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Thomsen MM, Skouboe MK, Møhlenberg M, Zhao J, de Keukeleere K, Heinz JL, Werner M, Hollensen AK, Lønskov J, Nielsen I, Carter-Timofte ME, Zhang B, Mikkelsen JG, Fisker N, Paludan SR, Assing K, Mogensen TH. Impaired STING Activation Due to a Variant in the E3 Ubiquitin Ligase AMFR in a Patient with Severe VZV Infection and Hemophagocytic Lymphohistiocytosis. J Clin Immunol 2024; 44:56. [PMID: 38277122 PMCID: PMC10817851 DOI: 10.1007/s10875-024-01653-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 01/06/2024] [Indexed: 01/27/2024]
Abstract
Varicella zoster virus (VZV) is a neurotropic alphaherpesvirus exclusively infecting humans, causing two distinct pathologies: varicella (chickenpox) upon primary infection and herpes zoster (shingles) following reactivation. In susceptible individuals, VZV can give rise to more severe clinical manifestations, including disseminated infection, pneumonitis, encephalitis, and vasculopathy with stroke. Here, we describe a 3-year-old boy in whom varicella followed a complicated course with thrombocytopenia, hemorrhagic and necrotic lesions, pneumonitis, and intermittent encephalopathy. Hemophagocytic lymphohistiocytosis (HLH) was strongly suspected and as the condition deteriorated, HLH therapy was initiated. Although the clinical condition improved, longstanding hemophagocytosis followed despite therapy. We found that the patient carries a rare monoallelic variant in autocrine motility factor receptor (AMFR), encoding a ubiquitin ligase involved in innate cytosolic DNA sensing and interferon (IFN) production through the cyclic GMP-AMP synthase-stimulator of IFN genes (cGAS-STING) pathway. Peripheral blood mononuclear cells (PBMCs) from the patient exhibited impaired signaling downstream of STING in response dsDNA and 2'3'-cGAMP, agonists of cGAS and STING, respectively, and fibroblasts from the patient showed impaired type I IFN responses and significantly increased VZV replication. Overexpression of the variant AMFR R594C resulted in decreased K27-linked STING ubiquitination compared to WT AMFR. Moreover, ImageStream technology revealed reduced STING trafficking from ER to Golgi in cells expressing the patient AMFR R594C variant. This was supported by a dose-dependent dominant negative effect of expression of the patient AMFR variant as measured by IFN-β reporter gene assay. Finally, lentiviral transduction with WT AMFR partially reconstituted 2'3'-cGAMP-induced STING-mediated signaling and ISG expression in patient PBMCs. This work links defective AMFR-STING signaling to severe VZV disease and hyperinflammation and suggests a direct role for cGAS-STING in the control of viral infections in humans. In conclusion, we describe a novel genetic etiology of severe VZV disease in childhood, also representing the first inborn error of immunity related to a defect in the cGAS-STING pathway.
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Affiliation(s)
- Michelle Mølgaard Thomsen
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Morten Kelder Skouboe
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Michelle Møhlenberg
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Jian Zhao
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Kerstin de Keukeleere
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Johanna Laura Heinz
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Marvin Werner
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Anne Kruse Hollensen
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Jonas Lønskov
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Ian Nielsen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | | | - Baocun Zhang
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | | | - Niels Fisker
- Department of Pediatrics, Odense University Hospital, Odense, Denmark
| | - Søren R Paludan
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Kristian Assing
- Department of Clinical Immunology, Odense University Hospital, Odense, Denmark
| | - Trine H Mogensen
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark.
- Department of Biomedicine, Aarhus University, Aarhus, Denmark.
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Sethi Y, Agarwal P, Murli H, Waheed S, Matar SG, Baklola M, Chopra H, Emran TB, Hasabo EA. Neuropsychiatric manifestations of monkeypox: A clinically oriented comprehensive review. Brain Behav 2023; 13:e2934. [PMID: 37043648 PMCID: PMC10097072 DOI: 10.1002/brb3.2934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/25/2022] [Accepted: 02/14/2023] [Indexed: 03/02/2023] Open
Abstract
Monkeypox (MPX) has emerged as a threatening outbreak in recent months. The understanding of disease pathogenesis and its systemic involvement has evolved with time. Both the virus and its vaccine, like other members of the Orthopoxvirus family, were always expected to have neuropsychiatric consequences. Several neurological complications have been reported with MPX and its vaccines that include but not limited to headaches, myalgia, encephalitis, and coma. Psychiatric complications like anxiety and depression have also been reported; however, we lack evidence to present a direct causality. We conducted a literature review to compile recent evidence on neuropsychiatric manifestations and underline the importance of evolving aspects and complications of MPX. We advocate for better reporting of cases and adverse events, to enhance our understanding of the disease, aiding physicians to make more informed decisions, thus facilitating timely diagnosis and treatment.
