Varicella-zoster virus infection and immunization in the healthy and the immunocompromised host

Reassessment of Evidence about Coinfection of Chickenpox and Monkeypox (Mpox) in African Children

In west and central Africa, monkeypox occurs mainly in older children, adolescents and young adults. In two large epidemiology studies of monkeypox outbreaks, the investigators observed a sizable number of coinfections of chickenpox (varicella) and monkeypox. Based on a review of the literature, we propose that chickenpox (human herpesvirus-3 infection) is a risk factor for acquisition of monkeypox infection. Our hypothesis states that the chickenpox skin lesion provides an entry site for the monkeypox virus, which is harbored on a fomite in the environment of the patient. The fact that monkeypox can enter via a scratch or abrasion is a known mechanism of spread for three other poxviruses, including mousepox (ectromelia), orf and molluscum contagiosum. There are many similarities in pathogenesis between certain poxviruses and chickenpox, including a viremia with a cellular stress response leading to high levels of the IL-6 cytokine. One very revealing observation in the two epidemiology studies was that the number of pox as well as the severity of disease in children with chickenpox and monkeypox coinfection was not greater than found in children with monkeypox alone. Based on the above observations, we conclude that, when chickenpox precedes monkeypox, priming of the immune system by the earlier chickenpox infection moderates the severity of the secondary infection with monkeypox. This conclusion also has important public health implications about chickenpox surveillance.

Twelve Children with Varicella Vaccine Meningitis: Neuropathogenesis of Reactivated Live Attenuated Varicella Vaccine Virus

Varicella vaccine is a live attenuated varicella-zoster virus (VZV). Like its parental strain called VZV pOka, the vaccine virus vOka retains some neurotropic properties. To better understand vOka neuropathogenesis, we reassessed 12 published cases of vOka meningitis that occurred in once-immunized and twice-immunized children, all of whom had bouts of herpes zoster preceding the central nervous system infection. Eight of the 12 meningitis cases occurred in children who had received only one immunization. There was no pattern to the time interval between varicella vaccination and the onset of herpes zoster with meningitis. Four of the meningitis cases occurred in children who had received two immunizations. Since all four children were 14 years old when meningitis was diagnosed, there was a strong pattern to the interval between the first vaccination at age 1 year and onset of meningitis, namely, 13 years. Knowledge of pathogenesis requires knowledge of the location of herpes zoster; the majority of dermatomal rashes occurred at sites of primary immunization on the arm or thigh, while herpes zoster ophthalmicus was uncommon. Based on this literature review, currently there is no consensus as to the cause of varicella vaccine meningitis in twice-immunized children.

The round trip model for severe herpes zoster caused by live attenuated varicella vaccine virus

Varicella vaccine is a live attenuated varicella‐zoster virus. Varicella vaccine can enter latency and later reactivate as herpes zoster. Pseudorabies virus is another herpesvirus closely related to varicella‐zoster virus. The round trip model for pseudorabies virus explains pathogenesis of herpes zoster from vaccine virus.

Severe Herpes Zoster Following Varicella Vaccination in Immunocompetent Young Children

Varicella vaccination is now virtually universal in North America, as well as in some European and Asian countries. Since varicella vaccine is a live attenuated virus, the virus replicates in the skin after administration and can travel via sensory nerves or viremia to become latent in the dorsal root ganglia. In some immunized children, virus reactivates within a few months to a few years to cause the dermatomal exanthem known as herpes zoster (shingles). Herpes zoster caused by vaccine virus often reactivates within the same dermatome as the site of the original varicella vaccine injection. We present evidence that occasional cases of herpes zoster following varicella vaccination in immunocompetent children can be as severe as herpes zoster following wild-type varicella. Analysis of the virus in one case disclosed that the vaccine virus causing herpes zoster was a wild-type variant with a mutation in ORF0. With regard to dermatomal localization of the viral eruption, we predict that herpes zoster of the lumbar dermatomes in children is likely to be caused by vaccine virus, because herpes zoster in those dermatomes is rare in children after wild-type varicella. One of the children with herpes zoster subsequently developed asthma, a known risk factor for herpes zoster, but none of the children had an autoimmune disease. Although postherpetic neuralgia is exceedingly rare, children who develop herpes zoster following varicella vaccination are at risk (albeit low) of developing meningoencephalitis and should be carefully observed for a few weeks.

