Varicella zoster virus infection

Mini-review on the therapeutic vaccines targeting chronic infectious diseases: Evaluation system of therapeutic vaccines targeting HPV and EBV-related cancers

Chronic infectious diseases are threatening human health today, and their public health severity is increasing. The efficacy issues of drugs and the increase in drug-resistant pathogens require new response strategies for chronic infectious diseases, and therapeutic vaccines have recently been proposed as an effective alternative. However, research on therapeutic vaccines is still relatively underdeveloped. To solve this problem, an accurate understanding of the status and the challenge at hand of therapeutic vaccines targeting chronic infectious diseases is needed. In the present review, we provide an overview of the latest research trends in therapeutic vaccines targeting chronic infectious diseases and summarize the development status of therapeutic vaccines currently undergoing clinical research, focusing on the cases of human papillomavirus (HPV) and Epstein-Barr virus (EBV) as representative examples. We highlight the importance of standard methods for the evaluation of therapeutic vaccine, focusing on the cell-mediated immune response, which might accelerate therapeutic vaccine development.

A fresh look at varicella vaccination

The varicella vaccine is a live attenuated varicella zoster virus (VZV), first produced by Michiaki Takahashi (1974). Subsequent development of the fluorescent antibody to VZV membrane antigen test (FAMA), an immune correlate, permitted vaccine efficacy to be established, initially in immunodeficient and then in typical children and adults. Varicella vaccine is effective and safe; universal vaccination has almost eliminated varicella; moreover, endogenous boosting from subclinical VZV reactivation has evidently prevented an anticipated epidemic of zoster from occurring in response to the vaccine-induced loss of circulating varicella. The vaccine virus, moreover, reactivates less frequently than wild-type and an adjuvanted subunit vaccine against VZV gE safely prevents zoster. Doing so is important because VZV establishes latency and reactivates in sympathetic and enteric neurons; therefore, in addition to the painful cutaneous rash and postherpetic neuralgia of zoster, VZV reactivation can be an occult cause of vasculopathy, stroke, intestinal dysmotility, and achalasia.

Immunogenicity and safety of a live attenuated varicella vaccine in children aged 1 to 12 years: A double-blind, randomized, parallel-controlled phase III clinical trial in China

Chickenpox outbreaks frequently occur in collective settings such as kindergartens and schools, posing a significant threat to children's physical and mental health. This study aimed to evaluate the immunogenicity and safety of the freeze-dried live attenuated varicella vaccine (VarV) developed by Beijing Minhai Biotechnology Co. LTD. in healthy participants aged 1-12 years. In this phase III, single-center, randomized, double-blind, active-controlled trial,1,200 healthy participants randomly assigned in a 1:1 ratio to receive one dose of either the test vaccine or the active control vaccine. Venous blood samples were collected before vaccination and 42 days after vaccination, and the fluorescent antibody to membrane antigen (FAMA) assay was used to detect VZV antibody. Adverse events (AEs) observed within 42 days after vaccination and serious adverse events (SAEs) within six months after vaccination were recorded. The seroconversion rates in the test and control groups were 96.79% and 96.43%, respectively, with a difference of 0.36% (95% CI, -1.76%-2.48%). The geometric mean titers (GMTs) were 61.74 and 58.04, respectively, with a difference of 1.06 (95% CI, 0.92-1.23). The lower limits of the 95% CI for the differences in seroconversion rates and GMT ratios between the two groups were greater than their respective pre-set non-inferiority margins. The overall incidence of AEs (p = .0112) in the test group was significantly lower than that in the control group. The freeze-dried live attenuated VarV developed by Beijing Minhai Biotechnology Co. LTD. demonstrated good immunogenicity and higher safety compared to the active control vaccine in healthy participants aged 1-12 years.

The live attenuated varicella-zoster virus vaccine vOka: Molecular and cellular biology of its skin attenuation

Infection with varicella-zoster virus (VZV) causes chickenpox and shingles, both manifesting as a blistering skin rash. The skin is central to VZV, as the site of viral replication, transmission from cell-free virus in blisters and as the gateway to sensory nerves for establishing latency. The existing chickenpox vaccine is based on the live attenuated vOka strain and is impaired for replication in skin. While the genetics of the vOka vaccine have been extensively studied, critical gaps exist in understanding the molecular and cellular mechanisms of vOka attenuation, particularly in human skin models. This review aims to explore the molecular biology of vOka vaccine, focusing on its genetic diversity, interaction with host skin pathways, and the impact of vOka mutations in key VZV genes on attenuation mechanisms in human skin models. Insights from this review may guide the development of next-generation varicella vaccines and enhance the understanding of VZV pathogenesis.

Immunogenicity and safety of a live attenuated varicella vaccine in healthy subjects aged between 13 to 55 years: a double-blind, randomized, active-controlled phase III clinical trial in China

BACKGROUND

Adolescents and adults who contract chickenpox are at a higher risk of severe complications. Vaccination with the varicella vaccine (VarV) effectively prevents chickenpox.

RESEARCH DESIGN AND METHODS

In this phase III, single-center, randomized, double-blind, active-controlled trial, 1,200 healthy participants were randomly assigned in a 1:1 ratio to receive two doses of either the test vaccine or the active control vaccine. Varicella-zoster virus (VZV) antibody was detected before vaccination and 42 days after the two doses of vaccination.

RESULTS

The lower limits of the 95% CI for the differences in seroconversion rates and geometric mean titer (GMT) ratios between the two groups were greater than their respective pre-set non-inferiority margins. The overall incidence of Adverse events (AEs) and adverse reactions (ARs) in the test group was significantly lower than those in the control group. Additionally, the incidence rates of swelling and fatigue were lower in the test group compared to the control group after vaccination.

CONCLUSIONS

The test freeze-dried live attenuated VarV demonstrated good immunogenicity and higher safety compared to the active control vaccine in healthy participants aged 13-55 years.

CLINICAL TRIALS REGISTRATION

www.clinicaltrials.gov identifier: NCT06592456.

Bilateral In Vivo Confocal Microscopic Changes of the Corneal Subbasal Nerve Plexus in Patients with Acute Herpes Zoster Ophthalmicus

INTRODUCTION

Unilateral herpes zoster ophthalmicus (HZO) results in bilateral corneal denervation in patients with corneal involvement, which correlates with corneal sensation loss. The study aimed to analyze bilateral corneal nerve changes in patients with acute unilateral HZO and no keratitis compared with healthy controls.

METHODS

This was a prospective, single-center study. Using in vivo confocal microscopy (IVCM) and an automatized single image analysis software (ACCmetrics, University of Manchester, UK), seven corneal nerve parameters, including corneal nerve fiber density (CNFD; no/mm2), corneal nerve branch density (CNBD; no/mm2), corneal nerve fiber length (CNFL; mm/mm2), corneal nerve total branch density (CTBD; no/mm2), corneal nerve fiber area (CNFA; mm2/mm2), corneal nerve fiber width (CNFW; mm/mm2), and corneal nerve fiber fractal dimension (CFracDim) were analyzed. Additionally, central corneal sensitivity was measured.

RESULTS

Forty-six patients with HZO and 49 controls were recruited and compared. In the HZO group, ipsilateral and contralateral eyes presented a significant decrease (p < 0.001) in all seven IVCM parameters compared with controls: CNFD (13.25 ± 5.23 and 15.24 ± 4.70 vs. 23.54 ± 6.54), CNBD (14.67 ± 9.03 and 16.59 ± 7.98 vs. 31.72 ± 17.89), CNFL (8.42 ± 2.83 and 9.06 ± 2.69 vs. 13.08 ± 4.02), CTBD (27.11 ± 13.71 and 23.58 ± 12.69 vs. 46.88 ± 24.90), CNFA (0.0044 ± 0.002 and 0.0042 ± 0.001 vs. 0.0056 ± 0.002), CNFW (0.0213 ± 0.003 and 0.0221 ± 0.003 vs. 0.0222 ± 0.001) and CFracDim (1.39 ± 0.06 and 1.38 ± 0.06 vs. 1.45 ± 0.05). In the ipsilateral HZO eye group, a positive Hutchinson sign or a reduced corneal sensitivity was associated with more extensive corneal denervation. A significant negative correlation was found between patient age and CNFD (rho = - 0.312, p < 0.002), CNFL (rho = - 0.295, p = 0.004), and CFracDim (rho = - 0.284, p = 0.005).

CONCLUSIONS

Unilateral HZO in patients without apparent keratitis leads to bilateral subbasal nerve plexus alteration in the early days after disease onset, especially in those with a positive Hutchinson sign. Early follow-up of patients with HZO and bilateral application of preservative-free artificial tears during the initial months of symptom onset may help reduce the risk of developing neurotrophic keratopathy (NTK).