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Affiliation(s)
- Yashendra Sethi
- Department of MedicineGovernment Doon Medical CollegeDehradunIndia
| | - Pratik Agarwal
- Department of MedicineLokmanya Tilak Municipal Medical CollegeMumbaiIndia
| | - Hamsa Murli
- Department of MedicineLokmanya Tilak Municipal Medical CollegeMumbaiIndia
| | - Summaiya Waheed
- Department of MedicineDow Medical College, Dow University Of Health SciencesKarachiPakistan
| | | | | | - Hitesh Chopra
- Chitkara College of PharmacyChitkara UniversityPunjabIndia
| | - Talha Bin Emran
- Department of PharmacyBGC Trust University BangladeshChittagongBangladesh
- Department of Pharmacy, Faculty of Allied Health SciencesDaffodil International UniversityDhakaBangladesh
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Dooling K, Marin M, Gershon AA. Clinical Manifestations of Varicella: Disease Is Largely Forgotten, but It's Not Gone. J Infect Dis 2022; 226:S380-S384. [PMID: 36265857 DOI: 10.1093/infdis/jiac390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
After 25 years of varicella vaccination in the United States, classic varicella and its complications have become an uncommon occurrence. The clinical manifestation of varicella among vaccinated persons is usually modified, with fewer skin lesions, mostly maculopapular, and milder presentation. However, the potential for severe manifestations from varicella still exists among both vaccinated and unvaccinated persons, and thus healthcare providers should keep varicella in the differential diagnosis of a maculopapular or vesicular rash. The prompt recognition and diagnosis of varicella is important because when confirmed, clinical and public health measures need to be taken swiftly.
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Affiliation(s)
- Kathleen Dooling
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mona Marin
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Anne A Gershon
- Columbia University College of Physicians and Surgeons, New York, New York, USA
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Di Pauli F, Morschewsky P, Berek K, Auer M, Bauer A, Berger T, Bsteh G, Rhomberg P, Schanda K, Zinganell A, Deisenhammer F, Reindl M, Hegen H. Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease and Varicella Zoster Virus Infection - Frequency of an Association. Front Immunol 2021; 12:769653. [PMID: 34737756 PMCID: PMC8560958 DOI: 10.3389/fimmu.2021.769653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/05/2021] [Indexed: 11/13/2022] Open
Abstract
To determine whether there is a correlation between myelin oligodendrocyte glycoprotein (MOG) antibody-associated diseases and varicella zoster virus (VZV) infection. We provide a case report and performed a study to determine the frequency of MOG antibodies (MOG-IgG) in neurological VZV infections. Patients admitted to the Medical University of Innsbruck from 2008-2020 with a diagnosis of a neurological manifestation of VZV infection (n=59) were included in this study; patients with neuroborreliosis (n=34) served as control group. MOG-IgG was detected using live cell-based assays. In addition, we performed a literature review focusing on MOG and aquaporin-4 (AQP4) antibodies and their association with VZV infection. Our case presented with VZV-associated longitudinally extensive transverse myelitis and had MOG-IgG at a titer of 1:1280. In the study, we did not detect MOG-IgG in any other patient neither in the VZV group (including 15 with VZV encephalitis/myelitis) nor in the neuroborreliosis group. In the review of the literature, 3 cases with MOG-IgG and additional 9 cases with AQP4 IgG associated disorders in association with a VZV infection were identified. MOG-IgG are rarely detected in patients with VZV infections associated with neurological diseases.
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Affiliation(s)
- Franziska Di Pauli
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Paul Morschewsky
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Klaus Berek
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Auer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Angelika Bauer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Paul Rhomberg
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Kathrin Schanda
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Anne Zinganell
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Markus Reindl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Bozzola E, Guolo S, Macchiarulo G, Festa L, Spina G, Krzysztofiak A, Grandin A, Bozzola M, Raponi M, Villani A. Hospitalization for acute cerebellitis in children affected by varicella: how much does it cost? Ital J Pediatr 2020; 46:114. [PMID: 32762761 PMCID: PMC7410155 DOI: 10.1186/s13052-020-00875-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 07/27/2020] [Indexed: 11/16/2022] Open
Abstract
Background Chickenpox is a highly contagious airborne disease caused by the varicella zoster virus. It is generally benign and self-limiting, but it may be responsible of life-threatening complications. Acute cerebellitis (AC) is the most common neurological complication and is associated with prolonged hospitalization in the acute phase (HAP). Aim of the study To estimate the costs of AC HAP in children affected by varicella. Materials and methods We retrospectively reviewed the medical records of a pediatric cohort hospitalized for chickenpox AC over a period of 15 years (from October 2003 to October 2018) and we analyzed acute care costs. For any patient the HAP has been calculated. The final value includes cost of hospital accommodation and management at the Pediatric and Infectious Diseases Unit. To this cost, the price of procedures (imaging, laboratory exams, medical and paramedical evaluations) and medical treatments was added. Results In the study period, 856 children had been hospitalized for varicella. Out of them, 65 met a diagnosis of AC and were included in the study. The hospitalization length was of 10 days (range 3–20 days). The median cost of HAP for each patient was of 5366 euro, with an average annual cost of 23,252 €. The most significant part of HAP is due to the cost of hospital accommodation and management at the Pediatric Infectious Diseases Unit, which was about € 537.78 for a single day. Discussion Although AC post-varicella is rare, its HAP cost is not negligible resulting in substantial economic burden. Vaccination would have probably prevented varicella and AC complication, avoiding hospitalization. Conclusions Financial studies are important for evaluate the cost saving in order to influence public funding decisions. Further studies are necessary to investigate the economic burden of the disease.
