PMC3892630 DOI: 10.4081/idr.2012.e34] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2011] [Revised: 04/16/2012] [Accepted: 05/28/2012] [Indexed: 12/04/2022] Open
Abstract
We sought to determine predictors of shingles reports in adults with common variable immunodeficiency or immunoglobulin (Ig) G subclass deficiency (CVID/IgGSD). We tabulated observations at diagnosis of CVID/IgGSD in 212 white adult index patients (165 women, 47 men) who responded to a question about having had shingles. None had been vaccinated for herpes zoster. We analyzed age, sex, and shingles reports; blood levels of CD19+, CD4+, CD8+, and CD56+ mononuclear cells; serum levels of IgG subclasses, IgA, and IgM; and positivity for human leukocyte antigen (HLA)-A and -B haplotypes. Cell counts and immunoglobulin levels were normalized with loge (ln) transformation for analyses. Thirty-one patients (14.6%) reported shingles; 11 reported recurrent or disseminated shingles. Patients with shingles reports had greater mean age at diagnosis of CVID/IgGSD [54±13 (standard deviation) years vs. 47±12 years; P=0.0130] and a greater prevalence of HLA-A*01, B*08 positivity (35.5% vs. 17.7%; P=0.0227). In a 13-factor logistic regression model, there was a positive association of age with shingles reports [P=0.0151; odds ratio (1.05, 95% confidence interval 1.01, 1.08)]. HLA-A*01, B*08 positivity was also positively associated with shingles reports [P=0.0480; odds ratio 2.61 (1.00, 6.81)]. During a mean followup interval of 7.5 years after CVID/IgGSD diagnosis, the prevalence of recurrent shingles was almost five-fold greater in patients with previous shingles reports. In conclusion, in white adults at CVID/IgGSD diagnosis, age at diagnosis and positivity for HLA-A*01, B*08 have significant positive associations with reports of previous shingles.
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Affiliation(s)
- James C Barton
- Brookwood Medical Center, ; Southern Iron Disorders Center, ; Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Zhang J, Xie F, Delzell E, Chen L, Winthrop K, Lewis JD, Saag K, Baddley JW, Curtis JR. Association between vaccination for herpes zoster and risk of herpes zoster infection among older patients with selected immune-mediated diseases. JAMA 2012; 308:43-9. [PMID: 22760290 PMCID: PMC3683869 DOI: 10.1001/jama.2012.7304] [Citation(s) in RCA: 203] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
CONTEXT Based on limited data, the live attenuated herpes zoster (HZ) vaccine is contraindicated in patients taking anti-tumor necrosis factor (anti-TNF) therapies or other biologics commonly used to treat immune-mediated diseases. The safety and effectiveness of the vaccine are unclear for these patients. OBJECTIVE To examine the association between HZ vaccination and HZ incidence within and beyond 42 days after vaccination in patients with selected immune-mediated diseases and in relation to biologics and other therapies used to treat these conditions. DESIGN, SETTING, AND PATIENTS Retrospective cohort study of 463,541 Medicare beneficiaries 60 years and older with rheumatoid arthritis, psoriasis, psoriatic arthritis, ankylosing spondylitis, or inflammatory bowel disease using Medicare claims data from January 1, 2006, through December 31, 2009. MAIN OUTCOME MEASURES Herpes zoster incidence rate within 42 days after vaccination (a safety concern) and beyond 42 days; hazard ratios estimated using Cox proportional hazards models for HZ comparing vaccinated vs unvaccinated patients. RESULTS Median duration of follow-up was 2.0 years (interquartile range, 0.8-3.0); 4.0% of patients received HZ vaccine. The overall crude HZ incidence rate was 7.8 cases per 1000 person-years (95% CI, 3.7-16.5) within 42 days after vaccination. The rate among the unvaccinated was 11.6 cases per 1000 person-years (95% CI, 11.4-11.9). Among 633 patients exposed to biologics at the time of vaccination or within the subsequent 42 days, no case of HZ or varicella occurred. After multivariable adjustment, HZ vaccination was associated with a hazard ratio of 0.61 (95% CI, 0.52-0.71) for HZ risk after 42 days. CONCLUSIONS Receipt of HZ vaccine was not associated with a short-term increase in HZ incidence among Medicare beneficiaries with selected immune-mediated diseases, including those exposed to biologics. The vaccine was associated with a lower HZ incidence over a median of 2 years of follow-up.
