Varicella-zoster virus: atypical presentations and unusual complications

Fatal visceral disseminated varicella zoster virus infection during initial remission induction therapy in a patient with lupus nephritis: a case report and review of the literature

Visceral disseminated varicella zoster virus (VZV) infection is a severe complication, characterized by a notably high mortality rate. Herein, we present a case of a 36-year-old-man involving visceral disseminated VZV infection that emerged during remission induction therapy involving high-dose prednisolone (PSL), mycophenolate mofetil (MMF), and hydroxychloroquine for lupus nephritis. Two months after starting the immunosuppressive therapy, he experienced a rapid onset of severe upper abdominal pain. The following day, clinical manifestations and laboratory abnormalities rapidly deteriorated. Hyperferritinemia and hypertriglyceridemia, indicative of hemophagocytic lymphohistiocytosis (HLH), emerged, along with escalating liver and renal impairment and newly appeared disseminated intravascular coagulation, and multiple organ failure is suggested. The patient developed widespread blistering predominantly on the trunk and face, patient's condition failed to ameliorate, ultimately culminating in his demise a few hours later. At autopsy, the cutaneous lesions with blisters revealed positive immunostaining with anti-VZV antibody, and similar findings were detected in multiple organs. HLH was confirmed in lymph nodes. It is crucial to emphasize the awareness of visceral disseminated VZV, particularly in cases patients are undergoing concurrent PSL therapy alongside MMF for SLE. The progression of this fatal condition usually begins with abdominal pain, followed by a skin rash a few days later. The present case is the first to show evidence of HLH occurring as a result of visceral disseminated VZV infection. This disease is extremely rare but extremely serious, therefore, VZV-DNA should be measured in cases where you suspect this disease for early diagnosis and treatment.

Effect of herpes zoster vaccine on patients after hematopoietic stem cell transplantation: a systematic review and meta-analysis

BACKGROUND

Herpes zoster(HZ), a severe complication following hematopoietic stem cell transplantation (HSCT), is associated with significant morbidity. The effect of herpes zoster vaccine(HZV) for preventing HZ on patients after HSCT is unclear. We conducted a systematic review and meta-analysis investigating the efficacy and safety of HZV in HSCT recipients.

METHODS

The databases Pubmed, Embase, and Cochrane Library were searched to identify relevant studies. Random-effects models were used to calculate risk ratios (RRs) and 95% confidence intervals (CIs) for HZ infection and related events.

RESULTS

A total of 3048 individuals from five studies (four randomized controlled trials and one retrospective cohort study) were included. The overall incidence of HZ in the HZV group and control group was 6.4% and 18.3% respectively, resulting in a pooled RR of 0.36 (95%CI, 0.29-0.45; P < 0.001), indicating no heterogeneity (P = 0.88,I2 = 0). HZV demonstrated a reduction in the risk of PHN (RR, 0.40; 95% CI, 0.15-1.11), although statistical significance was not reached (P = 0.08). Furthermore, through two independent RCTs, HZV showed a decrease in the incidence of HZ-related complications compared to placebo administration. The overall incidence of adverse events in the HZV group and control group was found to be 63.6% and 60.2% respectively, with a pooled RR of 1.02 (95% CI, 0.97-1.06, P = 0.51), indicating no heterogeneity (P = 0.66, I2 = 0).

CONCLUSION

The HZV group demonstrated a significant reduction in the risk of HZ among HSCT recipients, without an increase in adverse events. This highlights the positive impact of HZV on decreasing the incidence of PHN and complications associated with HZ. Furthermore, our findings support the effectiveness and tolerability of HZV as a preventive measure against HZ for HSCT recipients.