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Affiliation(s)
- Elena Bozzola
- Pediatric and Infectious Disease Unit, Bambino Gesù Children Hospital, Rome, Italy.
| | - Stefano Guolo
- Medical Direction, Bambino Gesù Children Hospital, Rome, Italy
| | - Giulia Macchiarulo
- Pediatric and Infectious Disease Unit, Bambino Gesù Children Hospital, Rome, Italy
| | - Lidia Festa
- Pediatric and Infectious Disease Unit, Bambino Gesù Children Hospital, Rome, Italy
| | - Giulia Spina
- Pediatric and Infectious Disease Unit, Bambino Gesù Children Hospital, Rome, Italy
| | - Andrzej Krzysztofiak
- Pediatric and Infectious Disease Unit, Bambino Gesù Children Hospital, Rome, Italy
| | - Annalisa Grandin
- Pediatric and Infectious Disease Unit, Bambino Gesù Children Hospital, Rome, Italy
| | | | | | - Alberto Villani
- Pediatric and Infectious Disease Unit, Bambino Gesù Children Hospital, Rome, Italy
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Bozzola E, Carsetti R, Piano Mortari E, Masci M, Spina G, Villani A. The link between varicella and immune system: which children will develop acute cerebellitis? Ital J Pediatr 2020; 46:75. [PMID: 32471468 PMCID: PMC7260733 DOI: 10.1186/s13052-020-00840-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 05/21/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Varicella may complicate with cerebellitis in previously healthy children, requiring hospitalization. Aim of our study was to define whether children who experienced varicella cerebellitis have a normal immune system. Methods Patients over 3 years of age admitted at Bambino Gesù Children from January 2006 till June 2016 for cerebellitis in varicella were asked to participate to the follow-up study. The immune status was evaluated clinically and by laboratory investigations. Results Twenty-five patients were included in the study. At follow up, at least one immunological alteration was detected in 80% of patients. To avoid bias due to possible effects of the recent disease, we separately analyzed patients who had the follow-up control at least 1 year (Group 1) or between 1 month and 1 year (Group 2) after the hospitalization for acute varicella cerebellitis. The results were similar in both groups with immunological alterations detected in 84,6 and 75% of the patients, respectively. Conclusions Our preliminary results indicate that sub-clinical immunological defects may correlate to cerebellitis in varicella.
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Affiliation(s)
- Elena Bozzola
- Pediatric and Infectious Diseases Unit, University/hospital Department of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Rita Carsetti
- B cell Physiopathology Unit, Immunology Research Area, Bambino Gesù Children Hospital, Rome, Italy
| | - Eva Piano Mortari
- B cell Physiopathology Unit, Immunology Research Area, Bambino Gesù Children Hospital, Rome, Italy
| | - Marco Masci
- Pediatric and Infectious Diseases Unit, University/hospital Department of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giulia Spina
- Pediatric and Infectious Diseases Unit, University/hospital Department of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alberto Villani
- Pediatric and Infectious Diseases Unit, University/hospital Department of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Tripathy SK, Mishra P, Dwibedi B, Priyadarshini L, Das RR. Clinico-epidemiological Study of Viral Acute Encephalitis Syndrome Cases and Comparison to Nonviral Cases in Children from Eastern India. J Glob Infect Dis 2019; 11:7-12. [PMID: 30814829 PMCID: PMC6380098 DOI: 10.4103/jgid.jgid_26_18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objectives: The objective is to study the clinico-epidemiological features of viral acute encephalitis syndrome (AES) cases and compare them with nonviral AES cases in children from Eastern India. Methods: This prospective observational study was conducted in the department of pediatrics of a tertiary care teaching hospital in Eastern India over 18-month period. Children (6 months to 15 years) with acute onset of fever (≥37.5°C) and a change in mental status (including symptoms such as confusion, disorientation, coma, or inability to talk) and/or new onset of seizures (excluding simple febrile seizures) were included in the study. The main outcome measures were the etiology and proportion attributed to viruses causing AES with clinical correlation. Results: Of 834 of clinically suspected AES cases, viral etiology could be confirmed in 136 (16.3%) cases (herpes simplex virus-1 [HSV-I] was most common). The 5–15 years' age group was most commonly affected (boys > girls). More cases occurred from July to November. The presence of rash and Glasgow Coma Scale <8 at admission was significantly higher in viral AES. During hospitalization, development of shock, ventilatory requirement, duration of stay, and mortality was significantly higher in viral AES. On neuroimaging, global cerebral injury was common in HSV, Japanese encephalitis, and varicella-virus AES. Conclusions: Viral etiology forms a significant proportion of pediatric AES. Morbidity and mortality are high in viral compared to nonviral AES. Herpes encephalitis (HSV-I) is the most common cause of pediatric AES in Eastern India. Viral AES has poor prognosis compared to nonviral AES.
