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Mehrmal S, Mojica R, Guo AM, Missall TA. Diagnostic Methods and Management Strategies of Herpes Simplex and Herpes Zoster Infections. Clin Geriatr Med 2024; 40:147-175. [PMID: 38000858 DOI: 10.1016/j.cger.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Herpesviruses are medium-sized double-stranded DNA viruses. Of more than 80 herpesviruses identified, only 9 human herpesviruses have been found to cause infection in humans. These include herpes simplex viruses 1 and 2 (HSV-1 and HSV-2), varicella-zoster virus (VZV), human cyto-megalovirus (HCMV), Epstein-Barr virus (EBV), and human herpesvirus (HHV-6A, HHV-6B, HHV-7, HHV-8). HSV-1, HSV-2, and VZV can be problematic given their characteristic neurotropism which is the ability to invade via fusion of its plasma membrane and reside within neural tissue. HSV and VZV primarily infect mucocutaneous surfaces and remain latent in the dorsal root ganglia for a host's entire life. Reactivation causes either asymptomatic shedding of virus or clinical manifestation of vesicular lesions. The clinical presentation is influenced by the portal of entry, the immune status of the host, and whether the infection is primary or recurrent. Affecting 60% to 95% of adults, herpesvirus-associated infections include gingivostomatitis, orofacial and genital herpes,and primary varicella and herpes zoster. Symptomatology, treatment, and potential complications vary based on primary and recurrent infections as well as the patient's immune status.
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Affiliation(s)
- Sino Mehrmal
- Department of Dermatology, Saint Louis University School of Medicine, 1225 South Grand Boulevard, Saint Louis, MO 63104, USA
| | - Rafael Mojica
- Department of Dermatology, University of Florida College of Medicine, 4037 Northwest 86th Terrace, Gainesville, FL 32606, USA
| | - Aibing Mary Guo
- Department of Dermatology, Saint Louis University School of Medicine, 1225 South Grand Boulevard, Saint Louis, MO 63104, USA
| | - Tricia A Missall
- Department of Dermatology, University of Florida College of Medicine, 4037 Northwest 86th Terrace, Gainesville, FL 32606, USA.
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2
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Gao J, Feng L, Wu B, Xia W, Xie P, Ma S, Liu H, Meng M, Sun Y. The association between varicella zoster virus and dementia: a systematic review and meta-analysis of observational studies. Neurol Sci 2024; 45:27-36. [PMID: 37639023 DOI: 10.1007/s10072-023-07038-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/23/2023] [Indexed: 08/29/2023]
Abstract
PURPOSE The relationship between varicella zoster virus (VZV) infection and the risk of dementia has not been previously studied specifically. Therefore, this study sought to determine the relationship between studying VZV infection and dementia occurring in the general population by conducting an extensive meta-analysis of published cases. METHOD A systematic literature search was conducted in seven online databases by October 31, 2022. Heterogeneity was tested by the I2 index. Pooled HR and 95% CI were used to estimate the effect of VZV infection on dementia. Sensitivity analyses and publication bias were also performed. RESULT Nine studies involving 3,326,673 subjects were included. VZV infection was associated with an increased risk of dementia (HR = 1.11, 95% CI: 1.02-1.21). The risk of dementia was reduced in those who received antiviral therapy compared to those who did not (HR = 0.84, 95% CI: 0.71-0.99). In addition, VZV infection was found to be associated with an increased risk of developing dementia in the pooled results of the moderate quality study (HR = 1.81,95% CI: 1.27-2.59), and this association persisted when subgroup analyses were performed based on region (Asia: HR = 1.18,95% CI: 1.04-1.33). CONCLUSIONS Our results suggest that VZV infection might increase the risk of developing dementia, but there is no clear mechanism about the true relationship, and since there is no effective treatment for dementia, and our results suggest that some populations can benefit from antiviral therapy, it is at least arguable that patients who develop VZV infection should be treated with appropriate antiviral medications.
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Affiliation(s)
- Juan Gao
- Department of Epidemiology and Health Statistics, School of Public, Health Anhui Medical University, No. 81 Meishan Road, Hefei, 230032, Anhui, People's Republic of China
| | - Linya Feng
- Department of Epidemiology and Health Statistics, School of Public, Health Anhui Medical University, No. 81 Meishan Road, Hefei, 230032, Anhui, People's Republic of China
| | - Birong Wu
- Department of Epidemiology and Health Statistics, School of Public, Health Anhui Medical University, No. 81 Meishan Road, Hefei, 230032, Anhui, People's Republic of China
| | - Weihang Xia
- Department of Epidemiology and Health Statistics, School of Public, Health Anhui Medical University, No. 81 Meishan Road, Hefei, 230032, Anhui, People's Republic of China
| | - Peng Xie
- Department of Epidemiology and Health Statistics, School of Public, Health Anhui Medical University, No. 81 Meishan Road, Hefei, 230032, Anhui, People's Republic of China
| | - Shaodi Ma
- Department of Epidemiology and Health Statistics, School of Public, Health Anhui Medical University, No. 81 Meishan Road, Hefei, 230032, Anhui, People's Republic of China
| | - Haixia Liu
- Department of Epidemiology and Health Statistics, School of Public, Health Anhui Medical University, No. 81 Meishan Road, Hefei, 230032, Anhui, People's Republic of China
| | - Muzi Meng
- UK Program Site, American University of the Caribbean School of Medicine, Vernon Building Room 64, Sizer St, Preston, PR1 1JQ, UK
- Bronxcare Health System, 1650 Grand Concourse, The Bronx, NY, 10457, USA
| | - Yehuan Sun
- Department of Epidemiology and Health Statistics, School of Public, Health Anhui Medical University, No. 81 Meishan Road, Hefei, 230032, Anhui, People's Republic of China.
- Chaohu Hospital, Anhui Medical University, No. 64 Chaohubei Road, Hefei, 238000, Anhui, China.
- Center for Evidence-Based Practice, Anhui Medical University, Anhui, People's Republic of China.
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Wu CE, Wen KH, Huang CW. Delayed Nonarteritic Posterior Ischemic Optic Neuropathy following Herpes Zoster Ophthalmicus: A Case Report. Case Rep Neurol 2023; 15:69-75. [PMID: 37128573 PMCID: PMC10148233 DOI: 10.1159/000529837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 02/16/2023] [Indexed: 05/03/2023] Open
Abstract
Posterior ischemic optic neuropathy (PION), a relatively rare condition, is diagnosed primarily based on the clinical presentation of sudden visual impairment, an optic nerve-related visual field defect, and an initial normal optic disc that corresponds to its pathology of acute ischemia. Among its etiologies, nonarteritic PION is one of the most common causes. Studies on cases of PION associated with herpes zoster ophthalmicus (HZO) are limited, and the diagnosis was made based on the appearance of visual symptoms shortly following rashes. We describe a 64-year-old Asian woman with sudden painless visual loss in the upper half visual field of the left eye 6 weeks after ipsilateral HZO. Within a week, her left vision progressed to total visual loss. Initial examination revealed a near-total visual defect and a normal appearance of the optic disc in the left eye. Laboratory and imaging studies excluded the compressive, infiltrative, or inflammatory etiologies of the left optic nerve. Considering the temporal relationship between the skin rash and visual loss, HZO was the most likely cause of the nonarteritic PION. The patient was given a short course of oral valaciclovir and aspirin. At 6 weeks after the visual loss, an examination revealed stationary visual acuity and visual field defect in the left eye with a pale optic disc, and a retinal nerve fiber loss in the left eye. Compared with previous studies, our case demonstrated a delayed presentation of nonarteritic PION following HZO and broadened the scope of herpes zoster optic neuropathy.