Varicella zoster virus infection

Infection with varicella zoster virus (VZV) causes varicella (chickenpox), which can be severe in immunocompromised individuals, infants and adults. Primary infection is followed by latency in ganglionic neurons. During this period, no virus particles are produced and no obvious neuronal damage occurs. Reactivation of the virus leads to virus replication, which causes zoster (shingles) in tissues innervated by the involved neurons, inflammation and cell death - a process that can lead to persistent radicular pain (postherpetic neuralgia). The pathogenesis of postherpetic neuralgia is unknown and it is difficult to treat. Furthermore, other zoster complications can develop, including myelitis, cranial nerve palsies, meningitis, stroke (vasculopathy), retinitis, and gastroenterological infections such as ulcers, pancreatitis and hepatitis. VZV is the only human herpesvirus for which highly effective vaccines are available. After varicella or vaccination, both wild-type and vaccine-type VZV establish latency, and long-term immunity to varicella develops. However, immunity does not protect against reactivation. Thus, two vaccines are used: one to prevent varicella and one to prevent zoster. In this Primer we discuss the pathogenesis, diagnosis, treatment, and prevention of VZV infections, with an emphasis on the molecular events that regulate these diseases. For an illustrated summary of this Primer, visit: http://go.nature.com/14xVI1.

Association of herpes zoster infection with clinical characteristics and MBL2 gene polymorphisms in Chinese children with systemic lupus erythematosus

OBJECTIVES

In the first part of this study, we analyzed clinical factors associated with pediatric-onset systemic lupus erythematosus (SLE), and patient susceptibility to herpes zoster (HZ). In the second part of this study, we characterized MBL2 genotype polymorphisms in pediatric-onset SLE patients and their possible associations with HZ.

METHODS

This 10-year prospective cohort study compared pediatric-onset SLE patients from Taiwan with and without histories of HZ. By using 2 years as a standard interval, patients with early-onset and late-onset of HZ were compared. MBL2 gene polymorphisms in exon 1 at codon 54, and in the promoter at the position -221 and -550, were tested immediately after patient enrollment.

RESULTS

We initially enrolled 98 SLE patients, and analyzed complete clinical characteristics of 82 patients (35 patients with HZ, 47 patients without HZ). The incidence of HZ was higher in SLE patients who had methylprednisolone pulse therapy, cyclophosphamide pulse therapy, and received higher cumulative steroid dose (P < 0.05 for all 3). There were no significant associations of HZ with MBL2 genotype or serum level of mannose-binding lectin.

CONCLUSIONS

Pediatric-onset SLE patients were highly susceptible to HZ, with an incidence of 35.7%. Patients given steroid, cyclophosphamide, and high cumulative steroid dose were more likely to have had HZ. Deficiency of serum mannose-binding lectin and MBL2 gene polymorphism were not associated with HZ.

Calculation of the anterograde velocity of varicella-zoster virions in a human sciatic nerve during shingles

Zoster of the sciatic nerve, the longest nerve in the human body, is an uncommon event. We cared for a child with sciatic nerve zoster who had severe pain over the lower back 6 days before appearance of vesicular rash on the foot in the L4 dermatome. On the basis of the clinical data, we calculated an anterograde velocity for the varicella zoster virion of 5.55 mm/h or .0015 mm/s. Because there is no good animal model of varicella zoster virus reactivation from latency, this experiment of nature fills a notable gap in our knowledge about varicella zoster virus neuronal transportation.

Induction of cellular immunity to varicella-zoster virus glycoproteins tested with pernasal coadministration of Escherichia coli enterotoxin in mice

A mutant of Escherichia coli enterotoxin promotes the induction of cellular immunity to a live varicella vaccine (the Oka strain) as a mucosal adjuvant in mice. An investigation was carried out to determine which of the purified glycoproteins of the virus among three induced cellular immunity with a single nasal administration. Spleen cells from mice immunized nasally with the vaccine and toxin produced interleukin-2 (IL-2) at the same level on restimulation in vitro with glycoprotein H: glycoprotein L (gH:gL), gB, and gE:gI, but not IL-4. The spleen cells from mice immunized with gH:gL, gB, or gE:gI and toxin produced IL-2 on restimulation with gH:gL, gB, or gE:gI, respectively, and the vaccine, but not IL-4. Immunization with gH:gL and the toxin showed increased thymidine uptake and production of IL-2 and interferon-gamma (IFN-gamma) of the spleen cells, but not IL-4, depending on the dose of gH:gL used for immunization and restimulation in vitro. Purified gE:gI and gB have been reported to be the strongest stimulators of cellular immunity to varicella upon subcutaneous injection and are useful as a subunit vaccine. All the glycoproteins tested are excellent stimulators of cellular immunity to the virus and itself on nasal co-immunization with the toxin.