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Affiliation(s)
- Sandeep Kumar Tripathy
- Department of Pediatrics, SVP Post Graduate Institute of Paediatrics, SCB Medical College, Cuttack, Odisha,, India
| | - Pravakar Mishra
- Department of Pediatrics, SVP Post Graduate Institute of Paediatrics, SCB Medical College, Cuttack, Odisha,, India
| | | | - Lipsa Priyadarshini
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Rashmi Ranjan Das
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Davico C, Canavese C, Tocchet A, Brusa C, Vitiello B. Acute Hemichorea Can Be the Only Clinical Manifestation of Post-Varicella Vasculopathy: Two Pediatric Clinical Cases. Front Neurol 2018; 9:164. [PMID: 29615962 PMCID: PMC5869195 DOI: 10.3389/fneur.2018.00164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/05/2018] [Indexed: 11/13/2022] Open
Abstract
Acute hemichorea can occur in the context of infectious, autoimmune, metabolic, toxic, and vascular neuropathologies. Primary infection by varicella zoster virus (VZV) can result in vasculopathy with neurological manifestations, such as hemiparesis, at times accompanied by hemichorea. Isolated hemichorea, however, had not been reported. We here describe two cases of VZV-induced vasculopathy whose sole clinical manifestation was acute hemichorea. Both cases involved young boys of 3 years of age, who presented with acute hemichorea 4–6 months after initial VZV infection. All hematological, immunological, and toxicological tests were normal, except for the presence of VZV IgG. Brain structural magnetic resonance imaging (MRI) and magnetic resonance angiography revealed specific signs of vasculitis and ischemic lesions in the basal ganglia region (lentiform nucleus, thalamus, and internal capsule). Following corticosteroid and acetylsalicylic acid treatment, full symptomatic recovery was achieved within 3 weeks. Repeated MRI documented full neurostructural recovery, which was confirmed at extended follow-up for more than 1 year. These cases indicate that VZV-induced vasculopathy should be considered in the case of pediatric isolated acute hemichorea.
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Affiliation(s)
- Chiara Davico
- Division of Child and Adolescent Neuropsychiatry, University of Turin, Turin, Italy
| | - Carlotta Canavese
- Division of Child and Adolescent Neuropsychiatry, University of Turin, Turin, Italy
| | - Aba Tocchet
- Division of Child and Adolescent Neuropsychiatry, University of Turin, Turin, Italy
| | - Chiara Brusa
- Division of Child and Adolescent Neuropsychiatry, University of Turin, Turin, Italy
| | - Benedetto Vitiello
- Division of Child and Adolescent Neuropsychiatry, University of Turin, Turin, Italy
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Gowin E, Wysocki J, Michalak M, Januszkiewicz-Lewandowska D. Too young to be vaccinated: hospitalizations caused by varicella among children in the first year of life. Int J Infect Dis 2017; 62:52-55. [PMID: 28735059 DOI: 10.1016/j.ijid.2017.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 07/10/2017] [Accepted: 07/11/2017] [Indexed: 10/19/2022] Open
Abstract
AIM The aim of this study was to analyse the causes of hospitalization in the course of varicella in children during the first year of life. METHODS An analysis was performed of the medical documentation of 359 children hospitalized for varicella on the infectious diseases ward at the Children's Hospital in Poznan (Poland) between January 2007 and August 2015. RESULTS Of the 359 children in the study group, 96 were younger than 1 year old. The most common cause of hospitalization was respiratory infections, found in 31 (32%) children. A severe course of varicella was observed in 38 (14%) children, and 21 (22%) developed skin infections, while 11 (11%) exhibited more than one complication. Treatment with acyclovir was implemented in 90 cases and parenteral antibiotic therapy was applied in 49 children. Contact with siblings suffering from varicella was confirmed in 46 children; for 16, the source of the infection was the mother. CONCLUSIONS The main source of varicella virus among hospitalized children in the first year of life is home contact. An infant may become infected from its mother suffering from zoster. Children who are exclusively breastfed and are born of mothers who have previously had varicella may develop varicella with a severe course during the first year of life.
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Affiliation(s)
- Ewelina Gowin
- Department of Family Medicine, Poznan University of Medical Sciences, Poznan, Poland.
