The varicella-zoster virus: systemic and ocular features

Human Herpesviruses as Copathogens of HIV Infection, Their Role in HIV Transmission, and Disease Progression

Of eight human herpesviruses (HHVs), often, only herpes simplex virus types 1 (HSV-1) and 2 (HSV-2) find mention in medical literature as both of these viruses are commonly associated with genital lesions and oral ulcers, commonly known as cold sores. However, role of human herpesviruses as copathogens and in aggravation and in the transmission of other human diseases, especially the Acquired immunodeficiency syndrome (HIV/AIDS) has only very recently been recognized. Therefore, screening and treating subclinical HHV infections may offer slowing of HIV infection, disease progression, and its transmission. Beside HSV-1 and HSV-2, HHV-3 a causative agent of herpes zoster remained one of the first manifestations of HIV disease before the era of highly active antiretroviral therapy (HAART). HHV-5 also known as human Cytomegalovirus infection remains a significant risk factor for HIV-associated mortality and morbidity even in HAART era. It is proposed that Cytomegalovirus viremia could be a better predictor of HIV disease progression than CD4+ T-lymphocyte count. The role of HHV-4 or Epstein-Burr virus and HHV-6, HHV-7, and HHV-8 is still being investigated in HIV disease progression. This review provides insight into the current understanding about these 8 HHVs, their co-pathogenesis, and role in HIV/AIDS disease progression. The review also covers recent literature in favor and against administering anti-HHV treatment along with HAART for slower AIDS progression and interrupted sexual transmission.

Close correlation of herpes zoster-induced voiding dysfunction with severity of zoster-related pain: A single faculty retrospective study

Herpes zoster (HZ), a common vesiculo-erythematous skin disease associated with reactivation of varicella zoster virus in the cranial nerve, dorsal root, and autonomic ganglia, is accompanied by several related symptoms represented by postherpetic neuralgia. Among them, involvement of vesicorectal dysfunction is relatively rare. The vesicorectal symptom can usually be recovered in transient course, but is quite important in terms of impaired quality of life. Male individuals affected with HZ and skin lesions on sacral dermatome have been reported as independent risk factors of zoster-related voiding dysfunction. In this study, urinary symptoms were focused upon and six patients with zoster-related voiding dysfunction at a single faculty of dermatology in Japan from 2009 to 2014 were retrospectively analyzed. All patients showed HZ lesions on the sacral area and the urinary symptom recovered in approximately 2 months (14 days to 7 months). The term of treatment for zoster-associated urinary dysfunction was positively correlated with that for zoster-related pain without significance (r = 0.661, P = 0.153). Average treatment term for pain relief of sacral HZ accompanied by voiding dysfunction (91.3 ± 76.44 days) was significantly longer than that of sacral HZ without urinary symptom (18.9 ± 20.42 days) (P = 0.032). These results suggested that zoster-related voiding dysfunction would mainly be involved in sacral HZ and closely associated with severity of zoster-related pain. Dermatologists should be aware that severe zoster-related pain accompanied by sacral HZ, which is related to prolonged treatment of pain relief, can be a predictive factor of voiding dysfunction.

Herpes zoster: a clinical study in 205 patients

BACKGROUND

Even though herpes zoster is a common condition its incidence and pattern of occurrence in the era of HIV disease is significant.

AIM

To analyze the incidence, pattern of occurrence and evolution of herpes zoster with special attention to provocative factors if any.

MATERIALS AND METHOD

This was an analytical study conducted for 2 years based on a preformed proforma containing preliminary information, a detailed clinical evaluation regarding the segment of involvement, morphology, pattern of lesions, complications, disseminations etc. and investigations to establish provocative factors if any.