Atypical Presentation of Painless Herpes Zoster in an Elderly Male: A Case Report

Shingles, also known as herpes zoster, is a reactivation of the chickenpox virus that causes a painful, blistering rash. After a chickenpox infection, the virus lies dormant in nerve cells. When reactivated, usually in older adults or those with weakened immune systems, it travels along nerves, typically affecting a single strip of skin called a dermatome. Shingles usually presents as a painful, one-sided rash that may involve nerves in the head, face, and body. While it typically resolves on its own, it can lead to complications, especially in older adults. Antiviral medications are effective in reducing the severity and duration of shingles and should be started as soon as the rash appears. This report describes an unusual case of an elderly patient who developed shingles on their face after a wound, notably without experiencing any pain.

Atypical Presentation of Varicella-Zoster Virus Encephalitis: A Case Report

The varicella-zoster virus (VZV) is a neurotrophic alpha herpesvirus that only affects humans. Once infected (often in childhood), VZV causes varicella (chickenpox) before becoming dormant in the cranial nerve (CN) and dorsal root ganglia. It can reactivate after a period of time, resulting in zoster (shingles), which is occasionally followed by post-herpetic neuralgia. This case highlights a patient who presented with vague ear pain and multiple CN palsy, including CN VIII, IX, and X, preceded by a common cold symptom one week ago. Shortly after, he developed severe pain in his left ear and sought medical care at an ENT clinic. The diagnosis was lymphadenopathy, and he received pain medication and a single dose of antibiotics. The patient was conscious, alert, and oriented. He had no fever with normal WBC. Clinical examination revealed multiple CN palsies. Neuroimaging showed normal study. To address potential bacterial infection, the patient was given vancomycin and ceftriaxone as well as acyclovir after a lumbar puncture was performed. The CSF analysis revealed elevated lymphocytes and VZV DNA was detected in the CSF by using polymerase chain reaction. This is an atypical presentation of VZV encephalitis as the patient presented mainly with ear pain. The neurological complications, including CN palsies related to active CNS varicella-zoster infection, and meningeal involvement were clinically improved with empirical medications. The CSF analysis confirmed the diagnosis. Early diagnosis and treatment with antiviral medication are key to optimizing clinical outcomes.

Primary immunodeficiency-related genes and varicella-zoster virus reactivation syndrome: a Mendelian randomization study

Background

Currently, evidence regarding the causal relationship between primary immunodeficiency-related genes and varicella-zoster virus reactivation syndrome is limited and inconsistent. Therefore, this study employs Mendelian randomization (MR) methodology to investigate the causal relationship between the two.

Methods

This study selected 110 single-nucleotide polymorphisms (SNPs) of primary immunodeficiency-related genes as instrumental variables (IVs). Genetic associations of primary immunodeficiency-related genes were derived from recent genome-wide association studies (GWAS) data on human plasma protein levels and circulating immune cells. Data on genes associated with varicella-zoster virus reactivation syndrome were obtained from the GWAS Catalog and FINNGEN database, primarily analyzed using inverse variance weighting (IVW) and sensitivity analysis.

Results

Through MR analysis, we identified 9 primary immunodeficiency-related genes causally associated with herpes zoster and its subsequent neuralgia; determined causal associations of 20 primary immunodeficiency-related genes with three vascular lesions (stroke, cerebral aneurysm, giant cell arteritis); revealed causal associations of 10 primary immunodeficiency-related genes with two ocular diseases (retinopathy, keratitis); additionally, three primary immunodeficiency-related genes each were associated with encephalitis, cranial nerve palsy, and gastrointestinal infections.

Conclusions

This study discovers a certain association between primary immunodeficiency-related genes and varicella-zoster virus reactivation syndrome, yet further investigations are warranted to explore the specific mechanisms underlying these connections.

Primary Varicella Infection in a Young Adult from the Democratic Republic of the Congo: A Case Report and Mini-Review

We describe a case of an immunocompetent adult male patient originally from the Democratic Republic of Congo (DRC), who was referred to our unit for a several-day history of fever and a pruritic, vesicular rash. There was initial concern in the Emergency Department for Mpox (formerly known as "monkeypox") given the current epidemiology versus other viral etiologies. Primary varicella zoster virus (pVZV) infection was ultimately diagnosed by PCR from a swabbed, unroofed lesion, and he recovered completely with supportive management and without antiviral therapy. We herein describe how common viral exanthems may best be differentiated in an emergency or outpatient setting.