| | - Jacek Wysocki
- Department of Health Promotion, Poznan University of Medical Sciences, Poznan, Poland
| | - Michał Michalak
- Department of Biostatistics, Poznan University of Medical Sciences, Poznan, Poland
| | - Danuta Januszkiewicz-Lewandowska
- Department of Molecular Pathology, Institute of Human Genetics, Polish Academy of Sciences, Poznan, Poland; Department of Oncology, Haematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznan, Poland
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Decline of Neurologic Varicella Complications in Children During the First Seven Years After Introduction of Universal Varicella Vaccination in Germany, 2005-2011. Pediatr Infect Dis J 2017; 36:79-86. [PMID: 27749651 DOI: 10.1097/inf.0000000000001356] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Universal varicella vaccination for 1-year-old children was introduced in Germany in 2004. We investigated changes in the incidence and type of varicella-associated neurologic complications in children during the first 7 years after universal vaccination recommendation. METHODS A surveillance study was conducted based on patients <17 years of age with an International Classification of Diseases (10th Revision) discharge diagnosis of varicella, annually reported by 22-29 pediatric hospitals in Bavaria, Germany, 2005 to 2011. Annual incidences were estimated and linear trend across years was assessed by Poisson regression models. RESULTS Of a total of 1263 varicella-associated pediatric hospitalizations, 228 children (18.1%) had neurologic complications (median age 4 years, interquartile range 2-7; 56% male). The most frequent neurologic complications were febrile convulsion (32.0% of 228 children, median age 3.0 years), varicella encephalitis or meningitis (28.9%; median age 4.5 years), syncope (13.2%; median age 7.0 years) and cerebral convulsion (11.0%; median age 4.0 years). Other complications included ataxia (3.1%), facial nerve palsy (2.6%) and cerebral vasculitis/infarction (1.8%). Neurologic complications showed a continuous decrease between 2005 and 2011, from an incidence of 2.8 (95% confidence interval: 2.1-3.6) per 100,000 children <17 years of age to 1.2 (95% confidence interval: 0.7-2.1; P < 0.001). In particular, a marked decline was observed among children up to 7 years of age, mainly because of a decrease in the number of febrile convulsions and encephalitis or meningitis. CONCLUSION The incidence of varicella-associated neurologic complications in children decreased approximately by 60% during the first 7 years following the recommendation for universal vaccination.
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Valentini D, Bianchi S, Di Camillo C, Vittucci AC, Gonfiantini MV, De Vito R, Villani A. Fatal varicella pneumonia in an unvaccinated child with Down Syndrome: a case report. Ital J Pediatr 2016; 42:99. [PMID: 27855688 PMCID: PMC5114766 DOI: 10.1186/s13052-016-0312-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Accepted: 11/11/2016] [Indexed: 11/10/2022] Open
Abstract
Background Varicella is an acute infectious disease common during childhood. It has mostly an uncomplicated course in early childhood. Neverthless, it may result in severe complications, especially in particular age groups and clinical conditions. Down Syndrome represents a risk factor for developing complications, because of the frequent comorbidities and their immunodeficiency. Case presentation A 2-year-old white Caucasian female affected by Down Syndrome was referred to our hospital for cardiac arrest in course of varicella disease. After cardiopulmonary resuscitation and stabilization, her clinical conditions didn’t improve and she developed a massive pulmonary hemorrage, which led her to exitus. Conclusions Mortality due to varicella infection is rare, but it is more common in subjects with immune deficit or chronic pathologies, and in particular age-groups. The importance of the vaccine for preventable infectious diseases is stressed in this paper, in which we present a case of death in an unvaccinated cardiopathic child with Down Syndrome affected by varicella.
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Affiliation(s)
- Diletta Valentini
- Pediatric and Infectious Disease Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Simona Bianchi
- Pediatric and Infectious Disease Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Chiara Di Camillo
- Pediatric and Infectious Disease Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Anna Chiara Vittucci
- Pediatric and Infectious Disease Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Rita De Vito
- Pathology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alberto Villani
- Pediatric and Infectious Disease Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Varicella zoster virus related deaths and hospitalizations before the introduction of universal vaccination with the tetraviral vaccine. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2016. [DOI: 10.1016/j.jpedp.2016.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Bozzola E, Bozzola M. Varicella complications and universal immunization. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2016. [DOI: 10.1016/j.jpedp.2016.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Affiliation(s)
- Elena Bozzola
- Department of Pediatrics, Pediatric and Infectious Diseases Unit, Bambino Gesù Children's Hospital, Rome, Italy.
| | - Mauro Bozzola
- Internal Medicine and Therapeutics Department, Pediatrics and Adolescentology Unit, University of Pavia, Fondazione IRCCS San Matteo, Pavia, Italy
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de Martino Mota A, Carvalho-Costa FA. Varicella zoster virus related deaths and hospitalizations before the introduction of universal vaccination with the tetraviral vaccine. J Pediatr (Rio J) 2016; 92:361-6. [PMID: 26969400 DOI: 10.1016/j.jped.2015.10.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 10/11/2015] [Accepted: 10/21/2015] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE To characterize varicella zoster virus-related deaths and hospitalizations in Brazil before universal vaccination with the tetravalent (measles, mumps, rubella, and varicella) vaccine, attempting to collect baseline data on varicella morbidity and mortality in order to evaluate the impact of the varicella vaccination program. METHODS Varicella-associated mortality data were evaluated between 1996 and 2011 and varicella zoster virus-associated hospitalizations between 1998 and 2013. Data were gathered from the Informatics Department of the Unified Health System, considering the International Classification of Diseases, 10th Revision, code B01. All age groups were assessed. Varicella-specific mortality rates were calculated and seasonality of varicella-zoster virus-associated hospitalizations was described. RESULTS There were 2334 varicella deaths between 1996 and 2011, 19.3% in infants aged less than 1 year and 36% in children from 1 to 4 years. In infants under 1 year, varicella mortality rates reached 3.2/100,000/year. In children aged 1-4 years, varicella mortality rates reach 1.64/100,000/year. Average annual mortality rates for varicella in Brazil are 0.88/100,000 in infants under 1 year and 0.40/100,000 in children aged 1-4 years. The total number of hospitalizations associated with varicella zoster virus was 62,246 from 2008 to 2013. Varicella-associated hospitalizations have a seasonal distribution in children, peaking in November. In the elderly, monthly averages of herpes zoster-associated hospitalizations present no significant seasonal variation. CONCLUSIONS Varicella is associated, in the pre-vaccine period, to significant morbidity and mortality in Brazil. The universal vaccination program is expected to decrease the disease burden from varicella.