RESULTS

Incidence of herpes zoster was mainly in the fourth and third decades of life. A definite history of chicken pox was present in only 63.4% cases. In the majority (70%) herpes zoster occurred spontaneously. In 30% cases, immunosuppression due to chemotherapy, malignancy, HIV infection, diabetes mellitus were observed. The commonest segment affected was thoracic (42.4%) followed by cranial (28.2%) and cervical (12.1%). Majority resolved in 7-14 days except immunosuppressed. 34.6% of the patients had complications such as secondary bacterial infection, post herpetic neuralgia, and motor weakness. Ten patients had HIV infection as a provocative factor.

CONCLUSION

The results of incidence and clinical pattern of herpes zoster is almost parallel to the previous studies. Any factors of immunosuppression should be checked, especially HIV, particularly in disseminated and long-lasting cases.

Oral manifestations of internal malignancy and paraneoplastic syndromes

Malignant tumors of visceral organs are a fundamental feature of familial cancer and paraneoplastic syndromes. In many instances, the presence of an internal and often occult malignancy may be forewarned by various external manifestations. Several of these findings are preferentially localized to the head and neck region, including the oral cavity proper. This places the dental practitioner in a unique position to detect these "markers" of occult neoplastic involvement. Because these markers may present before an established syndrome or cancer diagnosis, even representing the first expression of disease in some cases, early recognition by a dentist may lead to timely diagnosis and management of these cancer-associated syndromes.

Recommendations for the management of herpes zoster

The objective of this article is to provide evidence-based recommendations for the management of patients with herpes zoster (HZ) that take into account clinical efficacy, adverse effects, impact on quality of life, and costs of treatment. Systematic literature reviews, published randomized clinical trials, existing guidelines, and the authors' clinical and research experience relevant to the management of patients with HZ were reviewed at a consensus meeting. The results of controlled trials and the clinical experience of the authors support the use of acyclovir, brivudin (where available), famciclovir, and valacyclovir as first-line antiviral therapy for the treatment of patients with HZ. Specific recommendations for the use of these medications are provided. In addition, suggestions are made for treatments that, when used in combination with antiviral therapy, may further reduce pain and other complications of HZ.

Ocular Manifestations After Primary Varicella Infection

PURPOSE

To report a case of ocular manifestations after a primary varicella infection.

METHODS

Review of the literature and a case report of a 10-year-old male patient with history of blurry vision and an enlarged pupil 2 months after a varicella infection. Examination revealed uveitis, interstitial keratitis, and internal ophthalmoplegia.

RESULTS

The uveitis resolved with topical steroids; the interstitial keratitis resolved with a faint scar, and the internal ophthalmoplegia persisted.

CONCLUSION

This case report describes a patient with uncommon ocular manifestations after primary varicella.

Ocular Findings in Japanese Patients with Varicella-Zoster Virus Infection

PURPOSE

To examine ocular findings in Japanese patients with varicella, herpes zoster ophthalmicus, and acute retinal necrosis.

METHODS

A retrospective study was conducted. Information on the ocular, cutaneous, systemic, and virologic findings on pediatric and adult patients was obtained from medical records.

RESULTS

A total of 77 (45 male and 32 female) patients were enrolled in the study: 4 children had varicella, 68 adults had herpes zoster ophthalmicus, and 5 adults had acute retinal necrosis. Children with varicella had eruptions on the eyelid. Patients with herpes zoster ophthalmicus had eruptions, conjunctivitis, keratitis, iridocyclitis, and other findings. Patients with acute retinal necrosis had intracameral cells and retinal lesions. Some patients with herpes zoster ophthalmicus had malignancy, type 2 diabetes mellitus, or other disease. One pregnant woman developed acute retinal necrosis shortly after varicella infection. A total of 48% of patients with negative Hutchinson sign had ocular lesions, while all patients with positive sign showed ocular lesions. Patients with varicella and herpes zoster ophthalmicus had good visual acuity at the last visit. Some patients with acute retinal necrosis had poor visual acuity at the last visit.

CONCLUSIONS

Patients with varicella, herpes zoster ophthalmicus, and acute retinal necrosis had several ocular complications. Some patients with acute retinal necrosis had poor visual outcomes. Ophthalmologists should be aware that acute retinal necrosis may develop shortly after varicella infection.