Zoster Sine Herpete Affecting Multiple Lower Cranial Nerves Presenting Severe Dysphagia in a Patient with Parkinson's Disease

We report the case of a 74-year-old woman with Parkinson's disease (PD) who developed acute dysphagia, dysarthria, and hoarseness. A neurological examination and nasopharyngeal fiberscopy revealed paralysis of the left glossopharyngeal, vagus, and hypoglossal nerves. No skin rash was observed. Cerebrospinal fluid testing showed lymphocytic pleocytosis, and an elevated varicella-zoster virus (VZV) IgG antibody index. She was diagnosed with zoster sine herpete unilaterally affecting multiple lower cranial nerves. Although dysphagia is common in patients with PD, acute exacerbations of dysphagia require careful investigation of various potential causes, including VZV infection.

Genomic analysis of Varicella zoster virus strains during an outbreak with atypical clinical presentations in Biswanath district of Assam, India

Chickenpox, caused by the Varicella Zoster Virus (VZV), presents as varicella (chickenpox) during primary infection and as herpes zoster (shingles) upon reactivation. With a high infectivity rate and transmission through airborne droplets and contact, VZV poses a significant public health challenge. While the disease is self-limiting, complications such as encephalitis and pneumonia can occur, particularly in unimmunized individuals and those with weakened immune systems. The introduction of varicella vaccination has significantly reduced incidence and complications in countries with universal vaccination programs, but India is yet to incorporate this vaccine into its national immunization schedule. In June 2023, an outbreak of varicella was reported in Biswanath district, Assam, affecting 18 individuals. The outbreak highlighted the impact of factors such as overcrowding, poor ventilation, and inadequate medical intervention. Clinical symptoms included fever, vesicular rash, and severe abdominal pain, with three fatalities linked to severe complications. Molecular and serological investigations confirmed VZV infection in the cases, and whole genome sequencing (WGS) identified the strain as belonging to Clade 5. Phylogenetic analysis revealed the strain's similarity to other Indian VZV sequences, aligning with the established VZV clade nomenclature. The outbreak investigation underscored the importance of timely medical intervention and effective vaccination strategies. Enhanced surveillance, community awareness, and a coordinated response involving various health stakeholders are crucial for managing varicella outbreaks and improving vaccination coverage. This study represents the first comprehensive genomic analysis of VZV from Northeast India, providing valuable insights into the strain circulation and reinforcing the need for vaccination and preventive measures.

The Use of Tricyclic Antidepressants for Postherpetic Neuralgia - A Case Series

Postherpetic neuralgia (PHN) is one of the most debilitating forms of neuropathic pain that can occur after a herpes zoster infection. PHN can significantly impair patients' quality of life due to persistent neuropathic pain. Current first-line treatments for PHN include anticonvulsants like gabapentin and pregabalin, topical agents such as lidocaine patches, and opioids in severe cases. However, many patients fail to achieve adequate pain control with these medications. Tricyclic antidepressants (TCAs) such as amitriptyline and nortriptyline may be considered as a second-line option, providing relief for patients with refractory pain. TCAs act by modulating neurotransmitters involved in pain pathways, offering analgesia in neuropathic conditions like PHN. This case series reviews four patients with PHN who found significant pain relief with the addition of TCAs after failing multiple other treatments. The patients, aged between 66 and 71, presented with severe PHN and had tried various treatments, including acetaminophen (APAP), nonsteroidal anti-inflammatory drugs (NSAIDs), lidocaine patches, gabapentinoids, and opioids, without achieving adequate pain relief. Each patient was prescribed a TCA, either amitriptyline or nortriptyline, alongside other pain medications. All four patients experienced notable reductions in pain intensity on the Numeric Rating Scale (NRS), resulting in improved daily function and better pain tolerance. Side effects were minimal, with only one patient reporting mild sedation and another reporting transient dry mouth, both of which were manageable. This case series underscores the potential of TCAs in managing PHN, particularly when other medications fail. While the results are promising, further research is needed to confirm the long-term efficacy and safety of TCAs in this patient population.

Severe skin complications of varicella in previously healthy children in Iran: emerging concern

BACKGROUND

Varicella, commonly known as chickenpox, is typically considered a mild childhood illness but can lead to severe complications necessitating hospitalization. In Iran, the varicella-zoster vaccine is not currently included in the routine immunization schedule. This case series study aimed to characterize severe skin complications of varicella in children admitted to an Iranian referral hospital.

MATERIALS AND METHODS

This case series study reviewed 17 pediatric cases hospitalized for severe skin complications of varicella and demographics data, clinical presentation, and the outcomes were collected.

RESULTS

Between December 2023 and March 2024, a total of 98 cases diagnosed with varicella were screened in our hospital, of which 17 cases (17.3%) presented with severe skin complications. Among 17 cases analyzed, 82.3% were males (n = 14) with a mean age of 6.9 ± 3.9 years. Severe skin complications of varicella manifested across diverse anatomical sites, with the chest and neck emerging as the most frequently affected areas. Cellulitis was a consistent finding across all cases, while abscess formation was noted in six instances. Particularly noteworthy was a case of necrotizing fasciitis localized to the thigh and leg region, underscoring the potential severity of varicella-related complications. Furthermore, we documented an instance of preseptal cellulitis linked to varicella zoster virus infection. Treatment involved local wound care, broad-spectrum antibiotics, and surgical intervention in six cases. Bacterial cultures identified Group A β-hemolytic Streptococcus in 35.3% of cases.

CONCLUSION

Our study highlights the spectrum of severe varicella-related skin complications and underscores the importance of prompt recognition and management to prevent morbidity and optimize outcomes. Further research and analysis of varicella epidemiology in Iran are essential to evaluate the benefits and feasibility of integrating the varicella-zoster vaccine into the national immunization program.

Efficacy of electroacupuncture on clinical signs and immunological factors in herpes zoster: The first systematic review, meta-analysis, and trial sequential analysis of randomized clinical trials

BACKGROUND

Electroacupuncture (EA) is utilized to address various health conditions. Herein, we designed a systematic review and meta-analysis to evaluate the efficacy of EA on clinical and immunological factors in herpes zoster (HZ) based on randomized clinical trials.

METHODS

Four international databases and 3 Chinese databases were searched until January 2024. We used RevMan 5.3 for meta-analysis and presented the data as standardized mean difference (SMD) or odds ratio (OR) and 95% confidence interval.

RESULTS

A total of 1361 records were identified in the databases and at last, 19 articles were entered into the meta-analysis. The result shows a negative pooled SMD of -2.55 (P < .00001) for the VAS score. The pooled SMD for cessation of pustules time in the case group compared to the control group was -0.69 (P = .0008), for pain relief time was -1.36 (P = .002), for the time to scab was -0.47 (P = .009), and for time to remove scab was -1.01 (P = .0003). The pooled OR for the incidence of postherpetic neuralgia was 0.11 (P < .00001), and the total effective rate was 4.25 (P < .00001). The pooled SMD for the cluster of differentiation (CD)3 count was 2.59 (P = .07), for the CD4 count was 2.81 (P = .04), for the CD8 count was -0.75 (P = .50), and for theCD4/CD8 ratio was 1.12 (P = .15).

CONCLUSIONS

The results indicate that the EA treatment had several significant benefits compared to Western medicine (WM) in HZ patients in terms of clinical and immunological factors. But, the combination of treatments of EA with WM had better effects compared to EA treatment alone.

Understanding the Mode of Action of Several Active Ingredients from the Micro-Immunotherapy Medicine 2LZONA®

Introduction

Varicella-zoster virus (VZV) affects over 90% of the global population. The initial encounter with VZV, often in the early years of childhood, results in varicella. From latency, VZV can reactivate in later stages of life, leading to the development of herpes zoster. Considering the importance of host immune responses in preventing reactivation and clinical manifestations associated with VZV infection, a therapy that sustains the immune system could be of great interest.

Objective

The present work aimed to set the basis of the possible mode of action of 2LZONA®, a micro-immunotherapy medicine composed of five different capsules. Thus, the effects of several active substances employed in this medicine were assessed in human primary immune-related cells.

Results and Discussion

Our results showed that DNA (8 CH) and RNA (8 CH), two active substances used in 2LZONA, displayed phagocytosis-enhancing capabilities in granulocytes and contained sub-micron particles that could explain, at least partially, the observed effect. These two active substances tested singularly and together with other actives of 2LZONA's capsules, modulated the proliferation of immature, transitory, and mature subsets of natural killer (NK) cells in an IL-15-like pattern, suggesting an enhancement of their activation levels. Moreover, the tested items of 2LZONA increased the secretion of IL-2, IL-6, IL-13, and TNF-α in human peripheral blood mononuclear cells (PBMCs). Furthermore, the proliferation of PBMCs-derived NK cells, intermediate monocytes, and neutrophils was slightly increased by this treatment. In CD3 and CD3/CD28 pre-primed conditions, actives present in one capsule of 2LZONA enhanced the secretion of IL-6 and TNF-α. Finally, one capsule of 2LZONA reduced the expression of human leukocyte antigen (HLA) in IFN-inflamed endothelial cells. Overall, these data provide, for the first time, preliminary experimental evidence of the mechanisms of action of some of the active ingredients employed in 2LZONA capsules.