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Affiliation(s)
- Alessandra de Martino Mota
- Laboratório de Epidemiologia e Sistemática Molecular, Instituto Oswaldo Cruz (IOC), Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Filipe Anibal Carvalho-Costa
- Laboratório de Epidemiologia e Sistemática Molecular, Instituto Oswaldo Cruz (IOC), Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, RJ, Brazil; Escritório Regional Fiocruz Piauí, Fundação Oswaldo Cruz (Fiocruz), Teresina, PI, Brazil.
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Wen SCH, Best E, Walls T, Dickson N, McCay H, Wilson E. Prospective surveillance of hospitalisations associated with varicella in New Zealand children. J Paediatr Child Health 2015; 51:1078-83. [PMID: 26041441 DOI: 10.1111/jpc.12937] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2015] [Indexed: 11/28/2022]
Abstract
AIM Varicella is a vaccine-preventable disease not notifiable in New Zealand (NZ), and varicella vaccine is not funded in the National Immunisation Schedule (NIS). Hospitalisations can occur because of bacterial secondary infection and other complications, which can result in long-term sequelae. Varicella may not be acknowledged in discharge coding when complications occur weeks after infection. Using the New Zealand Paediatric Surveillance Unit (NZPSU), the aim of this study was to document the hospitalisation burden of this disease. METHODS Cases (0-14 years) of varicella and post-varicella complications requiring hospitalisation, including stroke syndromes where varicella occurred in the preceding 6 months, were notified to NZPSU between 1 November 2011 and 31 October 2013. Herpes zoster cases were excluded. Questionnaires were used to capture demographics, clinical features, management and short-term outcomes. RESULTS One hundred seventy-eight notifications were received and 144 were confirmed cases. Overall incidence was 8.3/100,000 children per year. Fifty-two percent were women with a median age of 2.4 years. Māori and Pacific Island (PI) children accounted for 74% of hospitalisations, with incidence rate ratios compared with European children of 2.8 and 3.9, respectively (P < 0.01). Complications included: infection (75%), respiratory (11%), neurological (11%), electrolyte disturbance (6%) and haemorrhagic varicella (4%). Nine percent were immunocompromised. Median duration of hospital admission was 4 days with 9% requiring intensive care admission. There were no reported deaths; however, 19% had ongoing problems at discharge. CONCLUSION Varicella has more associated morbidity than commonly perceived in immunocompetent children. Māori and PI children are more likely to have complications. This surveillance gives support for inclusion of universal varicella vaccine in the NZ NIS.
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Affiliation(s)
- Sophie Chien-Hui Wen
- Departments of Paediatric Infectious Diseases, Starship Children's Hospital, Auckland, New Zealand
| | - Emma Best
- Departments of Paediatric Infectious Diseases, Starship Children's Hospital, Auckland, New Zealand.,Department of Paediatrics, University of Auckland, Auckland, New Zealand
| | - Tony Walls
- Department of Paediatrics, University of Otago, Christchurch, New Zealand
| | - Nigel Dickson
- New Zealand Paediatric Surveillance Unit, Department of Women's and Children Health, University of Otago, Dunedin, New Zealand
| | - Hamish McCay
- Department of Paediatrics, University of Auckland, Auckland, New Zealand.,Department of Paediatrics, Waikato Hospital, Waikato, Hamilton, New Zealand
| | - Elizabeth Wilson
- Departments of Paediatric Infectious Diseases, Starship Children's Hospital, Auckland, New Zealand
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Varicella-zoster virus infections of the central nervous system – Prognosis, diagnostics and treatment. J Infect 2015; 71:281-93. [DOI: 10.1016/j.jinf.2015.06.004] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 06/03/2015] [Accepted: 06/06/2015] [Indexed: 11/23/2022]
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An uncommon association: chicken pox and Guillain-Barre syndrome. J Infect Public Health 2014; 8:216-7. [PMID: 25466595 DOI: 10.1016/j.jiph.2014.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 09/30/2014] [Indexed: 12/14/2022] Open
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Acute peripheral facial palsy after chickenpox: a rare association. Case Rep Pediatr 2014; 2014:754390. [PMID: 25057424 PMCID: PMC4095705 DOI: 10.1155/2014/754390] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 06/16/2014] [Accepted: 06/18/2014] [Indexed: 12/15/2022] Open
Abstract
Chickenpox, resulting from primary infection by the varicella-zoster virus, is an exanthematous disease very common during childhood and with good prognosis. However, serious complications, namely, neurological syndromes, may develop during its course, especially in risk groups, including adolescents. Peripheral facial palsy is a rare neurologic complication that has been previously described.