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Affiliation(s)
- Cheng-En Wu
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | | | - Chin-Wei Huang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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4
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Kudo T, Yamauchi K, Suzuki Y, Nakazawa M, Ueno S. A case of herpes zoster ophthalmicus with optic neuritis of the total length of the optic nerve in the orbital space and ischemic optic neuropathy. Am J Ophthalmol Case Rep 2022; 28:101756. [DOI: 10.1016/j.ajoc.2022.101756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 10/30/2022] [Accepted: 11/11/2022] [Indexed: 11/25/2022] Open
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5
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Muacevic A, Adler JR. Corpus Callosum Infarct in the Background of Varicella-Zoster Infection: A Report of a Rare Case. Cureus 2022; 14:e29943. [PMID: 36348837 PMCID: PMC9635220 DOI: 10.7759/cureus.29943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 11/22/2022] Open
Abstract
Infarctions of the corpus callosum are rare due to a rich blood supply. Corpus callosum derives its blood supply from four vessels from the anterior and posterior circulation and for this reason, they have a rare, atypical presentation. There is scarce literature regarding this pathology. Corpus callosum infarcts usually present with non-specific signs and symptoms. Here, we describe a case of corpus callosum infarction in a 5-year-old boy who was a known case of acute lymphoblastic leukaemia. He presented with disseminated varicella infection and developed tonic-clonic seizures. MRI brain was performed and a diagnosis of corpus callosum infarct was made. The patient was treated conservatively.
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Bakradze E, Esenwa CC, Schmid DS, Kirchoff-Torres KF, Antoniello D, Mabie PC, Labovitz DL, Miao C, Liberman AL. Cross-Sectional Retrospective Study to Identify Clinical and Radiographic Features Associated With VZV Reactivation in Cryptogenic Stroke Patients With CSF Testing. Neurohospitalist 2022; 12:437-443. [PMID: 35755227 PMCID: PMC9214924 DOI: 10.1177/19418744221075123] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND AND PURPOSE A large proportion of ischemic stroke patients lack a definitive stroke etiology despite extensive diagnostic testing. Varicella-Zoster Virus (VZV) can directly invade blood vessels causing vasculitis and may be associated with cryptogenic stroke (CS). METHODS We conducted a retrospective cross-sectional study of CS patients tested for VZV. The following were considered evidence of VZV reactivation (VZV+): positive CSF VZV PCR, anti-VZV IgM in CSF, or anti-VZV IgG CSF/serum ratio of 1:10 or higher. We describe the cohort, report VZV+ proportion with 95% confidence intervals (CI) determined with the Wald method, and compare patient groups using standard statistical tests. RESULTS A total of 72 CS patients met full study inclusion criteria. Most of the patients were <65 years old, had few traditional vascular risk factors, and had multifocal infarcts. Mean age was 49 years (SD ±13) and 47% were women. A total of 14 patients (19.4%; CI: 11.4-30.8%) had evidence of CNS VZV reactivation. There was no difference in evaluated demographic or radiographic features between those with versus without evidence of VZV reactivation. History of ischemic stroke in the past year (11/14 vs 25/43, P<.05) and hypertension (13/14 vs 35/58 and P<.05) were associated with VZV+. CONCLUSION We found a high proportion of CNS VZV reactivation in a cross-sectional cohort of CS patients selected for CSF testing. Testing for VZV might be reasonable in CS patients who are young, have multifocal infarcts, or had an ischemic stroke within the past year, but additional research is needed.
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Affiliation(s)
- Ekaterina Bakradze
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Charles C. Esenwa
- Department of Neurology, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - D. Scott Schmid
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Daniel Antoniello
- Department of Neurology, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Peter C. Mabie
- Department of Neurology, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Daniel L. Labovitz
- Department of Neurology, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Congrong Miao
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ava L. Liberman
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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7
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Wu H, Wang R, Li Y, Sun X, Li J, Bi X. Cerebrovascular Complications After Adult-Onset Varicella-Zoster Virus Encephalitis in the Central Nervous System: A Literature Review. Neuropsychiatr Dis Treat 2022; 18:449-462. [PMID: 35250269 PMCID: PMC8890429 DOI: 10.2147/ndt.s343846] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/01/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Cerebrovascular complications after adult-onset varicella-zoster virus (VZV) encephalitis have been increasingly recognized. The aim of this study was to analyze clinical and neuroimaging findings, treatment and outcome of these patients. METHODS Literature review from January 2000 to December 2019. We searched for studies published in PubMed, Embase and Chinese Biomedical Literature Database. Clinical symptoms, neuroimaging findings, treatment and outcome were evaluated. RESULTS We analyzed 31 articles with a total of adult-onset 34 cases, including 25 cases of ischemic stroke, 6 of intracerebral hemorrhage and 3 with venous sinus thrombosis. Ischemic stroke was the major complication after VZV encephalitis accounting of 73.35%. There were more males than females in ischemia or venous sinus thrombosis groups. The middle-aged was prone to cerebral infarction, the elderly was for cerebral hemorrhage, and the young was for venous sinus thrombosis. Cognitive impairment was the most common symptom either in the ischemic group or hemorrhagic group. The lesions of VZV-associated cerebral infarction or hemorrhage were multifocal and mostly involved in the parietal lobe, followed by frontal or temporal lobes. Venous sinus thrombosis was common in the transverse sinus. Multiple stenosis of the anterior and posterior circulation vessels was found. A 60.87% of the patients with antiviral treatment in the ischemic group had favorable prognosis. All patients with anticoagulant therapy in venous sinus thrombosis group improved well; however, 60% of the patients with intracerebral hemorrhage had a poor prognosis or died. CONCLUSION Ischemic stroke was the majority of cerebrovascular complications after VZV encephalitis, which mainly occurred in middle-aged men. The lesions of VZV-associated cerebral infarction or hemorrhage were multifocal and did not accord with the characteristics of cerebrovascular diseases induced by atherosclerosis. The patients with venous sinus thrombosis had a relatively good prognosis. When the patient represents with some neurological symptoms about one month after VZV encephalitis, and multiple lesions probably induced by vasculitis are showed in neuroimaging, cerebrovascular complications related to VZV infection should be considered.
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Affiliation(s)
- Hangfei Wu
- Department of Neurology, Shanghai Changhai Hospital, Shanghai, People's Republic of China
| | - Ruoru Wang
- Department of Neurology, Shanghai Changhai Hospital, Shanghai, People's Republic of China
| | - Yuanyuan Li
- Department of Neurology, Shanghai Changhai Hospital, Shanghai, People's Republic of China
| | - Xu Sun
- Department of Neurology, Shanghai Changhai Hospital, Shanghai, People's Republic of China
| | - Jiasi Li
- Department of Neurology, Shanghai Changhai Hospital, Shanghai, People's Republic of China
| | - Xiaoying Bi
- Department of Neurology, Shanghai Changhai Hospital, Shanghai, People's Republic of China
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8
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Maramattom BV. Indolent varicella encephalitis with vasculopathy in an immunocompromised patient. J R Coll Physicians Edinb 2020; 50:39-41. [PMID: 32539035 DOI: 10.4997/jrcpe.2020.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
A 68-year-old female with B-cell non-Hodgkin's lymphoma presented to us with sequential blindness followed by hemiparesis. Four months earlier, the patient had developed chicken pox that was treated with intravenous acyclovir. An MRI brain showed multiple cerebral infarcts and beaded appearance of her intracranial vasculature. PET-CT showed hypermetabolism in the right frontal lobe and pons suggestive of encephalitis. Cerebral spinal fluid examination showed 15 cells and varicella zoster vasculopathy (VZVV) polymerase chain reaction was positive. A final diagnosis of indolent VZVV vasculopathy and encephalitis in an immunocompromised individual was made. This case highlights the slow and indolent progression of varicella central nervous system involvement.
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9
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Cutaneous Vasculitis and Central Nervous System Infarctions due to Varicella Zoster Virus Vasculopathy in an Immunocompromised Patient. Case Rep Transplant 2020; 2020:5049627. [PMID: 32318306 PMCID: PMC7165345 DOI: 10.1155/2020/5049627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 03/23/2020] [Indexed: 11/17/2022] Open
Abstract
Varicella zoster virus (VZV) infection commonly presents as varicella during childhood, and zoster, later in life. Here, we present a rare and interesting case of VZV infection that manifested with both cerebral and spinal infarctions and cutaneous vasculitis in the absence of a classic vesicular rash in an immunocompromised patient.
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10
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Lin CF, Hong CT, Lee WH, Wu D, Hu CJ, Chung CC. Disseminated cutaneous herpes zoster and multiple cerebral infarcts in an adult with diabetes mellitus. J Neurovirol 2020; 26:130-132. [PMID: 31942697 DOI: 10.1007/s13365-019-00790-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 07/11/2019] [Accepted: 08/08/2019] [Indexed: 10/25/2022]
Abstract
Ischemic stroke is a rare complication of varicella-zoster virus (VZV) infection. We present the case of a patient with a medical history of type 2 diabetes mellitus (DM) who experienced disseminated cutaneous VZV infection followed by multiple cerebral infarcts associated with VZV vasculopathy. Brain magnetic resonance imaging revealed multiple hyperintense lesions over the bilateral deep white matter and basal ganglia. A skin biopsy revealed small-vessel leukocytoclastic vasculitis with neutrophilic, lymphocytic, and eosinophilic infiltration. This case report describes the rare finding of cutaneous leukocytoclastic vasculitis in VZV infection and highlights that VZV infection is an uncommon but critical etiology of cryptogenic stroke in patients with DM.
