The global disease burden of varicella-zoster virus infection from 1990 to 2019

Varicella-Zoster Virus Pretransplant Vaccination and Posttransplant Infections Among Pediatric Solid Organ Recipients in the Two-Dose Varicella Era: A Single-Center, Multi-Organ Retrospective Study

BACKGROUND

Varicella-zoster virus (VZV) pretransplant immunization rates, exposures, and posttransplant disease are poorly characterized among pediatric solid organ transplant (SOT) recipients in the two-dose varicella vaccine era.

METHODS

A retrospective analysis of the electronic health records among children <18 years old who received SOT from January 1, 2011 through December 31, 2021, was performed at a single center to assess for missed pretransplant varicella vaccination opportunities, characterize VZV exposures, and describe posttransplant disease.

RESULTS

Among 525 children, 444 were ≥6 months old (m.o.) at SOT with a documented VZV vaccine status. Eighty-five (19%) did not receive VZV Dose One; 30 out of 85 (35%) could have been immunized. Infants 6-11 m.o. accounted for 14 out of 30 (47%) missed opportunities. Among children ≥12 m.o. with documented Dose Two status (n = 383), 72 had missed vaccination opportunities; 57 out of 72 (79%) were children 1-4 years old. Most children had unclassifiable pre-SOT serostatus as varicella serology was either not obtained/documented (n = 171) or the possibility of passive antibodies was not excluded (n = 137). Of those with classified serology (n = 188), 69 were seroimmune. Forty-seven of 525 (9%) children had recorded VZV exposures; two developed varicella-neither had documented pre-SOT seroimmunity nor had received post-exposure prophylaxis. Nine additional children had medically attended disease: four primary varicella and five zoster. Of the 11 cases, 10 had cutaneous lesions without invasive disease; one had multi-dermatomal zoster with transaminitis. Seven (64%) received treatment exclusively outpatient.

CONCLUSIONS

VZV exposure and disease still occur. Optimizing immunization among eligible candidates and ensuring patients have a defined VZV serostatus pretransplantation remain goals of care.

Epidemiology of autoimmune encephalitis and comparison to infectious causes-Experience from a tertiary center

OBJECTIVES

The incidence of autoimmune encephalitis (AIE) has risen in the last decade, yet recent studies are lacking. We compared the epidemiology of autoimmune and infectious encephalitis cases in Tel-Aviv Sourasky Medical Center (TASMC) between 2010 and 2020.

METHODS

All encephalitis cases, aged 18 and above, admitted to TASMC between the years 2010 and 2020 were reviewed for demographic, clinical, laboratory, and imaging data and categorized based on etiology.

RESULTS

Two hundred and twenty-five patients with encephalitis were identified. The most common identifiable cause was viral (42%), followed by autoimmune encephalitis (35%), bacterial (18%), and fungal/parasitic (5%). The incidence of AIE cases out of the yearly admitted cases increased substantially, from 3.8/100 K in 2010 to 18.8/100 K in 2020. The incidence of viral cases also increased while those of bacterial and fungal/parasitic infections remained stable. Patients with AIE were younger compared to infectious patients (p-value <0.001) and had lower markers of systemic and cerebrospinal fluid inflammation (p-value for all <0.001). Seizures were more common among AIE patients (p-value <0.001), yet one-year mortality rates were higher among infectious patients (p-value <0.001).

INTERPRETATION

AIE incidence has risen significantly in our institution during the past decade, with current rates comparable to those of all infectious causes combined. Based on this cohort, clinical clues for an autoimmune etiology include a non-inflammatory cerebrospinal fluid profile, the presence of seizures, and temporal lobe imaging abnormalities (also common in herpetic encephalitis). In light of its rising incidence and the importance of early treatment, AIE should be considered in the differential diagnosis of all encephalitis cases.

The global burden of lymphoma: estimates from the Global Burden of Disease 2019 study

OBJECTIVES

The aim of this study was to describe the global trends in the burden of lymphoma from 1990 to 2019.