Conclusion. We report the case of a teenager with peripheral facial palsy as a complication of chickenpox, aiming to increase the awareness of this rare association.
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Bozzola E, Bozzola M, Tozzi AE, Calcaterra V, Longo D, Krzystofiak A, Villani A. Acute cerebellitis in varicella: a ten year case series and systematic review of the literature. Ital J Pediatr 2014; 40:57. [PMID: 24942129 PMCID: PMC4079178 DOI: 10.1186/1824-7288-40-57] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 06/11/2014] [Indexed: 12/11/2022] Open
Abstract
Background Acute cerebellitis (AC) is the most common neurological complication of varicella. Nevertheless, it has been scarcely studied. The objective of this study were to asses the occurrence of AC among children hospitalized for varicella and to analyze its specific clinical picture and outcome. Methods We retrospectively reviewed the medical records of children admitted to the hospital for varicella between 1st October 2003 and 1st June 2013 and we compared our results with literature. Children were all unvaccinated for varicella. Results In our case series, AC was found out in 48 out of 457 patients (10.5%). The highest frequency of AC was observed in children from 1 to 5 years of age (60.9%). The most characteristic symptom of AC was a broad-based gait disturbance that progressed gradually over the course of a few days (95.8%). Other common symptoms included slurred speech (37.5%), vomiting (31.25%), headache (29.16%), dysmetry (25%) and tremor (22.91%). After a long hospitalization (median of 11 days), all but one children were dismissed without invalidating sequelae. Conclusions Data from this study may help to better address the problem of varicella cerebellar complications in hospitalized children and to monitor changes over time caused by an increase in vaccination coverage.
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Affiliation(s)
- Elena Bozzola
- Department of Pediatric, Bambino Gesù Children's Hospital, Pediatric and Infectious Diseases Unit, IRCCS, Rome, Italy.
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Kim JH, Lee SJ, Kim M. External ophthalmoplegia with orbital myositis in an adult patient after chickenpox infection. BMJ Case Rep 2014; 2014:bcr-2013-202415. [PMID: 24835802 DOI: 10.1136/bcr-2013-202415] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Herpes zoster and chickenpox are caused by a single virus, varicella-zoster virus. Herpes zoster ophthalmicus-associated ophthalmoplegia is well documented. Very rarely, herpes zoster and chickenpox cause external ophthalmoplegia. A 48-year-old man was diagnosed with chickenpox and treated with intravenous acyclovir. He suddenly reported diplopia and restricted left eye movement. MRI of the orbit revealed thickening and abnormal contrast enhancement of the preseptal space and lateral rectus muscle of the left eye. In this case, external ophthalmoplegia occurred following chickenpox with radiological evidence of orbital myositis. To the best of our knowledge, this is the first case report of external ophthalmoplegia of radiologically confirmed orbital myositis after chickenpox infection.
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Affiliation(s)
- Jung-Hoon Kim
- Kangwon National University, Chuncheon-Si, Republic of Korea
| | - Seung-Jun Lee
- Kangwon National University, Chuncheon-Si, Republic of Korea
| | - Moosang Kim
- Kangwon National University, Chuncheon-Si, Republic of Korea
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Wen SCH, Miles F, McSharry B, Wilson E. Varicella in a Paediatric Intensive Care Unit: 10-year review from Starship Children's Hospital, New Zealand. J Paediatr Child Health 2014; 50:280-5. [PMID: 24372783 DOI: 10.1111/jpc.12473] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2013] [Indexed: 11/27/2022]
Abstract
AIMS Varicella is now a vaccine-preventable disease but is generally considered benign, making it a low priority for a funded universal immunisation scheme. We aimed to increase the knowledge of the severity, morbidity and mortality caused by varicella, by a review of cases requiring paediatric intensive care in New Zealand where vaccine is available but not funded. METHODS This is a retrospective chart review of children admitted to the paediatric intensive care unit (PICU) over a 10-year period (July 2001-July 2011) identified from the PICU database with a primary or secondary code for varicella. RESULTS Thirty-four cases were identified and 26 cases were included. Of the 26 cases, 84.6% were Maori or Pacific Island ethnicity, 54% had no preceding medical condition and 23% were immunocompromised. Main PICU admission reasons were neurologic (38.5%), secondary bacterial sepsis or shock (26.9%), respiratory (15.4%), disseminated varicella (11.5%), or other causes (7.7%). Fifty per cent of children required inotropic support and 81% invasive ventilation. Four children died (15%), three of whom were immunocompromised. A further eight children (31%) had ongoing disability at hospital discharge. CONCLUSION Varicella, or its secondary complications, requiring paediatric intensive care, carries high mortality, particularly for immunocompromised patients, and long-term morbidities, mostly affecting previously healthy children.