Exploring the Link Between Diabetes, Herpes Zoster, and Post-Herpetic Neuralgia: Insights From Mendelian Randomization

Background

Diabetes mellitus (DM), herpes zoster (HZ) and its sequelae, post-herpetic neuralgia (PHN), are common in elderly individuals. Previous observational studies have shown that the prevalence of HZ and PHN in conjunction with DM is increasing. Nonetheless, few studies have investigated the causal relationships between DM and the risk of HZ and PHN.

Methods

A two-sample Mendelian randomization (TSMR) analysis was conducted on genome-wide association study (GWAS) data. We obtained four separate datasets for DM: type 1 diabetes (T1D), type 2 diabetes (T2D), mother diabetes mellitus (mother-DM) and father diabetes mellitus (father-DM), and two independent datasets for HZ and anti-varicella-zoster virus IgG (VZV-IgG), a single GWAS for PHN. The inverse variance weighted (IVW), MR‒Egger, weighted median and weighted mode analyses were used to estimate the causality.

Results

Genetically predicted T1D increased the level of VZV-IgG (IVW: OR=1.011, 95% CI 1.006-1.016, P -FDR=8.44×10-6). T2D (IVW: OR=1.313; 95% CI 1.043-1.655, P -FDR=0.041), mother-DM (IVW: OR=7.909; 95% CI 1.232-50.777, P -FDR=0.039), and father-DM (IVW: OR=11.798; 95% CI 2.051-67.874, P -FDR=0.023) increased the risk of PHN. No reverse causality was found between HZ, PHN, and DM.

Conclusion

Our research reveals a causal link between genetically determined T1D and increased VZV-IgG levels. Additionally, genetically predicted T2D and a family history of DM increase the risk of PHN. These discoveries deepen our comprehension of the underlying causes of HZ and PHN.

Immune response and safety of the adjuvanted recombinant zoster vaccine in adults 50 years of age and older in India: A randomized phase 3 trial

BACKGROUND

Reactivation of latent varicella-zoster virus can cause herpes zoster (shingles) and associated complications, such as post-herpetic neuralgia. The adjuvanted recombinant zoster vaccine (RZV) was shown to be efficacious in preventing herpes zoster and have an acceptable safety profile in adults ≥50 years of age. However, no clinical data on RZV were available in an Indian population. The aim of the current study was to assess the immunogenicity and safety of RZV in adults ≥50 years of age in India.

METHODS

In this randomized, placebo-controlled, observer-blind, multi-center trial, conducted between February 2022 and March 2023, participants ≥50 years of age received two doses (with a two-month interval) of RZV (N = 143) or placebo (N = 145). Blood samples were collected pre-dose 1 and one month post-dose 2 to quantify anti-glycoprotein E (gE) antibody concentrations. Solicited adverse events (AEs) with onset within seven days and unsolicited AEs with onset within 30 days following any RZV or placebo dose were recorded. Serious AEs (SAEs) and potential immune-mediated diseases (pIMDs) were recorded until trial end (six months post-dose 2).

RESULTS

At one month post-dose 2, vaccine response rate in the RZV group was 85.7 % (95 % confidence interval [CI]: 78.4 %-91.3 %), meeting the primary objective's success criterion (lower limit of 95 % CI ≥60 %). The adjusted geometric mean anti-gE antibody concentration ratio between the RZV and placebo groups was 19.8 (95 % CI, 14.1-27.8), meeting the secondary objective's success criterion (lower limit of 95 % CI ≥3). Solicited AEs were reported by 103 (72.0 %) RZV and 86 (59.3 %) placebo recipients; most had mild-to-moderate severity. No intervention-related unsolicited AE or SAE and no pIMD or death were reported.

CONCLUSION

Two doses of RZV induced a robust antibody response, comparable to that reported in other populations, and had a safety profile similar to the known RZV safety profile.

CLINICALTRIALS

gov: NCT05219253.

Impact of Universal Varicella Vaccination in Israel: A Time-Series Analysis, 2003 to 2020

BACKGROUND

Two-dose universal varicella vaccination (UVV) was included in Israel's national immunization program in 2008. We aimed to evaluate the impact of the UVV program on varicella incidence and healthcare costs in Israel.

METHODS

A retrospective observational study was conducted using the Maccabi Healthcare Services database between 2003 and 2020. Varicella incidence and varicella-related healthcare costs were assessed in the pre- (2003-2007) and post-UVV (2010-2020) periods. We used time-series analyses with seasonal autoregressive integrated moving average models to estimate the impact of UVV on varicella incidence and regression models with gamma distributions and log-link functions to assess the impact on healthcare costs. Analyses were conducted for the overall population and vaccine-targeted (1-7 years) and nontargeted (<1 and >7 years) populations.

RESULTS

Annual incidence rates per 100,000 declined from 5709.6 (pre-UVV) to 1062.9 (post-UVV) in the vaccine-targeted population and from 1269.8 to 409.6 in the overall population. Time-series analysis suggested 81.8% (95% prediction interval [PI], 67.5-87.4) and 67.1% (95% PI, 48.2-75.9) reductions in the vaccine-targeted vaccination and overall populations, respectively. The largest estimated reduction in varicella incidence was in children 1 to 2 years of age [91.2% (95% PI, 53.4-95.3)]. Mean direct medical costs decreased between pre- and post-UVV periods by 82% (95% confidence interval, 77-86) in the vaccine-targeted group and 51% (95% confidence interval, 44-58) overall.

CONCLUSIONS

This real-world study demonstrates the substantial reduction in the disease and economic burden of varicella in the vaccine-targeted and overall population following the introduction of a 2-dose UVV program in Israel.

Herpes Zoster: Risk Factors for Occurrence, Complications, and Recurrence with a Focus on Immunocompromised Patients

BACKGROUND

The varicella-zoster virus is a highly contagious human herpesvirus that primarily causes varicella (chickenpox) as an initial infection, targeting T cells, neurons, as well as skin cells, and can later reactivate to cause herpes zoster (shingles). Following reactivation, the varicella-zoster virus infection can lead to severe complications, the most common of which is postherpetic neuralgia. Risk factors include aging, immunosuppression, chronic diseases such as diabetes, cardiovascular disorders, respiratory conditions, and others.

OBJECTIVE

In this article, we present an analysis of factors increasing the risk of herpes zoster occurrence, complications, and recurrences (in particular in immunocompromised patients).

Insights into pathologic mechanisms occurring during serious adverse events following live zoster vaccination

An effective live zoster vaccine has been widely used around the world. Although no deaths occurred in the original large clinical trial, we analyzed 10 serious adverse events, including six deaths that have subsequently occurred in four countries. The goal is to define the viral pathogenesis of these unexpected adverse events secondary to a viremia with dissemination of the vaccine virus. We also propose a new hypothesis for acute retinal necrosis that occurs post-immunization.

A successful diagnostic case of Varicella zoster virus pneumonia by a Film Array assay for meningitis/encephalitis

Introduction

Although varicella zoster virus (VZV) infection is generally considered self-limiting and shows a favorable outcome, herpes zoster (HZ) can cause several complications such as neurological pain or meningitis, which lowers the patients' quality of life. HZ rarely manifests VZV pneumonia, resulting in a poor prognosis with a high mortality rate of 10-30 % if requiring a mechanical ventilation. Here, we present a rare successfully managed case of VZV pneumonia.

Case presentation

A 90-year-old man with a medical history of angina pectoris, prostate cancer, dementia, and brain infarction was diagnosed with pneumonia and was admitted to our institute. Four days before the admission, he had visited our outpatient clinic, where he had received anti-herpes therapy due to HZ on the right limb. Although TAZ/PIPC was started empirically, his respiratory status deteriorated. On day 3, we performed a Film Array Meningitis/Encephalitis (ME) PCR panel on a sputum specimen and VZV was identified. Thus, he was diagnosed as having VZV pneumonia and antiviral therapy with acyclovir was started. Since the patient's condition was improved, the antiviral therapy was ended on day 18. Despite that his VZV pneumonia was successfully cured, he passed away due to old age on day 63.

Conclusion

Due to poor medical conditions, some elderly patients cannot tolerate bronchoalveolar lavage fluid for diagnosing VZV pneumonia. Film Array ME panel on sputum specimen is a useful method to the diagnosis of VZV pneumonia.

Comparison of Two Different Neuromodulation Treatments in Patients With Acute Zoster-Related Trigeminal Neuropathic Pain and Pain Catastrophizing

OBJECTIVE

This study aimed to compare the efficacy of two neuromodulation techniques, peripheral nerve stimulation (PNS) and pulsed radiofrequency (PRF), in patients with acute zoster-related trigeminal neuropathic pain with pain catastrophizing.