STUDY DESIGN

The data used in this study were from the Global Burden of Disease 2019 study.

METHODS

This study described the age-standardised rates of incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs) of lymphoma (non-Hodgkin and Hodgkin's lymphoma, NHL and HL, respectively) annually from 1990 to 2019, stratified by sociodemographic index (SDI) and 21 world regions. The estimated annual percentage changes in these indexes were calculated.

RESULTS

In 2019, the age-standardised rates of HL per 100,000 population were lower than those of NHL in terms of incidence (1.1 vs 6.7 per 100,000 person-years, respectively) and prevalence (0.3 vs 5.7 per 100,000 person-years, respectively) but not mortality (21.6 vs 3.2 per 100,000 person-years, respectively). From 1999 to 2019, the global incidence of HL decreased and the incidence of NHL increased, and the prevalence of both HL and NHL increased, but the mortality rates decreased. When stratified by SDI, the incidence of HL decreased in all but middle-SDI regions, the mortality rate of HL decreased in all regions, and both the incidence and mortality rate of NHL increased in all but high-SDI regions. The prevalence of HL and NHL increased in all SDI regions, especially in middle-SDI regions. YLLs and DALYs of HL in all SDI regions and those of NHL in high-SDI regions decreased. YLDs slightly increased in middle- to high-SDI regions.

CONCLUSIONS

Lymphoma remains a major public health issue, and better prevention, precise identification, and promising treatments are vitally important.

Mendelian randomization analysis suggests no associations of human herpes viruses with amyotrophic lateral sclerosis

Background

The causal associations between infections with human herpes viruses (HHVs) and amyotrophic lateral sclerosis (ALS) has been disputed. This study investigated the causal associations between herpes simplex virus (HSV), varicella-zoster virus (VZV), Epstein-Barr virus (EBV), cytomegalovirus (CMV), HHV-6, and HHV-7 infections and ALS through a bidirectional Mendelian randomization (MR) method.

Methods

The genome-wide association studies (GWAS) database were analyzed by inverse variance weighted (IVW), MR-Egger, weighted median, simple mode, and weighted mode methods. MR-Egger intercept test, MR-PRESSO test, Cochran's Q test, funnel plots, and leaveone-out analysis were used to verify the validity and robustness of the MR results.

Results

In the forward MR analysis of the IVW, genetically predicted HSV infections [odds ratio (OR) = 0.9917; 95% confidence interval (CI): 0.9685-1.0154; p = 0.4886], HSV keratitis and keratoconjunctivitis (OR = 0.9897; 95% CI: 0.9739-1.0059; p = 0.2107), anogenital HSV infection (OR = 1.0062; 95% CI: 0.9826-1.0304; p = 0.6081), VZV IgG (OR = 1.0003; 95% CI: 0.9849-1.0160; p = 0.9659), EBV IgG (OR = 0.9509; 95% CI: 0.8879-1.0183; p = 0.1497), CMV (OR = 0.9481; 95% CI: 0.8680-1.0357; p = 0.2374), HHV-6 IgG (OR = 0.9884; 95% CI: 0.9486-1.0298; p = 0.5765) and HHV-7 IgG (OR = 0.9991; 95% CI: 0.9693-1.0299; p = 0.9557) were not causally associated with ALS. The reverse MR analysis of the IVW revealed comparable findings, indicating no link between HHVs infections and ALS. The reliability and validity of the findings were verified by the sensitivity analysis.

Conclusion

According to the MR study, there is no evidence of causal associations between genetically predicted HHVs (HSV, VZV, EBV, CMV, HHV-6, and HHV-7) and ALS.

Unraveling the debate: Can the skin manifestations of SARS-CoV-2 infection and vaccination be explained by the reactivation of herpes virus?