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Affiliation(s)
- Chun-Fu Lin
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, No. 291, Zhongzheng Rd., Zhonghe District, New Taipei City, 23561, Taiwan.,Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Chien-Tai Hong
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, No. 291, Zhongzheng Rd., Zhonghe District, New Taipei City, 23561, Taiwan.,Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan.,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wei-Hwa Lee
- Department of pathology, Shuang Ho Hospital, Taipei, Medical University, Taipei, Taiwan
| | - Dean Wu
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, No. 291, Zhongzheng Rd., Zhonghe District, New Taipei City, 23561, Taiwan.,Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan.,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chaur-Jong Hu
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, No. 291, Zhongzheng Rd., Zhonghe District, New Taipei City, 23561, Taiwan.,Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan.,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chen-Chih Chung
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, No. 291, Zhongzheng Rd., Zhonghe District, New Taipei City, 23561, Taiwan. .,Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan. .,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. .,Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.
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11
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Bakradze E, Kirchoff KF, Antoniello D, Springer MV, Mabie PC, Esenwa CC, Labovitz DL, Liberman AL. Varicella Zoster Virus Vasculitis and Adult Cerebrovascular Disease. Neurohospitalist 2019; 9:203-208. [PMID: 31534609 PMCID: PMC6739663 DOI: 10.1177/1941874419845732] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The role of Varicella zoster virus (VZV) in neurological illness, particularly cerebrovascular disease, has been increasingly recognized. Primary infection by VZV causes varicella (chickenpox), after which the virus remains latent in neuronal ganglia. Later, during aging or immunosuppression, the virus can reactivate causing zoster (shingles). Virus reactivation can also spread to cerebral arteries causing vasculitis and stroke. Zoster is a recognized risk factor for stroke, but stroke can occur without preceding zoster rash. The diagnosis of VZV cerebral vasculitis is established by abnormal brain imaging and confirmed by presence of viral DNA or anti-VZV antibodies in cerebrospinal fluid. Treatment with acyclovir with or without prednisone is usually recommended. VZV vasculitis is a unique and uncommon stroke mechanism that has been under recognized. Careful diagnostic investigation may be warranted in a subgroup of patients with ischemic stroke to detect VZV vasculitis and initiate appropriate therapy. In the following review, we detail the clinical presentation of VZV vasculitis, diagnostic challenges in VZV detection, and suggest the ways to enhance recognition and treatment of this uncommon disease.
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Affiliation(s)
- Ekaterina Bakradze
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kathryn F. Kirchoff
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Daniel Antoniello
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Peter C. Mabie
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Neurology, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Charles C. Esenwa
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Daniel L. Labovitz
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ava L. Liberman
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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12
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Wu PH, Chuang YS, Lin YT. Does Herpes Zoster Increase the Risk of Stroke and Myocardial Infarction? A Comprehensive Review. J Clin Med 2019; 8:jcm8040547. [PMID: 31013629 PMCID: PMC6518274 DOI: 10.3390/jcm8040547] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 04/11/2019] [Accepted: 04/18/2019] [Indexed: 12/16/2022] Open
Abstract
Herpes zoster (HZ) caused by varicella zoster virus (VZV) reactivation is characterized as a vesicular rash of unilateral distribution that can also cause multiple complications; such as post-herpetic neuralgia; ophthalmic zoster; and other neurological issues. VZV can also increase incident hemorrhagic or ischemic complications by causing inflammatory vasculopathy. Thus; emerging epidemiological and clinical data recognizes an association between HZ and subsequent acute strokes or myocardial infarction (MI). This study reviewed published articles to elucidate the association between HZ and cerebrovascular and cardiac events. Individuals exposed to HZ or herpes zoster ophthalmicus had 1.3 to 4-fold increased risks of cerebrovascular events. Higher risks were noted among younger patients (age < 40 years) within one year after an HZ episode. The elevated risk of CV events diminished gradually according to age and length of time after an HZ episode. The putative mechanisms of VZV vasculopathy were also discussed. Several studies showed that the development of herpes zoster and herpes zoster ophthalmicus increased the risks of stroke; transient ischemic attack; and acute cardiac events. The association between VZV infection and cardiovascular events requires further studies to establish the optimal antiviral treatment and zoster vaccination to reduce zoster-associated vascular risk
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Affiliation(s)
- Ping-Hsun Wu
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan.
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan.
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan.
| | - Yun-Shiuan Chuang
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan.
| | - Yi-Ting Lin
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan.
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan.
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan.
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Lofaro T, Saha A, Raj K, Dillon R. Non-malignant CSF lymphocytosis in a patient with acute lymphoblastic leukemia. IDCases 2018; 14:e00447. [PMID: 30202728 PMCID: PMC6129732 DOI: 10.1016/j.idcr.2018.e00447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 08/21/2018] [Accepted: 08/27/2018] [Indexed: 11/23/2022] Open
Abstract
Patients with haematological malignancy are often profoundly immune suppressed, and more so if they require more than one line of therapy. Infection should always be considered when they become unwell. We discuss the differential diagnoses of a young man with multiply-relapsed Philadelphia chromosome-positive B-cell acute lymphoblastic leukaemia who presented with neurological symptoms and cerebrospinal fluid lymphocytosis. The diagnostic approach needs to be rapid and structured, and may require microbiology and neurology support.
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Affiliation(s)
- Thomas Lofaro
- Department of Hematology, Epsom and St Helier University Hospital, UK
| | - Aritra Saha
- Internee at Assam Medical College and Hospital, India
| | - Kavita Raj
- Department of Hematology, Guys and St. Thomas's Hospital, UK
| | - Richard Dillon
- Department of Hematology, Guys and St. Thomas's Hospital, UK
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14
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Increased risk of dementia following herpes zoster ophthalmicus. PLoS One 2017; 12:e0188490. [PMID: 29166672 PMCID: PMC5699837 DOI: 10.1371/journal.pone.0188490] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 11/05/2017] [Indexed: 12/17/2022] Open
Abstract
This retrospective cohort study aimed to examine the relationship between herpes zoster ophthalmicus (HZO) and the subsequent risk of dementia using a population-based database. We retrieved the study sample from the Taiwan Longitudinal Health Insurance Database 2005. The study group included 846 patients with HZO, and the comparison group included 2538 patients without HZO. Each patient was individually followed for a 5-year period to identify those patients who subsequently received a diagnosis of dementia. We performed a Cox proportional hazards regression to calculate the hazard ratios (HRs) along with 95% confidence intervals (CIs) for dementia during the follow-up period between patients with HZO and comparison patients. The respective incidence rates of dementia per 1000 person-years were 10.15 (95% CI: 7.22~13.87) and 3.61 (95% CI: 2.61~4.89) for patients with HZO and comparison patients. The Cox proportional analysis showed that the crude HR of dementia during the 5-year follow-up period was 2.83 (95% CI: 1.83–4.37) for patients with HZO than comparison patients. After adjusting for patients’ characteristics and comorbidities, HZO patients were still at a 2.97-fold greater risk than comparison patients for developing dementia. Furthermore, we found that of sampled male patients, the crude HR of dementia for patients with HZO was as high as 3.35 (95% CI = 1.79–6.28) compared to comparison patients. This study demonstrated an association between HZO and dementia. Clinicians must be alert to suspect dementia in patients with cognitive impairment who had prior HZO.