Prognostic value of Hutchinson's sign in acute herpes zoster ophthalmicus

PURPOSE

To determine the prognostic value of nasociliary skin lesions (Hutchinson's sign) for ocular inflammation and corneal sensory denervation in acute herpes zoster ophthalmicus.

METHODS

A longitudinal observational study with a 2-month follow-up was performed involving 83 non-immunocompromised adults with acute herpes zoster ophthalmicus, with a skin rash duration of less than 7 days, referred by their general practitioner. All skin lesions at the tip, the side and the root of the nose, representing the dermatomes of the external nasal and infratrochlear branches of the nasociliary nerve, were documented by taking photographs and marking anatomical drawings. Ocular inflammatory signs were observed by slit-lamp biomicroscopy, and corneal sensitivity was measured with the Cochet-Bonnet esthesiometer at 2-month follow-up.

RESULTS

Hutchinson's sign was a powerful predictor of ocular inflammation and corneal denervation in herpes zoster ophthalmicus [relative risks: 3.35 (CI 95%: 1.82-6.15) and 4.02 (CI 95%:1.55-10.42), respectively]. The manifestation of herpes zoster skin lesions at the dermatomes of both nasociliary branches was invariably associated with the development of ocular inflammation.

CONCLUSION

Clinicians should be alert for early skin lesions within the complete nasociliary dermatome, because they are a reliable prognostic sign of sight-threatening ocular complications in acute herpes zoster ophthalmicus.

Clinical manifestations of varicella-zoster virus infection

Infections by VZV, the virus that causes chickenpox and herpes zoster, usually are diagnosed by the classic clinical presentations. In immunocompromised patients, however, the atypical presentation can make the diagnosis more challenging. Although varicella typically follows an uncomplicated course in children, adults and immunocompromised patients can develop complications involving several organs; some complications may be fatal. Prevention of disease with the vaccine is ideal. When varicella or zoster infection does occur, proper treatment should be initiated, depending on the age and immune status of the patient.

Varicella-Zoster virus infections of the nervous system: clinical and pathologic correlates

BACKGROUND

Diseases that present with protean manifestations are the diseases most likely to pose diagnostic challenges for both clinicians and pathologists. Among the most diverse disorders caused by a single known toxic, metabolic, neoplastic, or infectious agent are the central and peripheral nervous system complications of varicella-zoster virus (VZV).

METHODS

The pathologic correlates of the neurologic complications of VZV infection, as well as current methods for detecting viral infections, are discussed and presented in pictorial format for the practicing pathologist.

RESULTS

Varicella-zoster virus causes chickenpox (varicella), usually in childhood; most children manifest only mild neurologic sequelae. After chickenpox resolves, the virus becomes latent in neurons of cranial and spinal ganglia of nearly all individuals. In elderly and immunocompromised individuals, the virus may reactivate to produce shingles (zoster). After zoster resolves, many elderly patients experience postherpetic neuralgia. Uncommonly, VZV can spread to large cerebral arteries to cause a spectrum of large-vessel vascular damage, ranging from vasculopathy to vasculitis, with stroke. In immunocompromised individuals, especially those with cancer or acquired immunodeficiency syndrome, deeper tissue penetration of the virus may occur (as compared with immunocompetent individuals), with resultant myelitis, small-vessel vasculopathy, ventriculitis, and meningoencephalitis. Detection of the virus in neurons, oligodendrocytes, meningeal cells, ependymal cells, or the blood vessel wall often requires a combination of morphologic, immunohistochemical, in situ hybridization, and polymerase chain reaction (PCR) methods. The PCR analysis of cerebrospinal fluid remains the mainstay for diagnosing the neurologic complications of VZV during life.

CONCLUSIONS

Varicella-zoster virus infects a wide variety of cell types in the central and peripheral nervous system, explaining the diversity of clinical disorders associated with the virus.