Long-term persistence of cellular immunity to Oka vaccine virus induced by pernasal co-administration with Escherichia coli enterotoxin in mice

A mutant of Escherichia coli enterotoxin induced cellular immunity to a live varicella vaccine (the Oka strain) as a mucosal adjuvant in mice. The persistence of this cellular immunity was investigated. A commercially available live Oka vaccine virus and toxin were administered once simultaneously via the nasal route, in mice. Ten or 12 months later, a delayed-type hypersensitivity to the vaccine virus was detected by footpad test, but an antibody neutralizing the varicella-zoster virus was not. When spleen cells from mice immunized with the vaccine and toxin were re-stimulated by live vaccine in vitro, their thymidine uptake and IL-2 production were higher than those from mice immunized with the vaccine alone, but lower than those of spleen cells prepared from mice 2 months after nasal administration. Production of IL-4 in these cells, however, was not induced by re-stimulation in vitro. These results suggest that although humoral immunity for Oka vaccine virus is only weakly induced by one co-administration of the vaccine and toxin, cellular immunity is induced and maintained over 1 year, though it declines with age. The nasal administration of the vaccine and toxin might be effective for maintaining cellular immunity to the varicella-zoster virus long term.

Pre-eruptive neurologic manifestations associated with multiple cerebral infarcts in varicella

A boy, 4 years, 9 months of age, presented with acute hemiplegia, lethargy, ataxia, and dysarthria 24 hours prior to the eruption of typical varicella exanthem. Magnetic resonance imaging findings were typical of multiple cerebral ischemic infarcts. It is suggested that during the period of secondary viremia varicella zoster virus invaded the cerebral blood vessels causing vasculopathy and cerebrovascular infarcts.

External ocular herpesvirus infections in immunodeficiency

Infections of the eye with members of the herpes family of viruses (e.g. HSV, CMV, VZV) are frequent manifestations of acquired and inherited defects in cell mediated immunity. Herpesvirus infections in the immunocompromised may reflect frequent viral reactivation from the latent state, as well as extensive productive infection of ocular structures following reactivation or primary infection. A review of experimental and clinical studies of both acquired and inherited immune dysfunction implicates specific immune mechanisms influencing the establishment of latency, viral reactivation and the control of active viral replication in ocular tissues.

Viral vaccines of the future

Varicella vaccine seems close to licensure in the United States. It is likely to be recommended for routine use in healthy children, either administered singly or as a combination of MMR. Healthy children who have been immunized develop excellent antibody and cell-mediated responses to VZV in the absence of significant adverse effects, and they are well protected against subsequent infection with VZV. Although it will not be known for certain for many years, it seems most unlikely that immunization will result in an increased incidence of zoster, a secondary type of infection with VZV that is caused by reactivation of latent VZV. Varicella vaccine may also be given to healthy adults who have never had chickenpox with a great degree of success, although its protection is somewhat less effective than in children. Leukemic children who are at high risk for developing severe or fatal varicella also derive a great deal of protection from varicella vaccine, but the vaccine must be administered to them with great caution. Other viral vaccines that may be licensed in the future but that are not as fully developed as varicella vaccine include vaccines against CMV, hepatitis A, HSV, and AIDS. These are in various degrees of study, and, should any of them be licensed, it is uncertain whether they would be live attenuated, recombinant, or subunit vaccines. It is hoped, however, that they will eventually be licensed for future use because if effective, they could significantly decrease morbidity and mortality of infants, children, and adults.

Enhancement of varicella-zoster virus plaquing efficiency with an agarose overlay medium

The infectivity titers of varicella-zoster virus (VZV) are routinely estimated by plaque production in cell culture. In this report, we show that plaque counts for VZV (strain Oka/Merck), in MRC-5 cell cultures, are significantly enhanced (54% average enhancement) by the use of an agarose overlay medium, as compared to a fluid overlay medium. Evidence also is presented that less variability (P less than 0.05) in plaque counts occurs with the use of an agarose overlay medium.