MATERIALS AND METHODS

A total of 65 patients with acute zoster-related trigeminal neuropathic pain and pain catastrophizing were recruited from the Department of Pain Management of the Affiliated Hospital of Southwest Medical University between March 2019 and March 2024. According to the order of enrollment, participants were randomly assigned to two groups: the PNS group (n = 31), which received stimulation of the supraorbital nerve, and the PRF group (n = 34), which underwent PRF treatment of the same nerve. Pain levels were assessed using a visual analog scale (VAS), and the dosage of the anticonvulsant pregabalin was recorded at baseline, one week, two weeks, one month, three months, and six months postoperatively. Additionally, patients were evaluated using the Pain Catastrophizing Scale (PCS) and the Short Form 36 (SF-36) Health Survey at baseline and one, three, and six months postoperatively. Both groups were also monitored for adverse events and patient satisfaction throughout the study period.

RESULTS

Both the PNS and PRF groups experienced significant pain relief. However, the PNS group demonstrated superior outcomes compared with the PRF group at both short-term follow-up time points (p < 0.05). No significant difference in VAS scores was observed between the PNS and PRF groups during the long-term (six-month) follow-up. Improvements were noted in the SF-36 (across all eight dimensions) and PCS scores in both groups following treatment (p < 0.05). Notably, the PCS scores in the PNS group were consistently lower than those in the PRF group at all follow-up time points (p < 0.05). Additionally, patients in the PNS group exhibited greater improvements in physical role limitations, somatic pain, general health, social functioning, emotional role limitations, and mental health compared with those in the PRF group (p < 0.05). There were no significant differences between the two groups regarding improvements in physical functioning and vigor. After treatment, the average daily dose of pregabalin (mg/d) was reduced in both groups, with patients in the PNS group requiring a lower dose than those in the PRF group. Furthermore, patients in the PNS group reported a significantly higher level of satisfaction (p < 0.05) based on satisfaction evaluations. No instances of bleeding, infection, or other adverse effects were observed in either group after treatment.

CONCLUSION

Both PNS and PRF are effective and feasible for managing pain in patients with acute zoster-related trigeminal neuropathic pain and pain catastrophizing. However, PNS demonstrates superior efficacy in terms of early pain relief, reduction of pain catastrophizing, and improvements in quality of life, accompanied by higher patient satisfaction compared with PRF.

Abnormal Alterations of the White Matter Structural Network in Patients with Herpes Zoster and Postherpetic Neuralgia

PHN is one of the most common clinical complications of herpes zoster (HZ), the pathogenesis of which is unclear and poorly treated clinically, and many studies now suggest that postherpetic neuralgia (PHN) pain may be related to central neurologic mechanisms. This study aimed to investigate the white matter structural networks and changes in the organization of the rich-club in HZ and PHN. Diffusion imaging (DTI) data from 89 PHN patients, 76 HZ patients, and 66 healthy controls (HCs) were used to construct corresponding structural networks. Using graph-theoretic analysis, changes in the overall and local characteristics of the structural networks and rich-club organization were analyzed, and their correlations with clinical scales were analyzed. Compared with HCs, PHN patients had reduced global efficiency (Eg), reduced local efficiency (Eloc), a reduced clustering coefficient (Cp), a longer characteristic path length (Lp), and reduced nodal efficiency (Ne) in several brain regions, including the right posterior cingulate gyrus, the right supraoccipital gyrus, the bilateral postcentral gyrus, and the right precuneus; HZ patients had reduced Eg, a longer Lp, and reduced right orbital frontalis suprachiasmatic Ne. Moreover, HZ and PHN patients showed a significant reduction in the strength of rich-club connections. Compared with HZ patients, the intensities of the rich-club and feeder connections were lower in the PHN patients. Moreover, the changes in the structural networks and rich-club organization topology indices of the patients in the HZ and PHN patients were significantly correlated with disease duration, pain scores, and emotional changes. The structural networks of HZ and PHN patients exhibited reduced network transmission efficiency and rich-club connectivity, possibly due to structural damage to the white matter, and this was more obvious in PHN patients. The rich-club connectivity of HZ patients showed incomplete compensation in the acute pain stage.

Extended Prodromal Period in Herpes Zoster: A Case Report and Management Implications

Herpes zoster typically presents with a prodromal phase of pain lasting three to five days before the appearance of characteristic vesicular lesions. We report a case of herpes zoster in an immunocompetent man in his 70s who experienced an unusually prolonged prodromal period of two weeks. The patient initially presented with radicular pain in the right lower extremity, leading to evaluation for lumbar spinal stenosis. After the appearance of vesicular lesions in the L4-S1 dermatomes, he was diagnosed with herpes zoster and treated with valacyclovir and pregabalin. Despite the delayed initiation of therapy, the patient's symptoms resolved completely without recurrence. This case demonstrates that prolonged prodromal periods can occur in immunocompetent individuals and highlights the importance of maintaining clinical suspicion for herpes zoster in cases of persistent radicular pain. Although our patient recovered well despite treatment delay, prompt initiation of antiviral therapy is recommended once herpes zoster is clinically suspected to ensure optimal outcomes.

Repression of varicella zoster virus gene expression during quiescent infection in the absence of detectable histone deposition

Varicella zoster virus (VZV) is a human-specific herpesvirus that establishes latency in peripheral neurons. The only transcripts detected in infected human trigeminal ganglia (TG) obtained shortly after death correspond to the VZV latency-associated transcript (VLT) and associated VLT-ORF63 splice variants. In vitro studies showed that VLT-ORF63 is translated into a protein (pVLT-ORF63) that induces VZV transcription. The mechanisms that lead to this restricted gene expression and the transition to lytic replication remain unknown, partly due to the difficulty of working with human neurons. In this study, we addressed whether the neuroblastoma-derived cell line SH-SY5Y could serve as a model to investigate the mechanisms that lead to repression of VZV gene expression followed by reactivation. VZV productively infected differentiated SH-SY5Y (dSH-SY5Y) whereas incubation with acyclovir (ACV) inhibited virus replication and induced a progressive repression of the virus. Upon removal of ACV there was production of viral particles in a subset of cells, while others contained non-replicating VZV genomes and VLT-containing transcripts for at least 20 days post-infection (dpi). Exogenous expression of VLT-ORF63 induced productive infection, suggesting that the non-replicating and repressed genomes remained functional. Interestingly, histone deposition was undetectable at VZV genomes in quiescently infected dSH-SY5Y cells, pointing to a potential novel mechanism leading to VZV repression in this neuronal setting.

Post-infectious central nervous system vasculitides in adults: an underdiagnosed and treatable disease : Part I. Overview

INTRODUCTION

The differential diagnosis of Primary Central Nervous System Angiitis (PACNS) is complex and includes several inflammatory and non-inflammatory conditions. Among the first ones, post-infectious CNS vasculitides represent a relevant topic and they are often underdiagnosed.

AIMS

The main aim of this review is to summarize the clinical and neuroimaging features of post-infectious vasculitides, highlighting the diagnostic clues and the need to carefully consider them in the differential diagnosis of PACNS.

FINDINGS

Several infectious agents (viruses, bacteria, fungi and parasites) can be involved in documented post-infectious vasculitides, often with a pathological confirmation. Post-infectious vasculitides involve not only immunocompromised hosts but also immunocompetent people and the diagnosis might be complicated by the lack of close time relationship between infections and neuro-logical symptoms, as in Varicella Zoster Virus (VZV) related vasculopathy in adults. Several complications may occur, ranging from ischemic to hemorrhagic stroke, from arterial to venous thrombosis, from large to small vessel involvement, often simultaneously.

CONCLUSIONS

Post-infectious vasculitides are caused by a broad spectrum of microorganisms and they should be carefully considered in the differential diagnosis of some neurological pictures and neuroradiologicals findings in immunocompetent adults too.

A Viral Comeback: Recurrent Varicella in A Young Adult Female

An otherwise healthy young adult female presented to our clinic with a second episode of varicella. Our patient had a diffuse vesicular rash, reminiscent of childhood varicella, accompanied by constitutional symptoms. This rare presentation of a common virus required careful diagnostic and therapeutic decision-making, with a targeted approach based on clinical presentation and risk factors. As this patient was sexually active, there was concern for a mild case of monkeypox or herpes simplex. A polymerase cain reaction test on a skin vesicle was crucial to distinguish between these viral infections and make a diagnosis. With symptomatic treatment, the outcome was favourable. However, internationally recognised practice guidelines do recommend antiviral treatment. Adolescents and adults are at a higher risk of disseminated varicella, with severe and fatal outcomes. Further investigation of underlying immune impairment is also warranted.

LEARNING POINTS

There are several possible causes of a diffuse vesicular rash in sexually active individuals.Varicella (chickenpox) can occur more than once.A polymerase chain reaction test may be required to distinguish between herpes simplex, varicella zoster and monkeypox infections.