Varicella zoster viral disease

Herpes zoster is cause of considerable morbidity, especially among elderly patients, with a suggestion of a slight increase in incidence among female patients. Substantial research on the biology of the varicella zoster virus has led to advances in our knowledge of the pathophysiology of the disease along with more successful therapy for the acute episodes of herpes zoster. Ophthalmic zoster is more common than zoster in other cranial nerves and is associated with pronounced suffering. This article reviews the epidemiology, biology, and latency of herpes zoster, discusses the pathophysiology of the disease, and describes treatment options with antivirals and corticosteroids. The pathophysiology and treatment options for postherpetic neuralgia are also addressed. The varicella vaccine is now available, and initial results suggest that this may lessen the effect of herpes zoster in the future.

Herpes zoster sine herpete. A potential cause of iridoplegic granulomatous iridocyclitis

OBJECTIVE

Herpes zoster ophthalmicus (HZO) is a recurrence of varicella zoster virus involving cranial nerve V-1, but does not always have skin manifestations. The objective of this work is to study iridoplegic granulomatous iridocyclitis as an acute, fulminant iridocyclitis that probably is caused by the recurrence of varicella zoster virus without skin eruptions.

PARTICIPANTS

The author reports 15 cases of iridoplegia granulomatous iridocyclitis with involvement of the anterior uveal tract without known skin eruptions.

RESULTS

All patients have had a clinical course of iridocyclitis closely resembling those cases of herpes zoster with skin eruptions. Nine of the 15 are documented to have had a recurrence of varicella zoster virus with an appropriate rise and fall of systemic titers. The remaining six patients had clinical findings, including loss of accommodation, iridoplegia, and sectoral iris atrophy that were more typical for HZO than other infectious agents.

CONCLUSIONS

Iridoplegic granulomatous iridocyclitis is a newly described, acute, fulminant uveitis probably caused by a herpes virus and most probably by varicella zoster virus. Herpes zoster sine herpete (erupticum) should be suspected as a potential diagnosis in patients with appropriate anterior segment manifestations. Further study is necessary to discern if any of such cases could be caused by herpes simplex.

Detection of herpes simplex and varicella-zoster infection from cutaneous lesions in different clinical stages with the polymerase chain reaction

BACKGROUND

The polymerase chain reaction (PCR) can be used to diagnose a variety of infectious processes.

OBJECTIVE

We sought to determine whether Tzanck smear debris, vesicle fluid swabs, crusts, or fixed tissue specimens are the best source for template herpes simplex virus (HSV) or varicella-zoster virus (VZV) DNA for the PCR.

METHODS

Patients with both clinical and histologic evidence of HSV (n = 6) or VZV (n = 16) infection were examined. Stained Tzanck smears, vesicle fluid swabs, dried crusts, and skin biopsy specimens were obtained at the same time from each patient. DNA was extracted from the different clinical specimens and then examined for HSV or VZV DNA with PCR. Fifteen control subjects did not have clinical or histologic evidence of herpesvirus infection.

RESULTS

In cases of suspected VZV infection, PCR detected VZV DNA sequences from all 15 Tzanck smears, all 15 vesicle swabs, one of one crust, and 14 of 16 fixed tissue specimens. HSV DNA sequences were detected from all six Tzanck smears, all four vesicle fluid swabs, two of two crusts, and five of six fixed tissue specimens.

CONCLUSION

PCR can detect VZV and HSV DNA sequences from a variety of sources including formalin-fixed tissue specimens. Although viral DNA was detected slightly more frequently from Tzanck smear debris, crusts, and vesicle fluid swabs compared with fixed tissue specimens, each was an excellent source of target DNA for the PCR to confirm the diagnosis of herpesvirus infection.

