Varicella with rapidly progressive hepatitis presenting with multiple hepatic nodules in a child with acute leukemia

PEPtalk 3: oral aciclovir is equivalent to varicella zoster immunoglobulin as postexposure prophylaxis against chickenpox in children with cancer - results of a multicentre UK evaluation

OBJECTIVE

To compare the occurrence of chickenpox in children with cancer who received varicella immunoglobulin (VZIG) or aciclovir as postexposure prophylaxis (PEP).

DESIGN

Prospective multicentre service evaluation of children with cancer who received either VZIG or aciclovir as PEP following significant exposure to varicella zoster virus (VZV) over a 24-month period from May 2018.

SETTING

Data were collected from 9 UK Paediatric Oncology Primary Treatment Centres.

PATIENTS

Children under 16 years old with a diagnosis of cancer and/or previous haematopoietic stem cell transplant who were VZV seronegative at exposure and/or diagnosis and received PEP following significant VZV exposure.

MAIN OUTCOME MEASURES

The primary outcome was the incidence of breakthrough varicella within 6 weeks of VZV exposure and treatment with PEP.

RESULTS

A total of 105 eligible patients were registered with a median age of 4.9 years (range 1.1-10.5 years). Underlying diagnoses were acute leukaemia (64), solid tumours (22), Langerhans cell histiocytosis (9), central nervous system (CNS) tumours (8) and other (2). Aciclovir was received by 86 patients (81.9%), 18 received VZIG (17.1%) and 1 valaciclovir (0.9%). There were seven reported break-through VZV infections in 103 patients at follow-up (7/103, 6.8%). Clinical VZV developed in 5/84 of the aciclovir group (6.0%, 95% CI 2.0 to 13.3) and 2/18 of VZIG group (11.1%, 95% CI 1.4 to 34.7). All breakthrough infections were either mild (5/7) or moderate (2/7) in severity.

CONCLUSION

Aciclovir is a safe and effective alternative to VZIG as VZV PEP in children with cancer and should be considered as standard of care.

Attention should be paid to acute hepatitis of unknown etiology in children

Since April 5, 2022, an increase in cases of severe acute hepatitis of unknown etiology among children with no underlying conditions was first reported in the United Kingdom (UK). Testing excluded viral hepatitis types A, B, C, D, and E and other known common and uncommon infectious and non-infectious causes of acute hepatitis. As of May 26, 2022, 650 cases of acute hepatitis of unknown etiology in children have been reported in at least 33 countries worldwide, with 99 additional cases pending classification. Here, the current prevalence of this condition around the world, a hazard analysis, possible causes, the risk of an outbreak in China, and advice on prevention have been briefly reviewed.

[The investigation on the acute, severe hepatitis of unknown origin in children]

In April 2022, the United Kingdom notified the World Health Organization (WHO) of an unexpected increase of acute hepatitis of unknown origin in children. Subsequent investigations have found more than 400 cases in more than 20 countries and regions around the world. Although the potential role of adenovirus type 41 in the pathogenesis of these cases is one hypothesis, but it is probably not the only pathogenic factor, and other infectious and non-infectious causes cannot be completely ruled out. For hepatitis caused by non-hepatitis A, B, C, D and E viruses, there is a lack of systematic monitoring and research, and many unknowns still exist. According to the current etiology speculation and epidemiological characteristics of adenovirus in China, cases of acute hepatitis with unknown origin may be found in China in the future. There is also a risk of imported cases. This article systematically sorts out the reports and studies on child acute hepatitis of unknown origin, hoping to attract the attention of pediatric clinicians in China, raise awareness and vigilance, and calmly prepare for possible abnormal situations.

Different Clinical Presentations and Outcomes of Disseminated Varicella in Children With Primary and Acquired Immunodeficiencies

Primary infection with varicella-zoster virus (VZV) causes chickenpox, a benign and self-limited disease in healthy children. In patients with primary or acquired immunodeficiencies, primary infection can be life-threatening, due to rapid dissemination of the virus to various organs [lung, gastrointestinal tract, liver, eye, central nervous system (CNS)]. We retrospectively described and compared the clinical presentations and outcomes of disseminated varicella infection (DV) in patients with acquired (AID) (n= 7) and primary (PID) (n= 12) immunodeficiencies. Patients with AID were on immunosuppression (mostly steroids) for nephrotic syndrome, solid organ transplantation or the treatment of hemopathies, whereas those with PID had combined immunodeficiency (CID) or severe CID (SCID). The course of the disease was severe and fulminant in patients with AID, with multiple organ failure, no rash or a delayed rash, whereas patients with CID and SICD presented typical signs of chickenpox, including a rash, with dissemination to other organs, including the lungs and CNS. In the PID group, antiviral treatment was prolonged until immune reconstitution after bone marrow transplantation, which was performed in 10/12 patients. Four patients died, and three experienced neurological sequelae. SCID patients had the worst outcome. Our findings highlight substantial differences in the clinical presentation and course of DV between children with AID and PID, suggesting differences in pathophysiology. Prevention, early diagnosis and treatment are required to improve outcome.

Systemic viral infection in children receiving chemotherapy for acute leukemia

Systemic viral diseases frequently occur in allogeneic hematopoietic stem cell transplantation, but data in children receiving chemotherapy for acute leukemia are scarce. We therefore collected and analyzed the published data on symptomatic infection from cytomegalovirus, herpes simplex virus, varicella zoster virus, parvovirus B19, or adenovirus in pediatric acute leukemia. Reports on 68 children were identified, of whom 16 patients have died from the infection. Further studies have to (1) evaluate the true incidence of these infections in pediatric acute leukemia, (2) their impact on outcome, and (3) whether a subpopulation of patients could benefit from screening and prophylactic strategies.