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Central Nervous System Varicella Zoster Virus Vasculopathy in Human Immunodeficiency Virus Patients. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2017. [DOI: 10.1097/ipc.0000000000000491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Donald H. Gilden, M.D. J Neuroimmunol 2017; 308:2-5. [DOI: 10.1016/j.jneuroim.2017.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 01/04/2017] [Indexed: 11/20/2022]
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17
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Stroke Associated With Varicella Zoster Vasculopathy: A Clinicoradiological Profile of 3 Patients. Neurologist 2017; 22:64-67. [PMID: 28248918 DOI: 10.1097/nrl.0000000000000111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Varicella zoster (VZ) vasculopathy is a rare but well recognized cause of stroke. In the absence of zoster rash and infection in remote past, the disease can pose diagnostic challenge. We report 3 cases of anterior circulation stroke occurring in close temporal relation to VZ. Their clinical, radiologic, and angiographic features are discussed. CASE REPORT Of the 3 patients, 2 had stroke within a span of 4 to 6 weeks of herpes zoster ophthalmicus while the third patient had zoster of cervical dermatome. Magnetic resonance imaging revealed acute subcortical infarcts in 2, while 1 patient showed acute on chronic infarct in left middle cerebral artery territory. The magnetic resonance angiography was abnormal in 2 patients while it was normal in third. All the patients were treated with acyclovir and antiplatelets with good recovery in 2. CONCLUSIONS VZ associated vasculopathy may have diverse clinical profile and neuroimaging features. It should be considered as an important and treatable cause of stroke in appropriate clinical settings.
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Abstract
PURPOSE OF REVIEW This article describes the clinical features and laboratory and imaging abnormalities of the protean neurologic disorders produced by varicella-zoster virus (VZV) reactivation. Diseases include not only zoster, but also chronic pain (postherpetic neuralgia), meningoencephalitis and cerebellitis, single or multiple cranial nerve palsies (polyneuritis cranialis), myelopathy (myelitis and spinal cord infarction), and VZV vasculopathy of intracerebral and extracerebral arteries that causes ischemic or hemorrhagic stroke, aneurysm, subarachnoid and intracerebral hemorrhage, arterial ectasia, and dissection. The article addresses accurate diagnosis of VZV infection of the nervous system in the absence of rash, and optimal treatment. RECENT FINDINGS All neurologic disorders produced by VZV can occur in the absence of rash. Diagnosis is confirmed by the presence of VZV DNA or anti-VZV antibodies in CSF. Based on evidence from recent studies, VZV has been implicated as a cause of giant cell arteritis. SUMMARY Clinicians must be aware that VZV reactivation produces multiple disorders of the central nervous system (CNS) and peripheral nervous system, often without rash. Rapid virologic verification and prompt treatment with antiviral agents can lead to complete recovery, even in patients with protracted disease.
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Gilden D, Grose C, White T, Nagae L, Hendricks RL, Cohrs RJ, Nagel MA. Successful antiviral treatment after 6years of chronic progressive neurological disease attributed to VZV brain infection. J Neurol Sci 2016; 368:240-2. [PMID: 27538641 DOI: 10.1016/j.jns.2016.07.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 06/29/2016] [Accepted: 07/13/2016] [Indexed: 11/28/2022]
Abstract
We describe an extraordinary case of an immunocompetent patient who developed sacral-distribution zoster, followed 3months later by neurological disease that progressed for 6years and was attributed to varicella zoster virus (VZV) infection of the brain. Despite the prolonged infection, neurologic symptoms and signs resolved rapidly and completely after treatment with intravenous acyclovir.
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Affiliation(s)
- Don Gilden
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA; Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Charles Grose
- Children's Hospital, University of Iowa, Iowa City, IA, USA
| | - Teresa White
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Lidia Nagae
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert L Hendricks
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Immunology, Microbiology and Molecular Genetics and Biochemistry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Randall J Cohrs
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA; Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Maria A Nagel
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
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Borbinha C, Marto JP, Calado S, Viana-Baptista M. A Young Woman with Ischemic Stroke: Should We Pay More Attention to Varicella Zoster Infection? Case Rep Neurol 2016; 8:145-50. [PMID: 27504091 PMCID: PMC4965528 DOI: 10.1159/000447296] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 05/30/2016] [Indexed: 12/28/2022] Open
Abstract
Ischemic and hemorrhagic stroke are recognized complications of Varicella zoster virus (VZV) infections, although uncommon and poorly documented. The authors report the case of a 31-year-old woman admitted with acute ischemic stroke of the right posterior cerebral artery and a history of a thoracic rash 1 month before. Aspirin and simvastatin were prescribed, but the patient suffered a stepwise deterioration the following days, with new areas of infarction on brain imaging. Despite no evidence of cardiac or large vessel embolic sources, anticoagulation was started empirically 6 days after stroke onset. One week later, symptomatic hemorrhagic transformation occurred. The diagnosis of VZV vasculopathy was then considered, and treatment with acyclovir and prednisolone was started with no further vascular events. Cerebrospinal fluid analysis and digital subtraction angiography findings corroborated the diagnosis. The patient was discharged to the rehabilitation center with a modified Rankin scale (mRS) score of 4. On the 6-month follow-up, she presented only a slight disability (mRS score 2). In conclusion, VZV vasculopathy needs to be considered in young adults with stroke. A high index of suspicion and early treatment seem to be important to minimize morbidity and mortality. Anticoagulation should probably be avoided in stroke associated with VZV vasculopathy.
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Affiliation(s)
- Cláudia Borbinha
- Neurology Department, Hospital Egas Moniz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - João Pedro Marto
- Neurology Department, Hospital Egas Moniz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Sofia Calado
- Neurology Department, Hospital Egas Moniz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal; CEDOC, Nova Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Miguel Viana-Baptista
- Neurology Department, Hospital Egas Moniz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal; CEDOC, Nova Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
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Shah J, Poonawala H, Keay SK, Serulle Y, Steven A, Gandhi D, Cole JW. Varicella-Zoster Virus Vasculopathy: A Case Report Demonstrating Vasculitis using Black-Blood MRI. ACTA ACUST UNITED AC 2015; 6. [PMID: 27065314 PMCID: PMC4825687 DOI: 10.4172/2155-9562.1000342] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Infections are rare but important causes of stroke. Among these, varicella zoster virus has been known to cause ischemic stroke. During an attack of herpes zoster ophthalmicus, it has been hypothesized that the virus replicates in the trigeminal ganglion and travels via the trigeminal nerve centrally to cause cerebral vasculopathy. Here we present a case of a 69 year-old Caucasian immunocompromised woman who suffered recurrent ischemic infarcts within the same vascular distribution following an episode of zoster ophthalmicus three months prior. An imaging technique termed black-blood magnetic resonance imaging was utilized to aid in the diagnosis of cerebral vasculitis. The case is used to provide a literature review of the pathogenesis, diagnosis, and treatment of cerebral varicella zoster vasculopathy. In situations where an isolated unilateral cerebral vasculopathy is identified, neurologists are urged to consider varicella zoster as a treatable etiologic agent, as untreated vasculopathy can lead to further strokes.
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Affiliation(s)
- Jay Shah
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Husain Poonawala
- Department of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland
| | - Susan K Keay
- Department of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland ; Medical Service, VAMHCS, Baltimore, Maryland
| | - Yafell Serulle
- Department of Radiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Andrew Steven
- Department of Radiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Dheeraj Gandhi
- Department of Radiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - John W Cole
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland ; Veterans Affairs Maryland Health Care System (VAMHCS) Geriatrics Research, Education, and Clinical Center, Baltimore, Maryland
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Asiki G, Stockdale L, Kasamba I, Vudriko T, Tumwekwase G, Johnston T, Kaleebu P, Kamali A, Seeley J, Newton R. Pilot study of antibodies against varicella zoster virus and human immunodeficiency virus in relation to the risk of developing stroke, nested within a rural cohort in Uganda. Trop Med Int Health 2015; 20:1306-10. [PMID: 26083834 DOI: 10.1111/tmi.12556] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The risk of stroke rises after episodes of herpes zoster and chickenpox, which are caused by varicella zoster virus (VZV). We conducted a pilot case-control study of stroke, nested within a long-standing cohort in Uganda (the General Population Cohort), to examine antibodies against VZV prior to diagnosis. METHODS We used stored sera to examine the evolution of IgG and IgM antibodies against VZV among 31 clinically confirmed cases of stroke and 132 matched controls. For each participant, three samples of sera were identified: one each, taken at or near the time of (pseudo)diagnosis, between 5 and 10 years prior to diagnosis and at 15 years prior to diagnosis. RESULTS All participants had detectable antibodies against VZV, but there were no significant differences between cases and controls in the 15 years prior to diagnosis. As a secondary finding, 16% (5/31) of cases and 6% (8/132) of controls had HIV (OR 3.0; 95% CI 0.8-10.1; P = 0.06). CONCLUSIONS This is the first prospective study to examine a biological measure of exposure to VZV prior to diagnosis of stroke and although we identified no significant association, in this small pilot, with limited characterisation of cases, we cannot exclude the possibility that the virus is causal for a subset. The impact of HIV on risk of stroke has not been well characterised and warrants further study.