T-cell responses to predicted amphipathic peptides of varicella-zoster virus glycoproteins II and IV

Four peptides from the predicted amino acid sequences of varicella-zoster virus (VZV) glycoproteins II and IV selected for potential amphipathicity and a terminal lysine residue were synthesized. The peptides elicited weak proliferative responses by T cells with the CD4+ UCHL1+ CD45R- phenotype from the blood of VZV-immune individuals. The frequency of responder cells in individuals with specific response to peptides was 1:80,000 or fewer blood mononuclear cells, and the number of peptides responded to did not correlate with the proliferative response to VZV antigen. Of 40 peptide-specific T-cell clones obtained by limiting dilution, 10 were restimulated by extracted VZV antigen in the presence of autologous antigen-presenting cells. A total of 50% of these clones lysed HLA class II-positive lymphoblasts which had been preincubated with the appropriate peptide, and 2 of 15 cytotoxic clones lysed lymphoblast targets superinfected with VZV. The data indicated that T cells with specificity for putative VZV peptides may readily be cultured from the subset of blood mononuclear cells which bears the phenotype associated with memory.

Epstein-Barr virus: the hematologic and oncologic consequences of virus-host interaction

Varicella-zoster virus (VZV) and Epstein-Barr virus (EBV) are two of the human herpesviruses. The others include herpes simplex virus (HSV) type 1, HSV type 2, and cytomegalovirus (CMV). In a series of two articles, we review the clinical diseases caused by VZV and EBV infections; we pay particular attention to the manifestations of these two viral infections in immunosuppressed and immunocompromised patients. In addition to the clinical reviews, each of the two articles begins with a brief discussion of the molecular aspects of VZV and EBV, respectively; this introduction describes features of the genome and immunogenic viral proteins which have clinical relevance. A model for pathogenesis is included. The first review concerns VZV infections. Recent data about the DNA sequence of the entire VZV genome are included, as well as a review of the VZV glycoproteins. Primary VZV infection (chickenpox) and VZV reactivation (zoster) are described in detail in both healthy individuals and people with cancer. The decade-long VZV vaccine trials in children with leukemia receive special emphasis because they have engendered considerable interest and debate. The second review (published here) covers EBV infections. This virus has been implicated in the causation of a wide variety of human hematological and oncological disorders, besides classical infectious mononucleosis. In particular, Burkitt's lymphoma, nasopharyngeal carcinoma, and lymphoproliferative disorders are strongly associated with EBV infection of the transformed cells. In addition, immunologically mediated cytopenias occasionally follow EBV infection. Finally, treatment regimens with antiviral chemotherapy and other agents are discussed for both VZV and EBV infections.

Phenotype, cytotoxic, and helper functions of T cells from varicella zoster virus stimulated cultures of human lymphocytes

Blood mononuclear cells (MNC) were stimulated with VZV in the form of live cell-associated virus, glutaraldehyde-fixed VZV-infected fibroblasts or an extracted VZV antigen. After 7 days of culture with live virus, IL2 receptors (IL2R) were found on CD4 and CD8 cells while cultures stimulated with fixed or extracted antigen had IL2R only on CD4 cells. Clones derived by limiting dilution from these cultures were tested for specificity by cytotoxicity to autologous VZV-superinfected B lymphoblasts, and by proliferation in the presence of antigen and antigen presenting cells. The CD8+ clones were not VZV specific in tests of cytotoxicity or proliferation. 50% of the CD4+ clones with specificity for VZV also proliferated in cultures stimulated with individual VZV glycoproteins gp I, II or III. Included amongst these were clones cytotoxic for lymphoblast targets prepared with live VZV. Most of the VZV-specific T cell clones which failed to lyse targets prepared with live VZV lysed targets prepared with heat killed VZV. Target cells were susceptible to lysis after VZV antigens were no longer demonstrable on the cell surface by immunofluorescence and monoclonal antibodies to VZV glycoproteins failed to block cytotoxicity. 5 of 8 VZV-specific CD4+ clones provided antigen-specific help to B cells for IgG antibody production. The data are consistent with the view that CD4+ T cells respond to processed VZV antigen fragments, and that these fragments include epitopes present on gp I, gp II and gp III. Additionally, some the cloned progeny of VZV specific T cells were bifunctional (expressing cytotoxicity and help for B cells) in tissue culture.