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Affiliation(s)
- Sophie Chien-Hui Wen
- Department of Paediatric Infectious Disease, Starship Children's Hospital, Auckland, New Zealand
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Zhang Y, Tao C, He Y, Kanjamala P, Liu H. Network-based analysis of vaccine-related associations reveals consistent knowledge with the vaccine ontology. J Biomed Semantics 2013; 4:33. [PMID: 24209834 PMCID: PMC4177205 DOI: 10.1186/2041-1480-4-33] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 11/04/2013] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Ontologies are useful in many branches of biomedical research. For instance, in the vaccine domain, the community-based Vaccine Ontology (VO) has been widely used to promote vaccine data standardization, integration, and computer-assisted reasoning. However, a major challenge in the VO has been to construct ontologies of vaccine functions, given incomplete vaccine knowledge and inconsistencies in how this knowledge is manually curated. RESULTS In this study, we show that network-based analysis of vaccine-related networks can identify underlying structural information consistent with that captured by the VO, and commonalities in the vaccine adverse events for vaccines and for diseases to produce new hypotheses about pathomechanisms involving the vaccine and the disease status. First, a vaccine-vaccine network was inferred by applying a bipartite network projection strategy to the vaccine-disease network extracted from the Semantic MEDLINE database. In total, 76 vaccines and 573 relationships were identified to construct the vaccine network. The shortest paths between all pairs of vaccines were calculated within the vaccine network. The correlation between the shortest paths of vaccine pairs and their semantic similarities in the VO was then investigated. Second, a vaccine-gene network was also constructed. In this network, 4 genes were identified as hubs interacting with at least 3 vaccines, and 4 vaccines were identified as hubs associated with at least 3 genes. These findings correlate with existing knowledge and provide new hypotheses in the fundamental interaction mechanisms involving vaccines, diseases, and genes. CONCLUSIONS In this study, we demonstrated that a combinatorial analysis using a literature knowledgebase, semantic technology, and ontology is able to reveal important unidentified knowledge critical to biomedical research and public health and to generate testable hypotheses for future experimental verification. As the associations from Semantic MEDLINE remain incomplete, we expect to extend this work by (1) integrating additional association databases to complement Semantic MEDLINE knowledge, (2) extending the neighbor genes of vaccine-associated genes, and (3) assigning confidence weights to different types of associations or associations from different sources.
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Affiliation(s)
- Yuji Zhang
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN 55905, USA.
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Turel O, Bakir M, Gonen I, Hatipoglu N, Aydogmus C, Hosaf E, Siraneci R. Children Hospitalized for Varicella: Complications and Cost Burden. Value Health Reg Issues 2013; 2:226-230. [PMID: 29702869 DOI: 10.1016/j.vhri.2013.05.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate the direct medical cost of hospital admissions for patients with varicella (i.e., chickenpox) to assess the cost burden of varicella from a health care perspective for ultimate use in health economics studies in Turkey. METHODS Records of children hospitalized with varicella at the Bakirkoy Maternity and Children's Hospital between November of 2006 and June of 2011 were reviewed. Reasons for hospitalization, types of varicella-associated complications, and direct medical cost of hospitalization were noted. Patients with underlying risk factors were excluded. Data obtained from one hospital were used to estimate the national cost of the disease. RESULTS During the 4.5-year study period, 234 patients were hospitalized with varicella. Of these cases, 48 (20%) children previously ill with underlying cancers or chronic diseases were excluded from the study. Ultimately, 186 previously healthy children (age range: 14 days to 159 months, median age: 14 months) were included. The main reasons for hospitalization were complications related to varicella (79%), the most frequent of which was skin and soft tissue infections, followed by neurological complications and pneumonia. The median cost of hospitalization per patient was US $283, 50% of which was attributed to medication costs. The annual cost for varicella hospitalizations in Turkey was estimated at US $396,200. CONCLUSIONS A significant number of healthy children are hospitalized for varicella and associated complications. Descriptions of these complications and their related costs provide important data for cost-effectiveness studies for decisions about the inclusion of the varicella vaccine in a childhood vaccination program.
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Affiliation(s)
- Ozden Turel
- Department of Pediatrics, Bezmialem Vakif University Faculty of Medicine, Istanbul, Turkey.
| | - Mustafa Bakir
- Department of Pediatrics, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Ismail Gonen
- Department of Pediatrics, Bezmialem Vakif University Faculty of Medicine, Istanbul, Turkey; Department of Pediatrics, Bakirkoy Maternity and Children's Educational and Treatment Hospital, Istanbul, Turkey
| | - Nevin Hatipoglu
- Department of Pediatrics, Bakirkoy Maternity and Children's Educational and Treatment Hospital, Istanbul, Turkey
| | - Cigdem Aydogmus
- Department of Pediatrics, Bakirkoy Maternity and Children's Educational and Treatment Hospital, Istanbul, Turkey
| | - Emine Hosaf
- Department of Microbiology, Bakirkoy Maternity and Children's Educational and Treatment Hospital, Istanbul, Turkey
| | - Rengin Siraneci
- Department of Pediatrics, Bakirkoy Maternity and Children's Educational and Treatment Hospital, Istanbul, Turkey
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