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Affiliation(s)
- Gershim Asiki
- Medical Research Council, Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda
| | - Lisa Stockdale
- London School of Hygiene and Tropical Medicine, London, UK
| | - Ivan Kasamba
- Medical Research Council, Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda
| | - Tobias Vudriko
- Medical Research Council, Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda
| | - Grace Tumwekwase
- Medical Research Council, Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda
| | - Tom Johnston
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
| | - Pontiano Kaleebu
- Medical Research Council, Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda
| | - Anatoli Kamali
- Medical Research Council, Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda
| | - Janet Seeley
- Medical Research Council, Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda
- London School of Hygiene and Tropical Medicine, London, UK
| | - Robert Newton
- Medical Research Council, Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
- International Agency for Research on Cancer, Lyon, France
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Varicella-zoster virus infections of the central nervous system – Prognosis, diagnostics and treatment. J Infect 2015; 71:281-93. [DOI: 10.1016/j.jinf.2015.06.004] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 06/03/2015] [Accepted: 06/06/2015] [Indexed: 11/23/2022]
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Muramatsu T, Hayashi H, Kishitani T, Miura T, Arai Y, Kobayashi Y. [A long-term follow up of right ophthalmoplegia and severe right middle cerebral artery stenosis with right herpes zoster ophthalmics: a case report]. Rinsho Shinkeigaku 2015; 55:406-11. [PMID: 26103813 DOI: 10.5692/clinicalneurol.cn-000651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Here we report a case of a 68-year-old man with severe stenosis of the right middle cerebral artery (MCA) following herpes zoster ophthalmicus. He presented with right-sided ptosis and ophthalmoplegia 2 months after herpes zoster ophthalmicus. Cerebrospinal fluid (CSF) analysis revealed monocytosis, increased protein levels, and positivity for herpes zoster virus immunoglobulin M (IgM). Brain magnetic resonance imaging (MRI) revealed a small asymptomatic infarct in the right basal ganglia and severe stenosis of the right MCA (M1 segment). One month later, he presented with muscle weakness of the fingers of the left hand. Repeat CSF analysis revealed similar abnormalities to the previous analysis, and MRI showed a new small infarct in the right-sided motor area corresponding to the left fingers. He was treated with acyclovir (750 mg/day), prednisolone (1 mg/kg/day), and aspirin (100 mg/day). O2-gas positron emission tomography (PET) revealed decreased cerebral blood flow (CBF) after acetazolamide injection and normal cerebral vascular reactivity (CVR). He was on continuous treatment with prednisolone and aspirin for 1 year. The muscle weakness of the fingers of the left hand and right-sided ophthalmoplegia improved, and magnetic resonance angiography revealed considerable decrease in the stenosis of the right middle cerebral artery. CBF before and after acetazolamide injection and CVR on O2-gas PET also normalized. These results suggested that long-term treatment may prevent subsequent infarcts following herpes zoster ophthalmics.
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Affiliation(s)
- Tomoko Muramatsu
- Department of Rehabilitation and Neurology, Fukui General Hospital
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Kulkarni GB, Mustare V, Mirza MA. Unilateral herpes zoster ophthalmicus with bilateral cerebral infarcts in human immunodeficiency virus seropositive patient. J Neurosci Rural Pract 2014; 5:265-8. [PMID: 25002767 PMCID: PMC4078612 DOI: 10.4103/0976-3147.133584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Ischemic stroke is a recognized complication of herpes zoster ophthalmicus. Arterial involvement is usually seen on the side of the rash. It is thought to be due to vessel inflammation by the virus, which travels from the trigeminal ganglion. Few case reports of bilateral and distant site of zoster lesions with stroke in the brain have been described. These reports suggest possibility of contiguous vascular, cerebrospinal fluid (CSF) or hematogenous spread of the virus from the ganglion to the cerebral blood vessels. Therapeutically acyclovir, anticoagulation, and steroids have been used in the treatment of the zoster associated with stroke. We describe a case of immunocompromised patient with ipsilateral zoster ophthalmicus with bilateral anterior circulation strokes, who was treated with above measures and made successful recovery. This report also raises/supports possible CSF/vascular/hematogenous spread of the virus from the ganglion to involve cerebral blood vessels leading to the stroke.
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Affiliation(s)
- Girish Baburao Kulkarni
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Veerendrakumar Mustare
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Masoom Abbas Mirza
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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Lee SJ, Lee DG. Isolated Gait Ataxia as a Sole Manifestation of Right Lateral Medullary Infarct following Ipsilateral Trigeminal Herpes Zoster. Case Rep Neurol 2014; 6:193-6. [PMID: 25076896 PMCID: PMC4105956 DOI: 10.1159/000364998] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cerebral infarct related to varicella-zoster virus (VZV) has been reported in the literature. In addition, lateral medullary infarct (LMI) can be manifested rarely as isolated gait ataxia without other characteristic symptoms. CASE REPORT A 70-year-old female was admitted to our hospital because of herpes zoster on the right trigeminal nerve distribution. On the 15th hospital day, she developed sudden vertigo and fine left-beating nystagmus with axial lateropulsion to the right side, without the other usual signs of LMI (Horner syndrome, dysarthria, swallowing difficulty or hemibody sensory change). Brain MRI showed a small infarct in the far dorsolateral portion of the right rostral medulla and pontomedullary junction. Cerebrospinal fluid study showed a positive VZV IgG antibody. CONCLUSIONS We reported a case of isolated gait ataxia as the sole manifestation of right LMI following herpes zoster on the right trigeminal distribution. A high index of clinical suspicion for concomitant central nervous system complication is necessary in patients with herpes zoster, although the concomitant neurologic symptom may be mild or less lateralized.
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Affiliation(s)
- Seung-Jae Lee
- Department of Neurology, Sejong General Hospital, Bucheon, South Korea
| | - Dong-Geun Lee
- Department of Neurology, Sejong General Hospital, Bucheon, South Korea
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27
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Gilden D. Association of varicella zoster virus with giant cell arteritis. Monoclon Antib Immunodiagn Immunother 2014; 33:168-72. [PMID: 24893151 DOI: 10.1089/mab.2014.0020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Don Gilden
- Departments of Neurology and Microbiology, University of Colorado School of Medicine , Aurora, Colorado
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Varicella-zoster virus vasculopathy. A review description of a new case with multifocal brain hemorrhage. J Neurol Sci 2014; 338:34-8. [DOI: 10.1016/j.jns.2014.01.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Revised: 12/21/2013] [Accepted: 01/06/2014] [Indexed: 11/18/2022]
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Breuer J, Pacou M, Gauthier A, Brown MM. Herpes zoster as a risk factor for stroke and TIA: a retrospective cohort study in the UK. Neurology 2014; 82:206-12. [PMID: 24384645 PMCID: PMC3902756 DOI: 10.1212/wnl.0000000000000038] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objectives: Stroke and TIA are recognized complications of acute herpes zoster (HZ). In this study, we evaluated HZ as a risk factor for cerebrovascular disease (stroke and TIA) and myocardial infarction (MI) in a UK population cohort. Methods: A retrospective cohort of 106,601 HZ cases and 213,202 controls matched for age, sex, and general practice was identified from the THIN (The Health Improvement Network) general practice database. Cox proportional hazard models were used to examine the risks of stroke, TIA, and MI in cases and controls, adjusted for vascular risk factors, including body mass index >30 kg/m2, smoking, cholesterol >6.2 mmol/L, hypertension, diabetes, ischemic heart disease, atrial fibrillation, intermittent arterial claudication, carotid stenosis, and valvular heart disease, up to 24 years (median 6.3 years) after HZ occurrence. Results: Risk factors for vascular disease were significantly increased in cases of HZ compared with controls. Adjusted hazard ratios (AHRs) for TIA and MI but not stroke were increased in all patients with HZ (AHR [95% confidence interval]: 1.15 [1.09–1.21] and 1.10 [1.05–1.16], respectively). However, stroke, TIA, and MI were increased in cases whose HZ occurred when they were younger than 40 years (AHR [95% confidence interval]: 1.74 [1.13–2.66], 2.42 [1.34–4.36], 1.49 [1.04–2.15], respectively). Subjects younger than 40 years were significantly less likely to be asked about vascular risk factors than were older patients (p < 0.001). Conclusion: HZ is an independent risk factor for vascular disease in the UK population, particularly for stroke, TIA, and MI in subjects affected before the age of 40 years. In older subjects, better ascertainment of vascular risk factors and earlier intervention may explain the reduction in risk of stroke after the occurrence of HZ.