Rare presentation of primary varicella zoster as fatal fulminant hepatitis in adult on low-dose,short-term steroid: Case report

Background

Varicella zoster virus presents clinically as primary (chickenpox) or secondary (herpes zoster) infection. Cutaneous and extracutaneous dissemination may occur, usually in immunocompromised patients. VZV hepatitis that progresses to fulminant hepatic failure is very rare and fatal. To the best of our knowledge, 9 cases have been reported to date, of which 7 were in immunocompromised adults, and only one patient was on short duration steroid therapy.

Presentation of case

We present a 26-year old man who was admitted initially with acute abdomen as query persistent biliary colic. Later, he showed clinical and laboratory findings of VZV hepatitis that progressed rapidly despite maximal medical ICU support and he expired on day 3 of admission.

Conclusions

Acute VZV infection may present as fulminant hepatitis. The presentation may initially be challenging for the diagnosis and should be considered if the patient has been in contact with a sick case. Low dose corticosteroid could carry a risk for fatal VZV fulminant hepatitis and should be used very cautiously especially with VZV patients' contacts. Further causative relationships remain to be established.

Successful Treatment of Fulminant Hepatitis due to Varicella Zoster Virus using Immunoglobulin in a Kidney Transplant Patient

The clinical benefit of adjuvant intravenous immunoglobulin (IVIG) therapy is controversial in immunocompromised patients with severe varicella. A twenty-one-year-old woman who had received a kidney transplant one year earlier presented with fever and generalized rash for 5 days. Initial immunoglobulin M (IgM) and IgG for varicella zoster virus (VZV) were negative; however, the patient was diagnosed with varicella with fulminant hepatitis because VZV-specific PCR from skin vesicles and blood was positive. The patient received intravenous acyclovir and 5-day IVIG. The decline of plasma viral load was steeper (beta coefficient −0.446) during IVIG therapy than after the therapy (beta coefficient −0.123) (P = 0.04), while VZV glycoprotein IgG titers and VZV-specific T cell responses were not detected during the 5-day IVIG therapy. The patient improved without any complications. This case provides an experimental evidence that adjuvant IVIG can significantly reduce viral load in immunocompromised patients with severe varicella.

Visceral disseminated varicella zoster virus infection with brachial plexus neuritis detected by fluorodeoxyglucose positron emission tomography and computed tomography

Varicella zoster virus (VZV) infection sometimes result in visceral disseminated VZV infection (VD-VZV), which is a fulminant disease featured by abdominal pain and the absence of skin lesions, particularly occurs in the immunosuppressive patients. Brachial plexus neuritis (BPN) is another rare type of VZV infection usually appears without blisters. Few diagnostic images of both VD-VZV and BPN-VZV have been reported. A 25-year-old woman receiving allogeneic hematopoietic stem cell transplantation (HSCT) for acute myeloid leukemia. Unexplained severe pain in the left upper extremity followed by severe stomachache, liver dysfunction and unconsciousness appeared on day 344 post-HSCT. Computed tomography (CT) showed left brachial plexus hypertrophy and edematous changes to the hepatoduodenal ligament, fluorodeoxyglucose positron emission tomography (FDG-PET) showed increased uptake in both lesions. Intravenous acyclovir therapy was started and successfully resolved all symptoms. Several days later, blisters appeared all over the body and positive VZV DNA from blood using polymerase chain reaction test was obtained. FDG-PET and CT may offer supportive findings for detecting or diagnosing blister-less VZV infectious diseases.

PEPtalk2: results of a pilot randomised controlled trial to compare VZIG and aciclovir as postexposure prophylaxis (PEP) against chickenpox in children with cancer

OBJECTIVE

To determine the likely rate of patient randomisation and to facilitate sample size calculation for a full-scale phase III trial of varicella zoster immunoglobulin (VZIG) and aciclovir as postexposure prophylaxis against chickenpox in children with cancer.

DESIGN

Multicentre pilot randomised controlled trial of VZIG and oral aciclovir.

SETTING

England, UK.

PATIENTS

Children under 16 years of age with a diagnosis of cancer: currently or within 6 months of receiving cancer treatment and with negative varicella zoster virus (VZV) serostatus at diagnosis or within the last 3 months.

INTERVENTIONS

Study participants who have a significant VZV exposure were randomised to receive PEP in the form of VZIG or aciclovir after the exposure.

MAIN OUTCOME MEASURES

Number of patients registered and randomised within 12 months of the trial opening to recruitment and incidence of breakthrough varicella.

RESULTS

The study opened in six sites over a 13-month period. 482 patients were screened for eligibility, 32 patients were registered and 3 patients were randomised following VZV exposure. All three were randomised to receive aciclovir and there were no cases of breakthrough varicella.

CONCLUSIONS

Given the limited recruitment to the PEPtalk2 pilot, it is unlikely that the necessary sample size would be achievable using this strategy in a full-scale trial. The study identified factors that could be used to modify the design of a definitive trial but other options for defining the best means to protect such children against VZV should be explored.

TRIAL REGISTRATION NUMBER

ISRCTN48257441, EudraCT number: 2013-001332-22, sponsor: University of Birmingham.