Vaccines in Dermatology-Present and Future: A Review

Dermatological vaccines have emerged as critical tools in preventing and managing a wide spectrum of skin conditions ranging from infectious diseases to malignancies. By synthesizing evidence from existing literature, this review aims to comprehensively evaluate the efficacy, safety, and immunogenicity of vaccines used in dermatology, including both approved vaccines and those currently being researched. Vaccines discussed in this paper include those targeting dermatoses and malignancies (e.g., acne vulgaris, atopic dermatitis, and melanoma); infectious diseases (e.g., human papillomavirus (HPV); varicella zoster virus (VZV); herpes zoster (HZ); warts; smallpox; mpox (monkeypox); hand, foot, and mouth disease (HFMD); candidiasis and Group B Streptococcus (GBS); and neglected tropical diseases (e.g., Buruli ulcer, leprosy, and leishmaniasis). Through this review, we aim to provide a detailed understanding of the role of vaccines in dermatology, identify knowledge gaps, and propose areas for future research.

Non-invasive methods for diagnosing portal hypertension and variceal bleeding due to liver cirrhosis secondary to NAFLD/MASLD: systematic review

Background

Non-alcoholic fatty liver disease (NAFLD), recently re-termed as metabolic dysfunction-associated steatotic liver disease (MASLD), is a global health concern affecting approximately 25% of adults. Complications such as portal hypertension and variceal bleeding are critical to diagnose but challenging with traditional invasive methods like hepatic venous pressure gradient (HVPG) measurement and esophagogastroduodenoscopy (EGD), which are not always feasible and carry risks.

Objectives

This systematic review aim to evaluate the diagnostic accuracy of non-invasive methods for diagnosing portal hypertension and variceal bleeding in patients with NAFLD/MASLD cirrhosis, comparing these methods to invasive standards.

Methods

A comprehensive literature search was conducted across PubMed, Cochrane Library, Google Scholar, and ScienceDirect from January 2000 to May 2024. Studies included evaluated non-invasive diagnostic techniques for portal hypertension and variceal bleeding, compared with HVPG and EGD, focusing on adult patients with confirmed NAFLD/MASLD cirrhosis. Data extraction covered study characteristics and diagnostic accuracy metrics. The quality of studies was assessed using the QUADAS-2 tool. Meta-analyses were performed using R and Python.

Results

Eleven studies involving 2,707 patients met the inclusion criteria. Liver stiffness measurement (LSM) via transient elastography demonstrated high sensitivity (85%) and specificity (79%) for diagnosing clinically significant portal hypertension (CSPH) at a 20 kPa cutoff. For severe portal hypertension (SPH), LSM had a sensitivity of 81% and specificity of 85% at 25 kPa. Combining LSM with platelet count resulted in a sensitivity of 97% but lower specificity (41%) for CSPH. Spleen stiffness measurement (SSM) also showed good diagnostic performance with a sensitivity of 89% and specificity of 75% for CSPH.

Conclusion

Non-invasive tests, particularly LSM and SSM, show promise in diagnosing portal hypertension and variceal bleeding in NAFLD/MASLD cirrhosis. These methods offer high sensitivity, especially in combination, supporting their use in clinical settings to potentially reduce the need for invasive procedures. Future research should aim to standardize protocols and explore additional biomarkers to further enhance diagnostic accuracy.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?, identifier CRD42024567024.

Bayesian phylodynamic inference of population dynamics with dormancy

Many organisms employ reversible dormancy, or seedbank, in response to environmental fluctuations. This life-history strategy alters fundamental eco-evolutionary forces, leading to distinct patterns of genetic diversity. Two models of dormancy have been proposed based on the average duration of dormancy relative to coalescent timescales: weak seedbank, induced by scheduled seasonality (e.g., plants, invertebrates), and strong seedbank, where individuals stochastically switch between active and dormant states (e.g., bacteria, fungi). The weak seedbank coalescent is statistically equivalent to the Kingman coalescent with a scaled mutation rate, allowing the use of existing inference methods. In contrast, the strong seedbank coalescent differs fundamentally, as only active lineages can coalesce, while dormant lineages cannot. Additionally, dormant individuals typically mutate at a slower rate than active ones. Consequently, despite the significant role of dormancy in the eco-evolutionary dynamics of many organisms, no methods currently exist for inferring population dynamics involving dormancy and associated parameters. We present a Bayesian framework for jointly inferring a latent genealogy, seedbank parameters, and evolutionary parameters from molecular sequence data under the strong seedbank coalescent. We derive the exact probability density of genealogies sampled under the strong seedbank coalescent, characterize the corresponding likelihood function, and present efficient computational algorithms for its evaluation based on our theoretical framework. We develop a tailored Markov chain Monte Carlo sampler and implement our inference framework as a package SeedbankTree within BEAST2. Our work provides both a theoretical foundation and practical inference framework for studying the population genetic and genealogical impacts of dormancy.

Effectiveness of a 2-dose varicella vaccination program in Changzhou, China, during the transitional period (2017-2022): a registry-based case-cohort study

BACKGROUND

The benefits of improving coverage and timeliness of varicella vaccination need to be quantified in countries where varicella vaccine (VarV) has not yet been included in national immunization programs. This longitudinal study analyzed the vaccine effectiveness (VE) of the varicella vaccination program implemented in Changzhou City during the transitional period (2017-2022).

METHODS

Using the Immunization Information System and National Notifiable Infectious Disease Surveillance System registry data, this retrospective case-cohort study assessed the VEs of varicella vaccination for Changzhou children born from 2016 to 2021. The subcohort was sampled using inverse probability weighting for the survival analysis design to evaluate the VEs under different dosages and cost types, eliminating confounding by age and location area. Sensitivity analysis for the exclusion part assessed the study's robustness.

RESULTS

A total of 5,172 children (1.12%) were sampled to the subcohort for studies, including 2,299 cases. VEs significantly rose with each successive dose, reaching 82.54% and 97.91%. VEs were lower for the single-dose subgroups until 2020, with significant increases in VEs in all subgroups in 2020 and after that. Most children who did not benefit from the "1-4" Vaccination Program had lower VEs due to delayed vaccination.

CONCLUSION

Improving 2-dose VarV vaccine coverage and timely vaccination could enhance the immune barrier for susceptible children. During the transitional period, the "1-4" Vaccination Program of VarV positively impacted coverage and timeliness in Changzhou.

Efficacy and safety of interferon-alpha 1b injection into the intervertebral foramen with ultrasonic guidance in patients with postherpetic neuralgia: study protocol for a randomized, double-blind, placebo-controlled, multicenter clinical trial

Purpose

Postherpetic neuralgia (PHN) is a type of refractory neuropathic pain that causes significant suffering, disability, economic loss, and medical burden. In this study, we aim to evaluate the efficacy and safety of interferon (IFN)-α1b injection into the intervertebral foramen of patients with PHN.

Patients and methods

This is a study protocol for a randomized, double-blind placebo-controlled multicenter clinical trial. A total of 200 participants with PHN from 11 hospitals will be recruited and randomly assigned to the treatment group administered with IFN-α1b and control group treated with placebo in a 1:1 ratio. Both groups will also receive oral pregabalin 150 mg twice daily and lidocaine injection into the intervertebral foramen as conventional therapy. This trial will involve a screening period, a 2-week intervention, and a 3-month follow-up. The primary outcomes will include the visual analog scale score and duration of pain relief. The secondary outcomes will include the 36-item short-form, dosage and duration of painkillers taken, viral load of varicella-zoster virus DNA, humoral cytokine level, and dosage and frequency of rescue medication. All adverse events and severe adverse events will be assessed during the study.

Conclusion

This study is expected to provide evidence for the efficacy and safety of IFN-α1b injection into the intervertebral foramen in patients with PHN.

Clinical trial registration

https://www.chictr.org.cn/indexEN.html, identifier ChiCTR240008996.

Metformin Against Herpes Zoster in Colon Cancer Patients with Type 2 Diabetes: A PSM Analysis

Background: Herpes zoster is a significant complication in cancer patients, particularly those with compromised immune systems. Previous studies have established the incidence of herpes zoster in gastrointestinal cancer patients, but there is a lack of specific analysis on colorectal cancer patients and the potential preventive role of metformin. This study aims to fill this gap by evaluating metformin's protective effects against herpes zoster in colon cancer patients with type 2 diabetes mellitus (T2DM). Methods: The study cohort comprised 1,510 T2DM colon adenocarcinoma patients without distant metastasis who received standard treatments from Taiwan Cancer Registry Database. Propensity score matching (PSM) was employed to balance covariates between metformin users and nonusers. Herpes zoster infection risk was assessed using Cox regression models and incidence rate calculations. The dose-dependent effects of metformin were analyzed based on cumulative defined daily doses (cDDD). Results: Metformin use was associated with a significantly reduced risk of herpes zoster infection (adjusted hazard ratio [aHR].: 0.69, 95% confidence interval [CI].: 0.51 to 0.93). A dose-dependent relationship was observed, with progressively lower aHRs across cDDD quartiles (p for trend < 0.0001). After adjusting for competing mortality risks, the aHR remained significantly lower (aHR: 0.70, 95% CI: 0.51 to 0.65). Metformin users had lower incidence rates and incidence rate ratios (IRR) of herpes zoster infection compared to nonusers (IRR: 0.75, 95% CI: 0.56 to 0.97). Conclusions: We are the first to demonstrate a dose-dependent protective effect of metformin against herpes zoster in colorectal cancer patients. Our findings indicate that higher doses of metformin correlate with a greater reduction in the risk of herpes zoster.