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Affiliation(s)
- Judith Breuer
- From the Division of Infection and Immunity (J.B.), and Institute of Neurology (M.M.B.), University College London; and Amaris (M.P., A.G.)
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Affiliation(s)
- Don Gilden
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA; Department of Microbiology, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Maria A Nagel
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Randall J Cohrs
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
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Frisch S, Guo AM. Diagnostic methods and management strategies of herpes simplex and herpes zoster infections. Clin Geriatr Med 2013; 29:501-26. [PMID: 23571042 DOI: 10.1016/j.cger.2013.01.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Herpes infections are extremely prevalent in the adult population. Recognizing early signs and symptoms is essential to provide effective treatment. The immunocompromised population presents treatment challenges requiring prolonged antiviral therapy and more frequent recurrences. Viral culture is often considered the gold standard diagnostic technique; however, polymerase chain reaction (PCR) should be done in tandem with culture especially for varicella zoster virus infections. Antivirals can decrease viral shedding, recurrences of herpes simplex, and hasten healing of herpes zoster. Herpes virus can be a challenging entity to treat with significant morbidity (both physically and psychologically).
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Affiliation(s)
- Stephanie Frisch
- Department of Dermatology, Saint Louis University, 1755 South Grand Boulevard 4th Floor, Saint Louis, MO 63104, USA
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Arteriopatía aneurismática cerebral e infección por el virus de la inmunodeficiencia humana. Rev Clin Esp 2013; 213:e55-7. [DOI: 10.1016/j.rce.2013.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Revised: 01/30/2013] [Accepted: 02/10/2013] [Indexed: 11/24/2022]
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Arroyo JC. Unsettled Issues of Zostavax Vaccine. Clin Infect Dis 2012; 55:889-90; author reply 889-90. [DOI: 10.1093/cid/cis546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Silver B, Nagel MA, Mahalingam R, Cohrs R, Schmid DS, Gilden D. Varicella zoster virus vasculopathy: a treatable form of rapidly progressive multi-infarct dementia after 2 years' duration. J Neurol Sci 2012; 323:245-7. [PMID: 22935406 DOI: 10.1016/j.jns.2012.07.059] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Revised: 07/24/2012] [Accepted: 07/26/2012] [Indexed: 12/01/2022]
Abstract
We describe an extraordinarily protracted case of varicella zoster virus (VZV) multifocal vasculopathy in a man who presented initially with ischemic optic neuropathy and then suffered 4 episodes of stroke manifesting as multi-infarct dementia over a 2-year period. Brain magnetic resonance imaging (MRI) and angiography (MRA) revealed cortical and subcortical infarctions as well as vasculitic occlusion and stenosis. The patient was treated with corticosteroids and later with cyclophosphamide. More than 2 years after the onset of neurological disease, two cerebrospinal fluid (CSF) examinations revealed the presence of anti-VZV IgG antibody with reduced serum-to-CSF ratios of anti-VZV IgG compared with ratios for total IgG and albumin, indicative of intrathecal synthesis of anti-VZV IgG. After definitive diagnosis, immunosuppressive drugs were discontinued and he was treated with intravenous acyclovir; both mental status and gait improved and no further episodes of neurological dysfunction ensued. The favorable outcome in this patient indicates that VZV vasculopathy can be treated successfully even after 26 months. VZV must be considered as a possible cause of neurological disease in any patient with idiopathic multifocal vasculopathy.
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Affiliation(s)
- Brian Silver
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
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35
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Chang GY. Clinical recognition of varicella zoster virus vasculopathy. Eur Neurol 2012; 67:297-9. [PMID: 22517383 DOI: 10.1159/000336260] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Accepted: 12/31/2011] [Indexed: 11/19/2022]
Abstract
INTRODUCTION It is important to recognize acutely evolving ischemic stroke attributable to reactivation of varicella zoster virus vasculopathy since antiviral agents are effective. METHODS Three cases seen by the author over a 2-year period are highlighted. RESULTS All patients presented with an evolving arterial or venous ischemia in the background of postherpetic neuralgia proceeding for weeks to months. CONCLUSION Chronic neuralgic pain in a dermatomal distribution of an evolving central nervous system vasculopathy is an important clue to its recognition.
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Kang JH, Sheu JJ, Kao S, Lin HC. Increased risk of multiple sclerosis following herpes zoster: a nationwide, population-based study. J Infect Dis 2011; 204:188-92. [PMID: 21653524 DOI: 10.1093/infdis/jir239] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
UNLABELLED (See the editorial commentary by Corona and Flores, on pages 177-8.) OBJECTIVE Varicella zoster virus (VZV) has been proposed to be involved in the pathogenesis of multiple sclerosis (MS). However, the epidemiological data regarding the MS occurrence rate following herpes zoster are still scanty. The goal of this study is to investigate the frequency and risk for MS following occurrence of herpes zoster. METHODS This study used the Taiwan National Health Insurance Research Database. A total of 315,550 patients with herpes zoster were included as the study group, and the control group consisted of 946,650 randomly selected subjects. The stratified Cox proportional hazard regression was performed to calculate the 1-year MS-free survival rate. RESULTS Of 1,262,200 sampled patients, 29 from the study group (.009%) and 24 from the control group (.003%) had MS during the 1-year follow-up period. After adjusting for monthly income and geographic region, the hazard of MS was 3.96 times greater (95% CI = 2.22-7.07, p < 0.001) for the study group than controls. CONCLUSIONS Our findings support the notion that occurrence of MS could be associated with herpes zoster attack. We found a significantly higher risk for MS within 1 year of herpes zoster attack compared with the control population.
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Affiliation(s)
- Jiunn-Horng Kang
- Department of Physical Medicine and Rehabilitation, Taipei Medical University, Taipei, Taiwan
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Salazar R, Russman AN, Nagel MA, Cohrs RJ, Mahalingam R, Schmid DS, Kleinschmidt-DeMasters BK, VanEgmond EM, Gilden D. Varicella zoster virus ischemic optic neuropathy and subclinical temporal artery involvement. ACTA ACUST UNITED AC 2011; 68:517-20. [PMID: 21482932 DOI: 10.1001/archneurol.2011.64] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To demonstrate varicella zoster virus (VZV) infection in an asymptomatic extracranial (temporal) artery in a patient with ischemic optic neuropathy produced by VZV vasculopathy in whom the pathological changes were mistakenly identified as giant cell arteritis. DESIGN Case report. SETTING Teaching hospital, pathology and virology laboratory. PATIENT An 80-year-old man with left ophthalmic distribution zoster who developed left ischemic optic neuropathy. INTERVENTION An ipsilateral temporal artery biopsy revealed inflammation that was mistakenly identified as giant cell arteritis. The patient was initially treated with steroids but his condition did not improve. When the diagnosis of VZV vasculopathy was confirmed virologically and the patient was treated with intravenous acyclovir, his vision improved. RESULTS Pathological and virological studies provided proof of VZV vasculopathy in the asymptomatic temporal artery. Varicella zoster virus antigen was abundant in arterial adventitia and scattered throughout the media. With intravenous antiviral therapy, the patient's vision improved. CONCLUSION Although in previously studied patients who died of chronic VZV vasculopathy after 10 to 12 months, VZV antigen was present exclusively in the intima, collective analyses of chronic cases and the asymptomatic VZV-infected temporal artery suggest that virus enters arteries through the adventitia and spreads transmurally to the intima.
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Affiliation(s)
- Richard Salazar
- Department of Neurology, Henry Ford Hospital, Detroit, Michigan, USA
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Abstract
Declining cell-mediated immunity to varicella zoster virus (VZV) in elderly individuals results in virus reactivation manifest by zoster (shingles) and postherpetic neuralgia (PHN). To prevent virus reactivation, a new VZV vaccine (Zostavax; Merck) that boosts cell-mediated immunity to VZV was developed. The 3-year Shingles Prevention Study showed that Zostavax significantly reduced burden of disease because of zoster and PHN. Despite its cost-effectiveness for adults aged 65-75 years, as determined in the United States, Canada and UK, <2% of immunocompetent adults over age 60 years in the United States were immunized in 2007. This was because of a combination of lack of patient awareness of the vaccine, physicians' uncertainty about the duration of protection and different cost-sharing plans for immunization. Nevertheless, zoster vaccine is safe, effective and highly recommended for immunization of immunocompetent individuals over age 60 years with no history of recent zoster.