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Affiliation(s)
- Jie Zhang
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Fenglong Xie
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL
| | - Elizabeth Delzell
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Lang Chen
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL
| | - Kevin Winthrop
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Science University, Portland, OR
| | - James D Lewis
- Center for Clinical Epidemiology and Biostatistics; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kenneth Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL
| | - John W Baddley
- Division of Infectious Diseases, University of Alabama at Birmingham and Birmingham Veteran Affairs Medical Center, Birmingham, AL
| | - Jeffrey R Curtis
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL
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Smoyer-Tomic KE, Amato AA, Fernandes AW. Incidence and prevalence of idiopathic inflammatory myopathies among commercially insured, Medicare supplemental insured, and Medicaid enrolled populations: an administrative claims analysis. BMC Musculoskelet Disord 2012; 13:103. [PMID: 22703603 PMCID: PMC3480956 DOI: 10.1186/1471-2474-13-103] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Accepted: 05/29/2012] [Indexed: 11/17/2022] Open
Abstract
Background Idiopathic inflammatory myopathies (IIMs) are a rare group of autoimmune syndromes characterized by chronic muscle inflammation and muscle weakness with no known cause. Little is known about their incidence and prevalence. This study reports the incidence and prevalence of IIMs among commercially insured and Medicare and Medicaid enrolled populations in the US. Methods We retrospectively examined medical claims with an IIM diagnosis (ICD-9-CM 710.3 [dermatomyositis (DM)], 710.4 [polymyositis (PM)], 728.81[interstitial myositis]) in the MarketScan® databases to identify age- and gender-adjusted annual IIM incidence and prevalence for 2004–2008. Sensitivity analysis was performed for evidence of a specialist visit (rheumatologist/ neurologist/dermatologist), systemic corticosteroid or immunosuppressant use, or muscle biopsy. Results We identified 2,990 incident patients between 2004 and 2008 (67% female, 17% Medicaid enrollees, 27% aged ≥65 years). Overall adjusted IIM incidence for 2004–2008 for commercial and Medicare supplemental groups combined were 4.27 cases (95% CI, 4.09-4.44) and for Medicaid, 5.23 (95% CI 4.74-5.72) per 100,000 person-years (py). Disease sub-type incidence rates per 100,000-py were 1.52 (95% CI 1.42-1.63) and 1.70 (1.42-1.97) for DM, 2.46 (2.33-2.59) and 3.53 (3.13-3.94) for PM, and 0.73 (0.66-0.81) and 0.78 (0.58-0.97) for interstitial myositis for the commercial/Medicare and Medicaid cohorts respectively. Annual incidence fluctuated over time with the base MarketScan populations. There were 7,155 prevalent patients, with annual prevalence ranging from 20.62 to 25.32 per 100,000 for commercial/Medicare (83% of prevalent cases) and from 15.35 to 32.74 for Medicaid. Conclusions We found higher IIM incidence than historically reported. Employer turnover, miscoding and misdiagnosing, care seeking behavior, and fluctuations in database membership over time can influence the results. Further studies are needed to confirm the incidence and prevalence of IIM.
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Otsuki K, Kenmochi T, Maruyama M, Akutsu N, Iwashita C, Ito T, Matsumoto I, Asano T. A case of Ramsay Hunt syndrome in living-kidney transplant recipient. Transplant Proc 2012; 44:307-8. [PMID: 22310640 DOI: 10.1016/j.transproceed.2011.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
A 36-year-old woman underwent ABO-incompatible living-donor kidney transplantation. Immunosuppression was achieved by quadruple therapy with tacrolimus, basiliximab, mycophenolate mofetil (MMF), and prednisone. Desensitization and removal of anti-ABO antibody was achieved by administration of MMF for 4 weeks before transplantation followed by intravenous administration of rituximab, double-filtered plasmapheresis, and plasma exchange. At 1 month after transplantation, she complained of left ear pain without vesicle rash, tinnitus, and vertigo. Physical examination revealed left facial paralysis and nystagmus. T2 fluid-attenuated inversion recovery magnetic resonance imaging (MRI) visualized swelling of the left facial nerve. Real-time polymerase chain reaction showed the existence of varicella zoster virus DNA in the patient's tears and saliva. The final diagnosis was Ramsay Hunt syndrome without vesicle rash, which is called zoster sine herpete. The patient was treated by intravenous administration of acyclovir (3 mg/kg, 3 times per day) in addition to the reduction of the MMF dose. For facial nerve palsy, prednisolone was prescribed for 3 days and then gradually tapered. These treatments improved the symptoms of tinnitus and vertigo after a month; the facial nerve palsy completely disappeared after 10 months. This case demonstrated MRI to be a useful modality for the early diagnosis of Ramsay Hunt syndrome without vesicle eruption.
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Affiliation(s)
- K Otsuki
- Department of Surgery, National Chiba-East Hospital, Chiba, Japan.