Cost-Effectiveness of Varicella Vaccination for 1-4-Year-Olds in Shanghai, China

INTRODUCTION

Varicella has not yet been included in the National Immunization Program (NIP) in China, and varicella vaccination strategies vary by region. To determine the optimal varicella vaccination strategy in Shanghai, China, the cost-effectiveness and 5-year costs of 5 immunization scenarios were analyzed.

METHODS

A static decision tree-Markov model was developed in 2022 to assess the cost-effectiveness and 5-year costs of voluntary and routine varicella vaccination programs in the 2019 birth cohort in Shanghai from a societal perspective. Parameters were collected in 2022 from the varicella surveillance system, a questionnaire survey of 414 guardians of patients with childhood varicella, and semi-structured interviews with 20 experts on varicella outbreaks from different institutions in Shanghai. The outcomes included varicella cases avoided, quality-adjusted life year (QALY) loss, and incremental costs per QALY (ICER). The 5-year costs were compared with local medical expenditures.

RESULTS

Among the 5 scenarios, one dose of routine varicella vaccination was the most cost-saving (USD 70.2) and cost-effective (Dominant) with a 5-year immunization expenditure of USD 9.9 million. Two doses of routine varicella vaccination had the highest QALY (29.9), and its ICER (USD 791.9/QALY) was below the willingness-to-pay threshold (USD 5,203-23,767/QALY). The 5-year immunization expenditure was USD 19.8 million. The effectiveness and price of vaccines, vaccination coverage, and per capita income are the 4 main factors that affect ICERs.

CONCLUSIONS

In Shanghai, the 2 doses of routine varicella vaccination strategy for 1- and 4-year-olds with a 95% coverage rate was found to be the optimal varicella immunization strategy.

Virus-Induced Hypercoagulable State: A Mythical Cause for Cerebral Venous Sinus Thrombosis in an Adult Male

Chickenpox is a common childhood disease that presents with erythematous rashes. In adults, varicella can cause complications with significant morbidity. Cerebral venous sinus thrombosis (CVST) is a life-threatening condition if not promptly treated. Here, we report a rare case of CVST complicating primary varicella-zoster virus infection. We present a case of a 34-year-old immunocompetent male with diffuse maculopapular rash and acute neurological deficit. Magnetic resonance venography revealed acute thrombosis involving the superior sagittal sinus, straight sinus, right transverse sinus, and confluence of sinuses. While arterial infarcts are well-known, venous thrombosis is less documented, particularly during active infection. The underlying mechanism may involve a hypercoagulable state induced by the infection or direct viral invasion of the venous endothelium, leading to endothelial damage and subsequent thrombosis.

Pediatric Varicella-related Hospitalization in Turkey Between 2008 and 2018: Impact of Universal Single Dose Varicella Vaccine (VARICOMP Study)

BACKGROUND

A single-dose varicella vaccine at 12 months of age was introduced to the National Immunization Program in February 2013 in Turkey. This study aimed to evaluate varicella-related hospitalization in children and the impact of a single-dose live attenuated varicella vaccine over the first 5.5 years of introducing a universal varicella vaccination.

METHODS

We analyzed data collected from the medical records of children <18 years old who required hospitalization due to varicella in 17 cities representing 50% of the childhood population in Turkey between 2008 and 2018. We calculated the rate of hospitalization for varicella per 100,000 children during the study period. The main objective of this study was to determine the yearly rate of hospitalization due to varicella and to compare these rates in the pre-vaccine and post-vaccine periods. The secondary objective was to compare demographic features, varicella-related complications, and outcomes between the pre-vaccine and post-vaccine periods.

RESULTS

A total of 4373 children (2458 boys and 1915 girls; 72.3% previously healthy) were hospitalized for varicella over a 10-year period, including 2139 children during the pre-vaccine period and 2234 children during the post-vaccine period. Overall, varicella hospitalization rates decreased significantly after the introduction of varicella vaccination [pre-vaccine vs. post-vaccine period; 3.79 vs. 2.87 per 100,000 per year; P < 0.001; odds ratio 0.75; 95% confidence interval 0.64-0.88]. The incidence of varicella-related hospitalization among children between 1 and 5 years of age was significantly lower in the post-vaccine era than in the pre-vaccine era, with a 60.2% decrease in hospitalizations (2.43 vs. 6.12 per 100,000 children; P < 0.001, odds ratio 0.39; 95% confidence interval 0.34-0.46). In both the <1-year and 6- to 10-year age groups, the incidence of varicella-related hospitalizations was similar in the pre-vaccine and post-vaccine periods. The incidence of varicella-related hospitalization was higher in the post-vaccine era among 11-15 years and >15-year-old groups ( P < 0.01 and P < 0.05). The mean age was higher during the post-vaccine period than during the pre-vaccine period ( P < 0.001). The absolute number of secondary bacterial infections ( P < 0.01), respiratory complications ( P < 0.01), and neurological complications ( P < 0.001) was significantly lower during the post-vaccine period. The incidence of severe varicella was lower during the post-vaccine period than during the pre-vaccine period ( P < 0.001).

CONCLUSIONS

After 5.5 years of routine single-dose varicella vaccine use, we observed the impact of varicella vaccination on the incidence of varicella-related hospitalizations, especially in the target age group. However, we did not observe herd protection in the other age groups. The implementation of a second dose of the varicella vaccine in the National Immunization Program would help control disease activity.

Immunogenicity and safety of live attenuated and recombinant/inactivated varicella zoster vaccines in people living with HIV: A systematic review

Few papers focus their attention on VZV vaccination effectiveness among people living with HIV (PLWH). Flanking the live attenuated vaccine (VZL) available, a newly recombinant vaccine (RZV) was recently introduced and approved for HZ prevention among adults. PLWH represents a population on which a particular attention should be applied, in order to guarantee the vaccine efficacy and safety. We performed a literature search in USNLM, PubMed, PubMed Central, PMC and Cochrane Library. From all the publications found eligible, data were extracted and processed per population, vaccine type, immunogenicity and ADRs. The review of the 13 included studies shows that both RZV and VZL are immunogenic and have an acceptable safety profile in adults and children living with HIV. However, given the lack of research available about vaccine efficacy in preventing VZV and HZ in PLWH, additional studies need to be performed, in order to achieve a full completeness of data.

Analysis of the implementation effect and evaluation of the vaccine protection effect of the live attenuated varicella vaccine program for school-age children in Bao'an district of Shenzhen,China

The objective of the study is to analyze the implementation effect of the Live Attenuated Varicella Vaccine (VarV) Vaccination Program for eligible children in Bao'an District, Shenzhen, and evaluate the vaccine effectiveness. Children's vaccination data was obtained from the Shenzhen Immunization Planning Information Management System, while varicella case data came from the China Disease Prevention and Control Information System. The Joinpoint regression method examined vaccination rate trends, and a retrospective cohort study assessed vaccine effectiveness. After program implementation, VarV vaccination rates significantly increased, surpassing provincial and national averages. Overall incidence declined 54.6% across age groups, with the largest reductions among 7- and 6-year-olds. One year post-vaccination, single-dose vaccine effectiveness was 91.1% (95% CI: 79.2% to 96.2%). However, two doses remained 91.4% effective(95% CI: 89.1% to 93.2%) after 7 years. Overall, Shenzhen's VarV program achieved positive results. For children under six, routine immunization with two doses of VarV should be strengthened. Furthermore, we recommend that physicians conduct thorough inquiries to ascertain patients' vaccination history and previous varicella infections. This will enable doctors to provide tailored vaccination recommendations based on comprehensive, practical evaluations.

The contributions of T cell-mediated immunity to protection from vaccine-preventable diseases: A primer

In the face of the ever-present burden of emerging and reemerging infectious diseases, there is a growing need to comprehensively assess individual- and population-level immunity to vaccine-preventable diseases (VPDs). Many of these efforts, however, focus exclusively on antibody-mediated immunity, ignoring the role of T cells. Aimed at clinicians, public health practioners, and others who play central roles in human vaccine research but do not have formal training in immunology, we review how vaccines against infectious diseases elicit T cell responses, what types of vaccines elicit T cell responses, and how T cell responses are measured. We then use examples to demonstrate six ways that T cells contribute to protection from VPD, including directly mediating protection, enabling antibody responses, reducing disease severity, increasing cross-reactivity, improving durability, and protecting special populations. We conclude with a discussion of challenges and solutions to more widespread consideration of T cell responses in clinical vaccinology.