Orbital multiple myeloma mimicking acquired angio-oedema

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A case of presumed congenital herpes zoster ophthalmicus

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Internal ophthalmoplegia--a complication of ocular varicella

We report a case of unilateral internal ophthalmoplegia associated with varicella zoster in a five-year-old boy. Pupillary dilatation and accommodative paralysis persist after three years. A brisk reaction to topical pilocarpine suggests a denervation. Bifocal spectacle correction has restored the visual acuity.

Oral acyclovir for herpes zoster ophthalmicus

BACKGROUND

Reports on the natural history of herpes zoster ophthalmicus stress its high morbidity related to vicious scars on eyelids, ocular complications, and post-herpetic neuralgia. Early treatment with oral acyclovir is effective, but the optimal duration of treatment has not been defined.

METHODS

The authors performed a bicentric, prospective, randomized, double-masked study of 86 patients with acute herpes zoster ophthalmicus, within 72 hours of skin eruption, who received oral acyclovir (800 mg 5 times daily), either for 7 days (plus 7 days oral placebo) or for 14 days. All patients concomitantly received ophthalmic 3% acyclovir ointment; follow-up was at least 6 months.

RESULTS

Statistical analyses of subjective symptoms, skin lesions, and ocular complications showed no significant differences between the groups, suggesting that a 7-day course of treatment was sufficient. Drug tolerance was good. Pooled data from both groups corroborated earlier reports that prompt treatment with oral acyclovir reduces the severity of the skin eruption, the incidence and severity of late ocular manifestations, and the intensity of postherpetic neuralgia. At 6 months, late ocular inflammatory complications were seen in 29.1% of our 86 patients, versus 50% to 71% of untreated patients described by others. Only 13% of our patients experienced post-herpetic neuralgia, which in no case required the use of analgesics.

CONCLUSION

The authors believe it is not useful to prolong treatment with 800 mg of oral acyclovir 5 times daily for more than 7 days in herpes zoster ophthalmicus. This study confirms the efficacy of oral acyclovir not only against skin lesions and ocular complications, but also against postherpetic neuralgia in herpes zoster ophthalmicus.

Varicella disciform stromal keratitis

We treated five patients, aged 26, 4, 6, 13, and 7 years, who developed disciform stromal keratitis one, four, four, eight, and ten weeks, respectively, after the onset of the acute vesicular exanthema. Serologic testing confirmed recent varicella and excluded other infectious causes in two cases. After initial improvement with a topical corticosteroid, three patients developed recurrent corneal inflammation resembling zoster keratitis. These cases and previous reports indicate that varicella-zoster virus is a cause of disciform stromal keratitis that may occur and recur several weeks or months after the primary skin rash has resolved.

Chronic ocular zoster

In a prospective open trial 40 patients suffering from acute herpes zoster ophthalmicus were treated with systemic acyclovir. An additional 10 patients were treated by topical acyclovir alone and dexamethasone eye-drops were administered to 5 of them to suppress ocular inflammation. In the topical treatment group the period of new skin lesion formation and progression of ocular inflammatory signs were significantly prolonged. Therapy with systemic acyclovir however resulted in a quick and complete resolution of ocular inflammation in all patients. Chronic ocular inflammation developed in 4 out of 10 patients treated with topical acyclovir. We consider chronic ocular zoster as a distinct clinical entity, possibly expressing a failing local immune response against VZV.

Iritis in children with varicella

A prospective study that included 82 consecutive children seen over 2 years by five pediatricians was undertaken to determine the incidence of iritis in children with chickenpox. Twenty-one (25%) children without pox on their lids were found to have iritis. Follow-up of children with objective evidence of iritis revealed no long-term sequelae.

Treatment of herpes zoster. Recombinant alpha interferon versus acyclovir

Sixty-four patients received systemic alpha-interferon (10 million units subcutaneously daily) and 63 received systemic acyclovir (5 mg/kg body weight intravenously thrice daily) in a randomized study of acute herpes zoster. Start of healing, complete healing, development of new skin lesions in the primarily affected and in other dermatomes, and degree and duration of pain were evaluated. Both drugs proved equally clinically efficient without statistically different findings between the two groups; herpes zoster neuralgia was not prevented by either interferon or acyclovir therapy. Minor clinical side effects occurred slightly more frequently during interferon treatment and included fever and nausea. Transient and moderate leukopenia was observed in nearly all patients in the interferon group.