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Li HT, Lu S, Liu JM. Herpes Zoster Vaccination in People Aged 50–59 Years. Clin Infect Dis 2012; 54:929-30. [DOI: 10.1093/cid/cir974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Hong-tian Li
- Department of Epidemiology, Institute of Reproductive and Child Health/Ministry of Health Key Laboratory of Reproductive Health, Peking University Health Science Center
| | - Shichao Lu
- Department of Dermatology, 306th Hospital of Chinese People’s Liberation Army, Beijing, China
| | - Jian-meng Liu
- Department of Epidemiology, Institute of Reproductive and Child Health/Ministry of Health Key Laboratory of Reproductive Health, Peking University Health Science Center
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Drolet M, Levin MJ, Schmader KE, Johnson R, Oxman MN, Patrick D, Fournier SO, Mansi JA, Brisson M. Employment related productivity loss associated with herpes zoster and postherpetic neuralgia: a 6-month prospective study. Vaccine 2012; 30:2047-50. [PMID: 22285632 DOI: 10.1016/j.vaccine.2012.01.045] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Revised: 01/13/2012] [Accepted: 01/17/2012] [Indexed: 10/14/2022]
Abstract
We conducted a prospective multi-center study to assess productivity loss associated with herpes zoster (HZ) and postherpetic neuralgia (PHN). From 10/2005 to 07/2006, we recruited immunocompetent subjects aged ≥50 years with HZ within 14 days of rash onset across Canada. Of the 249 patients recruited, 88 were employed. Data on employment status, absences from work, reasons for absence and effectiveness at work were documented at recruitment, 7-14-21-30-60-90-120-150 and 180 days later. The majority (64%) of employed subjects missed work because of HZ and 76% reported decreased effectiveness at work (i.e. presenteeism) because of HZ/PHN. Mean hours of absenteeism and presenteeism per working individual were 27 and 34 h, respectively. Pain severity and duration were associated with greater productivity loss. These results provide new information about the burden of HZ and PHN, which is useful for public health planning and cost-effectiveness analyses of HZ vaccination among individuals of working age.
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Affiliation(s)
- Mélanie Drolet
- URESP, Centre de recherche FRSQ du CHA universitaire de Québec, QC, Canada
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Neuropathic Pain. Neurology 2012. [DOI: 10.1007/978-0-387-88555-1_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Lionis CD, Vardavas CI, Symvoulakis EK, Papadakaki MG, Anastasiou FS, Antonopoulou MD, Apostolakis CM, Dimitrakopoulos SA, Fountakis GI, Grammatikopoulos IA, Komninos JD, Kounalakis DK, Ladoukaki ES, Makri KV, Petraki CS, Ploumis NG, Prokopiadou DP, Stefanaki IN, Tsakountakis NA, Tsiligianni IG, Tzortzis EN, Vasilaki AA, Vasilopoulos TK, Vrentzos GE. Measuring the burden of herpes zoster and post herpetic neuralgia within primary care in rural Crete, Greece. BMC FAMILY PRACTICE 2011; 12:136. [PMID: 22145678 PMCID: PMC3266196 DOI: 10.1186/1471-2296-12-136] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Accepted: 12/06/2011] [Indexed: 11/10/2022]
Abstract
Background Research has indicated that general practitioners (GPs) have good clinical judgment in regards to diagnosing and managing herpes zoster (HZ) within clinical practice in a country with limited resources for primary care and general practice. The objective of the current study was to assess the burden of HZ and post herpetic neuralgia (PHN) within rural general practices in Crete, Greece. Methods The current study took place within a rural setting in Crete, Greece during the period of November 2007 to November 2009 within the catchment area in which the Cretan Rural Practice-based Research Network is operating. In total 19 GP's from 14 health care units in rural Crete were invited to participate, covering a total turnover patient population of approximately 25, 000 subjects. For the purpose of this study an electronic record database was constructed and used as the main tool for monitoring HZ and PHN incidence. Stress related data was also collected with the use of the Short Anxiety Screening Test (SAST). Results The crude incidence rate of HZ was 1.4/1000 patients/year throughout the entire network of health centers and satellite practices, while among satellite practices alone it was calculated at 1.3/1000 patients/year. Additionally, the standardised incidence density within satellite practices was calculated at 1.6/1000 patients/year. In regards to the stress associated with HZ and PHN, the latter were found to have lower levels of anxiety, as assessed through the SAST score (17.4 ± 3.9 vs. 21.1 ± 5.7; p = 0.029). Conclusions The implementation of an electronic surveillance system was feasible so as to measure the burden of HZ and PHN within the rural general practice setting in Crete.
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Affiliation(s)
- Christos D Lionis
- Department of Social Medicine, Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, PO Box 2208, Postal Code 71003, Greece.
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