Expanded spectrum of varicella disease and the need for vaccination in India

Varicella vaccine was first licensed in Japan and South Korea in 1989 for use in healthy children and was introduced in US in 1995. So far, 29 countries have adopted varicella vaccine in their universal immunization program (UIP). No Asian country, India included, has adopted the varicella vaccine as part of their UIP. The extra-cutaneous sites for VZV diseases are central nervous system and gastrointestinal tract, the expanded disease spectrum includes vasculopathy, myelitis, inflammatory bowel disease, perforated ulcers, and gastritis. The actual disease burden of varicella is not known as most of the infected individuals may not visit the physician. The amplifiable VZV DNA will not always be detectable in cerebrospinal fluid (CSF) samples in protracted illnesses such as vasculopathies, but demonstrable anti-VZV IgG in CSF has diagnostic value. The World Health Organization (WHO) position paper 2014 recommends two doses of varicella and zoster vaccines in targeted population. In India, varicella vaccine is not included in the UIP due to the cost and the belief that lifelong immunity occurs following primary infection. The expanded spectrum of VZV disease and the mounting body of evidence, however, suggest the need for both varicella and zoster vaccines in routine immunization schedule.

A systematic literature review of the epidemiology and burden of herpes zoster in selected locales in Asia Pacific

Herpes zoster (HZ) is a painful rash which typically affects older adults. This is of concern in Asia-Pacific given its aging population. As HZ epidemiology and burden are evolving, this systematic literature review aimed to update the current understanding of HZ burden and associated costs for selected Asia-Pacific locales. MEDLINE and Embase were searched for English articles of HZ studies conducted in Australia, China, Hong Kong, Japan, Korea, New Zealand, Singapore, and Taiwan. Eligible outcomes included HZ incidence and prevalence, occurrence of HZ-related complications, healthcare resource utilization, costs, and HZ-associated quality of life outcomes. This paper focused on HZ data in the general adult population (N = 90 articles). Substantial HZ-related disease and economic burden were observed in these locales, consistent with global trends. These findings reinforce the increasing burden of HZ and need for preventive strategies, which may include raising awareness and encouraging timely vaccination.

Optimizing Varicella Vaccination Strategy: A Study on Age and Dose Impacts on Antibody Levels

Seropositivity study of Varicella in Healthy Populations in Guangzhou, China. Infection with varicella-zoster virus (VZV) leads to skin and mucous membranes blisters and the complications can be life threatening. A seroepidemiological study conducted from 2020 to 2022 in Guangzhou, China, aimed to evaluate varicella antibody levels. We measured varicella antibody concentrations using an enzyme-linked immunosorbent assay. A total of 3300 people were enrolled in the study. The mean varicella antibody level was 171.2 mIU/mL (95% CI: 158.9, 184.4), with an overall positivity rate of 67.00% (95% CI: 65.37, 68.60). The mean level of those positive subjective was 581.2 mIU/mL (95% CI: 552.3, 611.5). Varicella antibody levels were found to be influenced by age, vaccination dosage, and history of varicella infection. Antibody level increased with age and the number of vaccinations. The antibody induced by the varicella vaccine remained at protective levels for at least 6 years post-vaccination. We recommend two doses of the varicella vaccine for both children and adults and the integration of the varicella vaccine into the national routine immunization program.

After the Infection: A Survey of Pathogens and Non-communicable Human Disease

There are many well-established relationships between pathogens and human disease, but far fewer when focusing on non-communicable diseases (NCDs). We leverage data from The UK Biobank and TriNetX to perform a systematic survey across 20 pathogens and 426 diseases, primarily NCDs. To this end, we assess the association between disease status and infection history proxies. We identify 206 pathogen-disease pairs that replicate in both cohorts. We replicate many established relationships, including Helicobacter pylori with several gastroenterological diseases and connections between Epstein-Barr virus with multiple sclerosis and lupus. Overall, our approach identified evidence of association for 15 pathogens and 96 distinct diseases, including a currently controversial link between human cytomegalovirus (CMV) and ulcerative colitis (UC). We validate this connection through two orthogonal analyses, revealing increased CMV gene expression in UC patients and enrichment for UC genetic risk signal near human genes that have altered expression upon CMV infection. Collectively, these results form a foundation for future investigations into mechanistic roles played by pathogens in NCDs. All results are easily accessible on our website, https://tf.cchmc.org/pathogen-disease.

A case report of varicella-zoster virus-related cerebral infarction in an AIDS patient

RATIONALE

Acquired immune deficiency syndrome (AIDS) patients with varicella-zoster virus (VZV) encephalitis rarely progress to cerebral infarction. This case highlights the potential for such complications in immunocompromised individuals.

PATIENT CONCERNS

A 33-year-old male with AIDS experienced recurrent hospitalizations due to neurological complications associated with VZV.

DIAGNOSES

During the course of 3 hospitalizations, the patient's primary diagnoses included non-herpetic herpetic neuralgia, VZV meningoencephalitis, and cerebral infarction.

INTERVENTIONS

The patient initially presented with herpetic neuralgia due to VZV infection. Treatment with anti-VZV acyclovir, analgesics, and anti-human immunodeficiency virus therapy improved the patient's condition, leading to discharge. However, 8 days later, the patient developed fever, slurred speech, nausea, and vomiting. Testing confirmed VZV-related meningoencephalitis with high VZV deoxyribonucleic acid levels in the cerebrospinal fluid. Treatment included ganciclovir, foscarnet, and dexamethasone. Later, the patient suffered an acute cerebral infarction, resulting in limb paralysis and aphasia. Treatment adjustments included additional medications for VZV, human immunodeficiency virus, inflammation, antiplatelet function, and plaque stabilization, leading to improvement.

OUTCOMES

During rehabilitation, the patient has shown improvement in right limb paralysis and aphasia, achieving grade 4 muscle strength in the affected limb and enhanced basic communication abilities. However, complete recovery has not yet occurred.

LESSONS

This case emphasizes the rare but significant risk of cerebral infarction in AIDS patients with VZV infection. It underscores the importance of early diagnosis, aggressive management, and continuous monitoring of neurological symptoms to mitigate long-term disability and reduce mortality in this vulnerable population.

A simple, highly sensitive and specific serological test for the detection of antibodies to Varicella-zoster virus (Varicellovirus humanalpha3)

INTRODUCTION

Varicella-Zoster virus (VZV) is a highly contagious alpha-herpes virus. The diagnosis of chickenpox remains a difficult task especially in cases of breakthrough chickenpox, so the development of reliable laboratory tests is necessary. The simplest and most sensitive serological test for detecting antibodies in human and animal sera is the passive hemagglutination reaction (PHAR).

THE AIM

To develop of a simple, highly sensitive and specific serological tests for the detection of antibodies to VZV in human and animal blood sera.

MATERIALS AND METHODS

Human and animal cell cultures; various strains of VZV; human and animal immune sera; monoclonal antibody to VZV glycoprotein (GP) E. Formalin-treated erythrocytes of sheep, chickens and goats, sensibilised with GP of VZV from a virus-containing supernatant were used for PHAR.

RESULTS

Cell cultures with the maximum cytopathic effect at VZV infection were selected. A simple original method for obtaining virus-specific VZV GPs using lectins has been developed. Purified GPs were obtained by their elution from sheep erythrocytes after adsorption. The activity of VZV GP was confirmed in PHAR by an antibody diagnostic assay using formalin-treated sheep erythrocytes sensibilised using monoclonal antibodies to GP E of the "vOka" VZV strain (USA). Using GPs from different VZV strains, PHAR test and GP-based enzyme-linked immunosorbent assay (gpELISA) have been developed to detect antibodies in human and animal immune sera. These tests have high sensitivity, specificity and lack of cross-reactivity.

CONCLUSION

A highly specific, sensitive and reproducible tests for the detection of antibodies to VZV have been developed.

Public Awareness and Willingness to Vaccinate Against Herpes Zoster: A Nationwide Cross-Sectional Study in Poland

OBJECTIVES

Herpes zoster (HZ), caused by varicella zoster virus reactivation, affects a significant portion of the population, leading to substantial morbidity. Vaccination is highly effective in preventing HZ, yet awareness and uptake remain low. This study assessed awareness and willingness to vaccinate against HZ in Poland following the introduction of a reimbursement policy.

METHODS

A nationwide cross-sectional survey (September 2024) using a computer-assisted web interview (CAWI) method collected data from 1137 adults. Factors associated with HZ vaccine awareness and willingness were analyzed using logistic regression models.

RESULTS

Only 47% of respondents reported awareness of the HZ vaccine. Television was the primary information source (52%). Factors associated with awareness included chronic disease status (aOR = 1.35, 1.02-1.80, p = 0.04). Willingness to vaccinate was reported by 63.7% of eligible participants, with factors such as the absence of children (aOR = 1.30, 1.01-1.69, p = 0.04) and moderate financial status (aOR = 1.51, 1.04-2.18, p = 0.03) being associated with higher willingness.