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Affiliation(s)
- D Gilden
- Department of Neurology and Microbiology, University of Colorado School of Medicine, Aurora, CO 80045, USA.
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Molloy A, Forde D, De Gascun C, Fanning N, Wyse G, O'Toole O. A virulent vasculopathy. BMJ Case Rep 2011; 2011:2011/mar24_1/bcr1120103481. [PMID: 22700078 DOI: 10.1136/bcr.11.2010.3481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Arteriopathy is an uncommon complication of primary varicella zoster virus (VZV) infection in the immunocompetent adult. We report a case of a 39-year-old woman known to be VZV negative prior to the event. She presented to the emergency department having experienced an episode of expressive aphasia and right upper limb paraesthesia lasting 15 min. The symptoms followed a 3-day period of general malaise, arthralgia and a generalised maculopapular itchy rash involving face and limbs. No immunocompromise was detected but an infectious contact was identified in the home. Imaging findings were consistent with a focal cerebritis/vasculopathy and VZV infection was confirmed with cerebrospinal fluid PCR analysis. Resolution of radiological signs occurred following prompt treatment with appropriate antivirals.
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Affiliation(s)
- A Molloy
- Department of Neurology, Cork University Hospital, Cork, Ireland.
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Mareedu J, Hanumaiah RG, Hale E, Habte-Gabr E. Varicella zoster vasculopathy. ACTA ACUST UNITED AC 2011; 10:144-5. [PMID: 21430239 DOI: 10.1177/1545109710397366] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Varicella-zoster virus can cause neurological disease in primary and reactivated latent forms, with a wide spectrum of disorders throughout a person's lifetime. 35-year-old male with AIDS; histoplasmosis; mild, intermittent asthma; and hypertension presented to hospital with left-sided weakness and slurred speech. Exam showed left hemiparesis with left upper motor neurons facial palsy and dysarthria. Acute right basal ganglia infarct was detected in head CT without contrast. A subsequent MRI showed acute non-hemorrhagic infarct, right basal ganglia; fusiform dilatation, and proximal right middle cerebral artery. A CT angiogram of the bilateral carotid arteries revealed occlusion of the right anterior cerebral artery with conical dilatation at the origin; significant stenosis, and dilatation of the right middle cerebral artery. These findings were consistent with vasculitis. Patient was successfully treated with IV acyclovir. Rapid diagnosis of VZV vasculopathy is important because it is a treatable cause of stroke. Mortality rate is 25% without treatment.
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Affiliation(s)
- Jyotsna Mareedu
- Hurley Medical Center, Flint, Michigan/Michigan State University, Flint, MI, USA
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Haug A, Mahalingam R, Cohrs RJ, Schmid DS, Corboy JR, Gilden D. Recurrent polymorphonuclear pleocytosis with increased red blood cells caused by varicella zoster virus infection of the central nervous system: Case report and review of the literature. J Neurol Sci 2010; 292:85-8. [PMID: 20170926 DOI: 10.1016/j.jns.2010.01.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2009] [Revised: 01/12/2010] [Accepted: 01/21/2010] [Indexed: 10/19/2022]
Abstract
We describe an immunocompetent 45-year-old woman who had four episodes of neurological disease (meningoencephalitis, multifocal vasculopathy, myelitis and inflammatory brain stem disease) produced by varicella zoster virus (VZV) over an 11-month period, all in the absence of rash. The cerebrospinal fluid (CSF) contained anti-VZV IgG antibody, but not VZV DNA throughout her illness, reaffirming the superiority of detection of anti-VZV IgG in CSF compared to VZV DNA in diagnosing VZV infection of the nervous system. Moreover, 3 of 7 CSF samples examined during the 11 months showed a VZV-induced pleocytosis consisting predominantly of polymorphonuclear cells (PMNs), and 4 of 7 samples also contained increased numbers of red blood cells (RBCs). Because increased PMNs and RBCs in CSF can also occur in patients with central and peripheral nervous system disease produced by cytomegalovirus (CMV), the differential diagnosis of chronic nervous system infection with increased PMNs and RBCs in CSF should include analyses for both VZV and CMV.
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Affiliation(s)
- Aaron Haug
- Department of Neurology, University of Colorado Denver School of Medicine, Aurora, CO, USA
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GOLDSTEIN DEBORAHA, TIMPONE JOSEPH, CUPPS THOMASR. HIV-associated Intracranial Aneurysmal Vasculopathy in Adults. J Rheumatol 2009; 37:226-33. [DOI: 10.3899/jrheum.090643] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Diffuse fusiform intracranial aneurysms have been reported in children with human immunodeficiency virus (HIV) for over 2 decades, but have only recently been reported in adults with HIV. Although these aneurysms have important clinical implications, their etiology and optimal therapy are unknown. We present a systematic review of diffuse intracranial fusiform aneurysmal vasculopathy in patients who are HIV-positive. We conducted a comprehensive literature search for relevant case reports and reviews published before February 2009. Patients were included if they had HIV infection and radiographic imaging consistent with fusiform aneurysmal vasculopathy. We identify 11 published adult cases of intracranial fusiform aneurysmal vasculopathy and describe 1 unpublished case from our own institution. Available data regarding clinical presentation, characteristic imaging findings, and treatment of this complex syndrome are reviewed. Adults with HIV-associated intracranial aneurysmal vasculopathy typically are significantly immunosuppressed and present with gross neurologic dysfunction. Characteristic radiographic findings include diffuse cerebral fusiform aneurysms with hemorrhage or infarct. Treatment of any active infection followed by the initiation of antiretroviral therapy and corticosteroids may be a reasonable approach in this complex syndrome.
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Kang JH, Ho JD, Chen YH, Lin HC. Increased risk of stroke after a herpes zoster attack: a population-based follow-up study. Stroke 2009; 40:3443-8. [PMID: 19815828 DOI: 10.1161/strokeaha.109.562017] [Citation(s) in RCA: 156] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Varicella zoster virus-induced vasculopathy and postherpes zoster attack stroke syndromes have been reported previously; nevertheless, data regarding the exact prevalence and risk of stroke occurring postherpes zoster attack are still lacking. This study aims to investigate the frequency and risk of stroke after a herpes zoster attack using a nationwide, population-based study of a retrospective cohort design. Method- A total of 7760 patients who had received treatment for herpes zoster between 1997 and 2001 were included and matched with 23 280 randomly selected subjects. A 1-year stroke-free survival rate was then estimated using the Kaplan-Meier method. After adjusting for potential confounders, Cox proportional hazard regressions were carried out to compute the adjusted 1-year survival rate. RESULTS Of the sampled patients, 439 patients (1.41%) developed strokes within the 1-year follow-up period, that is, 133 individuals (1.71% of the patients with herpes zoster) from the study cohort and 306 individuals (1.31% of patients in the comparison cohort) from the comparison cohort. The log rank test indicated that patients with herpes zoster had significantly lower 1-year stroke-free survival rates than the control (P<0.001). The adjusted hazard ratios of stroke after herpes zoster and herpes zoster ophthalmicus during the 1-year follow-up period were 1.31 and 4.28, respectively. CONCLUSIONS The risk for stroke increased after a zoster attack. Although varicella zoster virus vasculopathy is a well-documented complication that may induce a stroke postherpes zoster attack, it does not fully account for the unexpectedly high risk of stroke in these patients.