Since the COVID-19 outbreak, there have been numerous reports concerning COVID-19 skin manifestations. Debate has ensued as to whether these lesions are unique or represent a form of viral reactivation. The aim of this research was to compare the incidence of herpetic skin lesions between a COVID-19 group, a Sars-CoV-2 mRNA vaccination group, and their respective controls, taking into account their Herpesviridae carrier status. To achieve this goal, the Maccabi Healthcare Services' database was scanned and cohorts of both verified COVID-19 and mRNA vaccinated patients were extracted and matched to random control groups. Patients with a documented occurrence of any Herpesviridae infection that occurred prior to the studied 'event' (i.e., COVID-19 or mRNA vaccination) were regarded as carriers of Herpesviridae. A COVID-19-related or vaccination-related lesion was defined as a clinically diagnosed herpetic lesion appearing 1 month after the index date. In the COVID-19 cohort, there was an insignificant difference in herpetic lesion incidence between the groups. However, logistic regression demonstrated that the interaction of COVID-19 with the Herpesviridae carrier status was statistically significant. For the vaccination cohort, the data showed statistically significant differences between groups in herpetic frequencies, which manifested as an almost 2-fold odds of developing a herpetic lesion. In conclusion, following the analysis of two large cohorts, there is evidence to support the contribution of both COVID-19 and the mRNA vaccine to the reactivation of Herpesviridae. Our results diminish the idea that COVID-19 has unique, herpetic-like lesions.

Infections in the first year of living related kidney transplantation in a young transplant cohort

BACKGROUND

Infection after a kidney transplant is a serious cause of morbidity and mortality. Weighing the risks and benefits of immunosuppression is of paramount importance for patient wellbeing and transplant survival.

METHODS

This is a prospective observational study exploring the variety of bacterial, viral and fungal infections occurring within the first year of living related kidney transplantation in a young transplant cohort. Fifty-one kidney transplant recipients (KTR) between the age of 18 and 45 who had a kidney transplant between Jan 2020 and Jan 2022 were enrolled and followed up for one year. Primary outcome was the occurrence of infection.

RESULTS

Twenty-four patients (47%) recorded a collective 33 episodes of infection. Seven patients had repeated infections and 17 had single infections. Twenty-seven patients had an uneventful year with no infections recorded. Commonest infection was lower urinary tract infection (UTI) (27.3%) followed by SARS-COV2 and Herpes Zoster (15.2%). The commonest pathogens causing lower UTI were Escherichia coli (E coli) (21.2%) and Klebsiella (18.2%). Median Tacrolimus level was (7.8) ng/ml in KTR with infection and (8.95) ng/ml in KTR without infection, p = 0.21. Median Haemoglobin (IQR) was (10.2) g/dl (7.8-14) gm/dl in KTR with infection compared to (10.8) g/dl (7.3-15.3) in KTR without infection odds ratio (OR) = 0.78, confidence interval (CI) (0.5-1.1); p = 0.16.In KTR with infection 25% had donors above the age of 60 compared to 11% in KTR without infection ( OR 2.6,CI (0.5-12), p = 0.2). Post transplant diabetes (PTDM) occurred in (25%) in KTR with infection compared to those without, but that was not statistically significant p = 0. 365.In KTR without infection, 59.3% had a preemptive transplant compared to 20.8% in the group with infection (OR = 0.18; 95% CI: 0.052-0.631; p = 0.007). Median tacrolimus was 7.8 ng/ml in KTR with single infection compared to 7.7 ng/ml in KTR with repeated infections.

CONCLUSION

This study shows that the commonest infection occurring in the first-year post kidney transplant was lower urinary tract infection followed by SARS-COV2 and Herpes Zoster. There was no difference in trough tacrolimus or haemoglobin levels between KTR who developed infection with those who did not.

Spinal cord stimulator explant caused by post-incisional cellulitis secondary to Varicella Zoster Virus (shingles) infection: a case report

INTRODUCTION

Spinal Cord Stimulation (SCS) is a well-established therapy for refractory neuropathic pain, known for its safety and minimally-invasive nature. However, complications, including surgical site infections (SSIs), can arise post-implantation. SCS-related SSIs occur in 3.4% to 4.6% of cases within 90 days post-implant, often requiring device removal and impacting pain management and healthcare costs. The impulse generator, electrode implant site and lumbar/thoracic surgical site are commonly affected, with local skin flora and circulating organisms being the primary causes of infection.