CONCLUSIONS

Significant gaps exist in public awareness and willingness to vaccinate against HZ in Poland. Multifaceted strategies, including targeted media campaigns, enhanced physician engagement and improved access, are needed to increase vaccination rates.

Comparison of ELISA Versus FAMA Titers in Children After Chemotherapy and Hematopoietic Stem Cell Transplantation Who Received the Live Attenuated MAV/06 Strain Varicella Vaccine

BACKGROUND

Varicella can lead to severe complications in immunocompromised children, including those undergoing hematopoietic stem cell transplantation (HSCT) or chemotherapy. Preventing primary varicella zoster virus (VZV) infection is crucial in these populations to mitigate morbidity and mortality. This study aimed to evaluate the immunogenicity and safety of the live attenuated MAV/06 varicella vaccine in pediatric patients post-HSCT and post-chemotherapy. Additionally, it sought to compare fluorescent-antibody-to-membrane-antigen (FAMA) and enzyme-linked immunosorbent assay (ELISA) titers to establish effective cut-off levels for protection against varicella.

METHODS

The FAMA assay was conducted at the Vaccine Bio Research Institute, and a VARICELLA-ZOSTER ELISA (Vircell, Granada, Spain) kit, which relies on lysate from whole cells infected with VZV, was used to determine VZV IgG. A prospective cohort study was conducted with 76 pediatric patients under 18 years old who tested negative for VZV IgG via ELISA. Patients post-HSCT and post-chemotherapy were included. Participants received the MAV/06 varicella vaccine, and serologic responses were evaluated using ELISA and FAMA.

RESULTS

The median age of participants was 9.8 years, with acute lymphoid leukemia and acute myeloid leukemia being the most common underlying disease. Post-dose 1, the seropositive rate was 56.1% by ELISA and 97.2% by FAMA. Based on the FAMA seropositive cut-off ≥1:4, post-dose 1 geometric mean titers (GMTs) of seropositive patients in the post-HSCT group were 14.7 (95% CI, 11.3-19.1) versus 20.2 (95% CI, 13.0-31.3) in the post-chemotherapy group (p = 0.690). Based on a FAMA seropositive cut-off ≥1:16, the post-dose 1 GMT of patients considered seropositive in the post-HSCT group was 19.3 (95% CI, 15.6-24.0) versus 34.1 (95% CI, 21.0-55.4) in the post-chemotherapy group (p = 0.116), and post-dose 2 FAMA titers of 76.1 (95% CI, 14.6-398.1) in the post-HSCT group and 64.0 (95% CI, 11.4-358.1) in the post-HSCT group (p = 0.853) were observed. In patients with lower baseline FAMA titers (1:4 to 1:8), 66.7% in the post-HSCT group and 71.5% in the post-chemotherapy group achieved a greater than four-fold increase in FAMA titers post-dose 1, while those with higher baseline titers (≥1:16) did not. There were no serious adverse events or vaccine-related rashes occurring in any of the patients.

CONCLUSION

The MAV/06 varicella vaccine is immunogenic in pediatric patients post-HSCT and post-chemotherapy, particularly when administered in a two-dose schedule using a cut-off FAMA titer of <1:16.

Silent reactivation of Varicella Zoster virus in hemodialysis patients.: A management dilemma

OBJECTIVES

To determine the seroprevalence of Varicella Zoster virus (VZV) immunoglobulin (Ig)G and IgM antibodies among hemodialysis patients (HDP). Additionally, the presence of VZV viral DNA has been investigated for possible reactivation status.

METHODS

Sera from 265 individuals were collected and tested. The study was carried out from November 2023 to February 2024. Enzyme linked immunosorbent assay was accomplished to determine the VZV IgG and IgM antibody levels. The viral DNA was tested by qPCR.

RESULTS

We found a significantly higher proportion of Host defense peptides (HDP) have positive antibody levels compared to healthy controls (HC) (92.0% of HDP have positive immune responses compared to 79.1% of HC, p=0.005). Patients with both hypertension and diabetes showed lower VZV seropositivity (25.6%) than those without (74.4%). Only 3 HDP had positive IgG and IgM levels (1.9%, n=3), while 14 patients (100%) had negative IgG and IgM levels. Additionally, all IgM-positive patients appeared to have detectable viral DNA of the VZV.

CONCLUSION

In conclusion, significantly higher VZV seroprevalence and antibody levels in HDP indicate greater viral exposure than HC. Screening of hemodialysis (HD) to VZV serologically or at the molecular level is most important to avoid the consequences of viral reactivation, especially in those with asymptomatic HDP.

Increase in Adult Patients with Varicella Zoster Virus-Related Central Nervous System Infections, Japan

An increase in the number of herpes zoster patients has been reported since universal varicella immunization was introduced, perhaps because of reduced opportunities for varicella patients to experience the natural booster effect caused by reexposure. We investigated recent trends of varicella zoster virus (VZV)-related central nervous system (CNS) infections at a university hospital in Japan. We enrolled patients with suspected CNS infection during 2013-2022 and tested cerebrospinal fluid samples by real-time PCR for DNA from 7 human herpesviruses. VZV DNA was the most commonly detected in 62 (10.2%) of 615 patients. Kulldorff's circular spatial scan statistics demonstrated a significant temporal cluster of patients with VZV-related CNS infections during 2019-2022 (p = 0.008). Among persons with such infections, the percentage with aseptic meningitis was significantly higher during 2019-2022 (86.8%), when the temporal cluster of cases occurred, than during 2013-2018 (50.0%) (p = 0.0029).

Non-hepatotropic viral hepatitis: a narrative review

Non-hepatotropic viral hepatitis (NHVH) refers to acute hepatitis or acute liver failure caused by viruses that do not primarily target the liver. These viruses include the Epstein-Barr virus (EBV), cytomegalovirus (CMV), herpes simplex virus (HSV)-1 and -2, varicella zoster, parvovirus, adenovirus, adeno-associated virus type 2, measles, and severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2). The epidemiology, pathogenesis, and clinical manifestations of hepatitis due to hepatotropic viruses (hepatitis A-E) have been well studied. However, there is a paucity of data on NHVH due to its rarity, self-limiting clinical course, and vague presentation. NHVH can occur as an isolated illness or as part of a disseminated disease, and its clinical features range from self-limiting transaminitis to acute liver failure. This activity reviews the most common non-hepatotropic viruses (NHV), with a focus on their biology, etiopathogenesis, clinical manifestations, and management.

Non-oral pharmacological interventions in the management of herpes zoster-related pain: a review of current research

Herpes zoster-associated pain is a difficult-to-treat pathologic pain that seriously affects patients' quality of life. In recent years, emerging therapeutic techniques such as autologous platelet-rich plasma, sympathetic nerve block and pulsed radiofrequency have been gradually applied in the field of pain with the advantages of less trauma, quicker recovery and significant efficacy. These therapeutic options have become a new hope for the treatment of herpes zoster-associated pain. This article reviews the studies on herpes zoster-associated pain in non-oral drug therapy, summarizes the efficacy, safety, and possible mechanisms, and provides a reference basis for clinical treatment.

The Emergence of Saliva as a Diagnostic and Prognostic Tool for Viral Infections

Saliva has emerged as a promising diagnostic fluid for viral infections, enabling the direct analysis of viral genetic material and the detection of infection markers such as proteins, metabolites, microRNAs, and immunoglobulins. This comprehensive review aimed to explore the use of saliva as a diagnostic tool for viral infections, emphasizing its advantages and limitations. Saliva stands out due to its simplicity and safety in collection, along with the convenience of self-collection without the need for healthcare supervision, while potentially being comparable to urine and blood in terms of effectiveness. Herein, we highlighted the significant potential of saliva in assessing viral loads and diagnosing viral infections, such as herpesviruses, HPV, PyV, TTV, SARS-CoV-2, and MPXV. The detection of viral shedding in saliva underscores its utility in early diagnosis, the monitoring of infection progression, and evaluating treatment responses. The non-invasive nature of saliva collection makes it an appealing alternative to more invasive methods, promoting better patient compliance and facilitating large-scale screening and surveillance. As such, we further highlight current evidence on the use of saliva as a prognostic tool. Although a significant amount of data is already available, further investigations are warranted to more comprehensively assess the added benefit from the utilization of salivary biomarkers in the clinics. Salivary biomarkers show great promise for the early detection and prevention of viral infection complications, potentially improving disease management and control at the population level. Integrating these non-invasive tools into routine clinical practice could enhance personalized healthcare strategies and patient outcomes. Future studies should focus on establishing standardization protocols, validating the accuracy of salivary diagnostics, and expanding clinical research to enhance the diagnostic and monitoring capabilities of salivary biomarkers.