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Affiliation(s)
- Jiunn-Horng Kang
- Department of Physical Medicine and Rehabilitation, the Neuroscience Research Center, Taipei Medical University Hospital, Taipei, Taiwan
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Gilden D, Cohrs RJ, Mahalingam R, Nagel MA. Varicella zoster virus vasculopathies: diverse clinical manifestations, laboratory features, pathogenesis, and treatment. Lancet Neurol 2009; 8:731-40. [PMID: 19608099 DOI: 10.1016/s1474-4422(09)70134-6] [Citation(s) in RCA: 351] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Vasculopathies caused by varicella zoster virus (VZV) are indicative of a productive virus infection in cerebral arteries after either reactivation of VZV (shingles) or primary infection (chickenpox). VZV vasculopathy can cause ischaemic infarction of the brain and spinal cord, as well as aneurysm, subarachnoid and cerebral haemorrhage, carotid dissection, and, rarely, peripheral arterial disease. VZV vasculopathy in immunocompetent or immunocompromised individuals can be unifocal or multifocal with deep-seated and superficial infarctions. Lesions at the grey-white matter junction on brain imaging are a clue to diagnosis. Involvement of both large and small arteries is more common than that of either alone. Most patients have a mononuclear cerebrospinal fluid pleocytosis, often with red blood cells. Cerebrospinal fluid pleocytosis and rash are absent in about a third of cases. Anti-VZV IgG antibody in the cerebrospinal fluid is found more frequently than VZV DNA. In recent years, the number of recognised VZV vasculopathies has grown, and accurate diagnosis is important for the effective treatment of these disorders.
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Affiliation(s)
- Don Gilden
- Department of Neurology, University of Colorado Denver School of Medicine, Aurora, CO 80045, USA.
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Gilden D, Nagel MA, Mahalingam R, Mueller NH, Brazeau EA, Pugazhenthi S, Cohrs RJ. Clinical and molecular aspects of varicella zoster virus infection. FUTURE NEUROLOGY 2009; 4:103-117. [PMID: 19946620 PMCID: PMC2782836 DOI: 10.2217/14796708.4.1.103] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
A declining cell-mediated immunity to varicella zoster virus (VZV) with advancing age or immunosuppression results in virus reactivation from latently infected human ganglia anywhere along the neuraxis. Virus reactivation produces zoster, often followed by chronic pain (postherpetic neuralgia or PHN) as well as vasculopathy, myelopathy, retinal necrosis and cerebellitis. VZV reactivation also produces pain without rash (zoster sine herpete). Vaccination after age 60 reduces the incidence of shingles by 51%, PHN by 66% and the burden of illness by 61%. However, even if every healthy adult over age 60 years is vaccinated, there would still be about 500,000 zoster cases annually in the United States alone, about 200,000 of whom will experience PHN. Analyses of viral nucleic acid and gene expression in latently infected human ganglia and in an animal model of varicella latency in primates are serving to determine the mechanism(s) of VZV reactivation with the aim of preventing reactivation and the clinical sequelae.
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Affiliation(s)
- Don Gilden
- Author for correspondence: Department of Neurology, University of Colorado Denver School of Medicine, 4200 E. 9 Avenue, Mail Stop B182, Denver, CO 80262, USA. Tel: 1-303-315-8281; Fax: 1-303-315-8281;
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Okanishi T, Kondo A, Inoue T, Maegaki Y, Ohno K, Togari H. Bilateral middle cerebral artery infarctions following mild varicella infection: a case report. Brain Dev 2009; 31:86-9. [PMID: 18793825 DOI: 10.1016/j.braindev.2008.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Revised: 07/31/2008] [Accepted: 08/01/2008] [Indexed: 11/28/2022]
Abstract
We report a two-year and one-month-old immunocompetent boy who developed aphasia and right hemiparesis eight months after mild varicella with only a few vesicles. Magnetic resonance images and angiography demonstrated mixed acute and old infarctions of the bilateral middle cerebral arteries. VZV-DNA was detected on polymerase chain reaction analysis of cerebral spinal fluid (CSF). He was treated with intravenous acyclovir and edaravone, and his speech and motor functions had almost recovered after two months. Cerebral lesions of the bilateral middle cerebral artery territories and virus DNA detection from CSF are rare in VZV-related vasculopathy and suggest incomplete immunoresponse to varicella in this patient.
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Affiliation(s)
- Tohru Okanishi
- Division of Child Neurology, Institute of Neurological Sciences, Faculty of Medicine, Tottori University, 36-1 Nishi-cho, Yonago 683-8504, Japan.
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Juntas Morales R, Tillier JN, Davous P. [Facial diplegia and acute inflammatory demyelinating neuropathy secondary to varicella]. Rev Neurol (Paris) 2008; 165:836-8. [PMID: 19081589 DOI: 10.1016/j.neurol.2008.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Revised: 09/01/2008] [Accepted: 10/08/2008] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Primo-infection by varicella-zoster virus (VZV) may be associated with several neurologic complications. Bilateral facial palsy is a rather uncommon manifestation. CASE REPORT We report the case of a 38-year-old woman who developed bilateral facial diplegia and paresthesia affecting all four limbs with subacute onset several days after varicella virus primoinfection. Ancillary tests showed hyperproteinorachia and signs of demyelinating polyneuropathy in nerve conduction tests. The diagnosis of Guillain-Barré syndrome was retained and a treatment with intravenous immunoglobulines was started, leading to progressive improvement. CONCLUSION Immunotherapy is a possible therapeutic approach in the context of neurologic postinfectious complications after VZV infection where an underlying mechanism is probable.
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Gilden D, Nagel MA, Ransohoff RM, Cohrs RJ, Mahalingam R, Tanabe JL. Recurrent varicella zoster virus myelopathy. J Neurol Sci 2008; 276:196-8. [PMID: 18945446 DOI: 10.1016/j.jns.2008.09.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2008] [Revised: 09/12/2008] [Accepted: 09/16/2008] [Indexed: 12/29/2022]
Abstract
Myelopathy is an uncommon complication of VZV infection and may develop in the absence of rash. We report the rare recurrence of myelopathy in an immunocompetent adult who initially developed myelopathy after ophthalmic-distribution zoster. Recurrent myelopathy two years later caused by VZV was verified by the presence of new-onset clinical symptoms and signs consistent with myelopathy, new lesions in the spinal cord detected by MRI, and evidence of intrathecal synthesis of anti-VZV IgG antibody in CSF. After virological verification and antiviral therapy, myelopathy did not recur and anti-VZV IgG antibody could not be detected in CSF. In contrast to earlier cases of recurrent VZV myelopathy in immunocompetent adults that developed weeks to months after the first episode of myelopathy, this is the first instance of recurrence years later.
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Affiliation(s)
- Don Gilden
- Department of Neurology, University of Colorado Denver, School of Medicine, Denver, CO, USA.
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Mueller NH, Gilden DH, Cohrs RJ, Mahalingam R, Nagel MA. Varicella zoster virus infection: clinical features, molecular pathogenesis of disease, and latency. Neurol Clin 2008; 26:675-97, viii. [PMID: 18657721 PMCID: PMC2754837 DOI: 10.1016/j.ncl.2008.03.011] [Citation(s) in RCA: 174] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Varicella zoster virus (VZV) is an exclusively human neurotropic alphaherpesvirus. Primary infection causes varicella (chickenpox), after which virus becomes latent in cranial nerve ganglia, dorsal root ganglia, and autonomic ganglia along the entire neuraxis. Years later, in association with a decline in cell-mediated immunity in elderly and immunocompromised individuals, VZV reactivates and causes a wide range of neurologic disease. This article discusses the clinical manifestations, treatment, and prevention of VZV infection and reactivation; pathogenesis of VZV infection; and current research focusing on VZV latency, reactivation, and animal models.
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Affiliation(s)
- Niklaus H Mueller
- Department of Neurology, University of Colorado School of Medicine, 4200 East 9th Avenue, Mail Stop B182, Denver, CO 80262, USA
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Mehta SK, Tyring SK, Gilden DH, Cohrs RJ, Leal MJ, Castro VA, Feiveson AH, Ott CM, Pierson DL. Varicella-zoster virus in the saliva of patients with herpes zoster. J Infect Dis 2008; 197:654-7. [PMID: 18260763 DOI: 10.1086/527420] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Fifty-four patients with herpes zoster were treated with valacyclovir. On treatment days 1, 8, and 15, pain was scored and saliva examined for varicella-zoster virus (VZV) DNA. VZV DNA was found in every patient the day treatment was started and later disappeared in 82%. There was a positive correlation between the presence of VZV DNA and pain and between VZV DNA copy number and pain (P <.0005). VZV DNA was present in 1 patient before rash and in 4 after pain resolved and was not present in any of 6 subjects with chronic pain or in 14 healthy subjects. Analysis of human saliva has potential usefulness in the diagnosis of neurological disease produced by VZV without rash.
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