CASE PRESENTATION

An 80-year-old Lebanese male with chronic neuropathic lower back and bilateral leg pain, significantly impairing function, underwent prolonged hospitalizations for COVID-19 infection and acute-on-chronic pain with Urinary Tract Infection (UTI). Considering SCS as a therapeutic option, a successful trial led to permanent implantation, resulting in improved pain severity and functional capacity. However, three months later, the patient developed post-incisional cellulitis and wound dehiscence secondary to Varicella Zoster Virus (shingles) Infection directly over the Implantable Pulse Generator (IPG) incision line. Despite antibiotic treatment, the infection progressed, necessitating SCS system explantation.

DISCUSSION

This represents the first reported case of VZV infection causing wound dehiscence and SCS explantation post-implantation. Contributing factors may include itching around the IPG site, facilitating deeper tissue inoculation. Laboratory and imaging tests may not reliably detect SSIs, and superficial infections may respond to antibiotics, while deep infections typically require implant removal. Early identification and intervention are vital to minimize complications.

CONCLUSION

This unique case emphasizes the need for heightened vigilance and monitoring in patients with viral infections near medical devices. A standardized approach to assessing and managing SCS-related infections is critical. Sharing such experiences contributes to improved understanding and treatment of these rare incidents.

Varicella-zoster virus infection and primary membranous nephropathy: a Mendelian randomization study

Primary membranous nephropathy (MN) is a rare autoimmune cause of kidney failure. Observational studies have suggested some relationship between virus infection and primary MN, but the association remains unclear. The current study performed a two‑sample Mendelian randomization (MR) analysis to explore the causal association between varicella-zoster virus (VZV) infection (chickenpox and shingles) and primary MN using genome‑wide association studies (GWASs) summary statistics. The exposure datasets containing chickenpox and shingles were obtained from the GWASs conducted by the 23andMe cohort. And summary-level statistics for primary MN were used as the outcome dataset, comprising 2150 cases and 5829 controls from European Ancestry. The inverse variance weighted method was adopted as the main analysis. As a result, we found that both genetically determined chickenpox (odds ratio [95% confidential interval] = 3.61 [1.74-7.50], p = 5.59e-04) and shingles (p = 7.95e-03, odds ratio [95% confidential interval] = 2.49 [1.27-4.91]) were causally associated with an increased risk of developing primary MN. In conclusion, our MR findings provided novel genetic evidence supporting the causal effect of VZV infection on primary MN. Further studies are needed to elucidate the underlying mechanisms mediating the causal association.

Real-World Effectiveness of the Varicella Vaccine among Children and Adolescents in Qatar: A Case-Control Study

BACKGROUND

Despite the availability of a highly efficacious vaccine, varicella outbreaks are still being reported globally. In this study, we evaluated the real-world effectiveness of varicella vaccination among children between the ages of 1 and 18 years old during the period 2017 to 2019 in Qatar.

METHODS

A matched case-control study was conducted that included all reported varicella-infected children who visited the primary healthcare system in Qatar from January 2017 to December 2019. The cases were children under the age of 18 years who were clinically diagnosed with varicella. The controls were of the same age, who visited the Primary Health Care Corporation (PHCC) during 2017-2019 with a skin rash where varicella infection was ruled out. The data on varicella vaccination for each participant were obtained from the electronic database in the PHCC during the study period.

RESULTS

We included 862 cases of varicella and 5454 matched controls, with a median age of 8 years (IQR 3-12); 47.4% were female and almost 50% were of Qatari nationality. The year 2019 had the highest varicella infection count with a total of 416 cases. The cases were less likely to be vaccinated against varicella, with approximately a quarter (25.6%) of cases and 36.7% of the controls having either one or two doses of the vaccine (p < 0.001). Compared to not being vaccinated, a single dose vaccination showed a 56% reduction in the odds of varicella infection [OR 0.44, 95% CI: 0.34-0.55; p < 0.000], and a two-dose vaccination showed an 86% reduction in the odds of varicella infection [OR 0.13, 95% CI: 0.06-0.29; p < 0.000].