Branch retinal arteriolar occlusion with chicken-pox

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Comparison of detection of varicella-zoster virus by the Tzanck smear, direct immunofluorescence with a monoclonal antibody, and virus isolation

A study comparing direct immunofluorescence assay using a new monoclonal antibody specific for a varicella-zoster virus glycoprotein complex, the Tzanck smear, and virus isolation for detection of varicella-zoster virus in 56 patients with clinically apparent herpes zoster is presented. Of 47 patients with clinical herpes zoster and with cultures negative for herpes simplex virus, 30 (64%) had positive Tzanck smears, direct immunofluorescence assay results were positive in 26 (55%), and cultures were positive in only 12 (26%). Both direct immunofluorescence assay and the Tzanck smear were found to be superior to culture technics; however, direct immunofluorescence assay was found to have greater specificity.

Medical complications of herpes zoster in immunocompetent patients

The vast majority of the more than 300,000 annual cases of herpes zoster in the United States occur among healthy, immunocompetent persons. Most patients recover from reactivated varicella-zoster infection, but some experience complications. The most common of these is postherpetic neuralgia, but other neurologic as well as ocular and dermatologic complications can occur as well. Zoster during pregnancy is not of serious concern. Ongoing trials of antiviral agents are aimed at resolving the infection quickly and decreasing the incidence and severity of postherpetic neuralgia.

Granuloma annulare arising in herpes zoster scars. Report of two cases and review of the literature

We present two patients who developed granuloma annulare in the scars from previous herpes zoster. The development of granuloma annulare in herpes zoster scars may represent an atypical delayed hypersensitivity immune reaction to herpes zoster/varicella virus antigen(s) or a tissue antigen altered by the virus.

Oral acyclovir in the therapy of acute herpes zoster ophthalmicus. An interim report

A prospective, randomized, double-masked, placebo-controlled clinical trial was conducted to study the effects of oral acyclovir on 55 patients with acute herpes zoster ophthalmicus. Treatment with oral acyclovir resulted in more prompt resolution of signs and symptoms, particularly in patients treated within 72 hours after onset of skin rash (P less than 0.05), and shortened the duration of viral shedding (P = 0.02). Vesicular skin lesions involving other dermatomes (microdissemination) occurred in five (19%) placebo-treated patients but in no acyclovir-treated patients (P = 0.03). Interim analysis of this longitudinal study suggests that the incidence and severity of secondary ocular inflammatory disease was reduced by acyclovir. Prolonged observation of these patients is ongoing to determine if oral acyclovir reduces post-herpes zoster neuralgia or the late ocular complications of ophthalmic zoster.

Corneal complications from herpes zoster ophthalmicus

Of 94 patients with acute herpes zoster ophthalmicus who were seen during a six-year period, 61 had corneal involvement. The corneal complications in the order of chronological clinical occurrence were punctate epithelial keratitis in 51%, early pseudodendrites in 51%, anterior stromal infiltrates in 41%, sclerokeratitis in 1%, kerato-uveitis/endothelitis in 34%, serpiginous ulceration in 7%, delayed corneal mucous plaques in 13%, disciform keratitis in 10%, neurotrophic keratitis in 25%, and exposure keratitis in 11%. Some of the earlier lesions seemed to result from viral infection, whereas later lesions resulted from limbal vasculitis, an immunologic mechanism to soluble viral antigen, a delayed hypersensitivity reaction, or damage to nerves and tissues. An elucidation of the lesions awaits better viral and immunologic detection techniques and further histopathologic study. Modern topical and systemic antiviral therapy, corticosteroids, and surgery have a role in treatment.