CONCLUSION

In this multicultural setting, a two-dose varicella vaccination shows reasonable protection against varicella infection.

Delineating the Seasonality of Varicella and Its Association With Climate in the Tropical Country of Colombia

BACKGROUND

Varicella causes a major health burden in many low- to middle-income countries located in tropical regions. Because of the lack of surveillance data, however, the epidemiology of varicella in these regions remains uncharacterized. In this study, based on an extensive dataset of weekly varicella incidence in children ≤10 during 2011-2014 in 25 municipalities, we aimed to delineate the seasonality of varicella across the diverse tropical climates of Colombia.

METHODS

We used generalized additive models to estimate varicella seasonality, and we used clustering and matrix correlation methods to assess its correlation with climate. Furthermore, we developed a mathematical model to examine whether including the effect of climate on varicella transmission could reproduce the observed spatiotemporal patterns.

RESULTS

Varicella seasonality was markedly bimodal, with latitudinal changes in the peaks' timing and amplitude. This spatial gradient strongly correlated with specific humidity (Mantel statistic = 0.412, P = .001) but not temperature (Mantel statistic = 0.077, P = .225). The mathematical model reproduced the observed patterns not only in Colombia but also México, and it predicted a latitudinal gradient in Central America.

CONCLUSIONS

These results demonstrate large variability in varicella seasonality across Colombia and suggest that spatiotemporal humidity fluctuations can explain the calendar of varicella epidemics in Colombia, México, and potentially in Central America.

Addressing vaccine-preventable encephalitis in vulnerable populations

PURPOSE OF REVIEW

Vaccinations have been pivotal in lowering the global disease burden of vaccine-preventable encephalitides, including Japanese encephalitis, tick-borne encephalitis, measles encephalitis, and rabies encephalitis, among others.

RECENT FINDINGS

Populations vulnerable to vaccine-preventable infections that may lead to encephalitis include those living in endemic and rural areas, military members, migrants, refugees, international travelers, younger and older persons, pregnant women, the immunocompromised, outdoor, healthcare and laboratory workers, and the homeless. There is scope for improving the availability and distribution of vaccinations, vaccine equity, surveillance of vaccine-preventable encephalitides, and public education and information.

SUMMARY

Addressing these gaps in vaccination strategies will allow for improved vaccination coverage and lead to better health outcomes for those most at risk for vaccine-preventable encephalitis.

G-quadruplexes formed by Varicella-Zoster virus reiteration sequences suppress expression of glycoprotein C and regulate viral cell-to-cell spread

G-quadruplex (G4) formed by repetitive guanosine-rich sequences plays important roles in diverse cellular processes; however, its roles in viral infection are not fully understood. In this study, we investigated the genome-wide distribution of G4-forming sequences (G4 motifs) in Varicella-Zoster virus (VZV) and found that G4 motifs are enriched in the internal repeat short and the terminal repeat short regions flanking the unique short region and also in some reiteration (R) sequence regions. A high density of G4 motifs in the R2 region was found on the template strand of ORF14, which encodes glycoprotein C (gC), a virulent factor for viral growth in skin. Analyses such as circular dichroism spectroscopy, thermal difference spectra, and native polyacrylamide gel electrophoresis with oligodeoxynucleotides demonstrated that several G4 motifs in ORF14 form stable G4 structures. In transfection assays, gC expression from the G4-disrupted ORF14 gene was increased at the transcriptional level and became more resistant to suppression by G4-ligand treatment. The recombinant virus containing the G4-disrupted ORF14 gene expressed a higher level of gC mRNA, while it showed a slightly reduced growth. This G4-disrupted ORF14 virus produced smaller plaques than the wild-type virus. Our results demonstrate that G4 formation via reiteration sequences suppresses gC expression during VZV infection and regulates viral cell-to-cell spread.