Varicella-zoster virus-related neurological complications: From infection to immunomodulatory therapies

The Varicella-zoster virus (VZV), classified as a neurotropic member of the Herpesviridae family, exhibits a characteristic pathogenicity, predominantly inducing varicella, commonly known as chickenpox, during the initial infectious phase, and triggering the reactivation of herpes zoster, more commonly recognized as shingles, following its emergence from a latent state. The pathogenesis of VZV-associated neuroinflammation involves a complex interplay between viral replication within sensory ganglia and immune-mediated responses that contribute to tissue damage and dysfunction. Upon primary infection, VZV gains access to sensory ganglia, establishing latent infection within neurons. During reactivation, the virus can spread along sensory nerves, triggering a cascade of inflammatory mediators, chemokines, and immune cell infiltration in the affected neural tissues. The role of both adaptive and innate immune reactions, including the contributions of T and B cells, macrophages, and dendritic cells, in orchestrating the immune-mediated damage in the central nervous system is elucidated. Furthermore, the aberrant activation of the natural defence mechanism, characterised by the dysregulated production of immunomodulatory proteins and chemokines, has been implicated in the pathogenesis of VZV-induced neurological disorders, such as encephalitis, myelitis, and vasculopathy. The intricate balance between protective and detrimental immune responses in the context of VZV infection emphasises the necessity for an exhaustive comprehension of the immunopathogenic mechanisms propelling neuroinflammatory processes. Despite the availability of vaccines and antiviral therapies, VZV-related neurological complications remain a significant concern, particularly in immunocompromised individuals and the elderly. Elucidating these mechanisms might facilitate the emergence of innovative immunomodulatory strategies and targeted therapies aimed at mitigating VZV-induced neuroinflammatory damage and improving clinical outcomes. This comprehensive understanding enhances our grasp of viral pathogenesis and holds promise for pioneering therapeutic strategies designed to mitigate the neurological ramifications of VZV infections.

Varicella mimicking complications of acute rhinosinusitis in an infant

Varicella is the manifestation of primary infection with the varicella-zoster virus, mainly affecting preschool and school-aged children. The children suffer from a generalised, vesicular rash and fever. Despite the infection's typically non-threatening course, a variety of severe complications have been described.The authors present the case of a female infant suffering from varicella and developing preseptal cellulitis with a frontal abscess while being treated with intravenous antibiotics. Otorhinolaryngology consultation was sought since the clinical image was highly suggestive for sinusitis complications, namely orbital cellulitis and frontal bone osteomyelitis (Pott's puffy tumour). However, the child was below the age of frontal sinus development and there was no other apparent sign of sinonasal involvement. Ultrasonography revealed a mid-frontal collection without signs of abscess formation preseptally or postseptally, leading to the diagnosis of cutaneous superinfection of varicella lesions. The frontal abscess was drained, and the child fully recovered under antibiotic treatment.

A Rare Case of Varicella Zoster Infection in Hemorrhoids in a Patient With Inflammatory Bowel Disease

ABSTRACT

Hemorrhoids are normal anatomical structures in the anus. When symptomatic, they prompt medical attention due to pain, rectal bleeding, and discomfort. Treatment includes dietary modifications, rubber band ligations, sclerotherapy, cryotherapy, or hemorrhoidectomy. Histologic examination is important to rule out incidental findings, such as perianal intraepithelial neoplasia, anal carcinoma, melanoma, or coexisting infections. Special attention should be given when patient is immunocompromised. We present a case of a 41-year-old man with a history of ulcerative colitis on adalimumab who presented with anal lesions. He was diagnosed with hemorrhoids and surgically treated. Microscopic examination confirmed the diagnosis of hemorrhoids. However, foci of epithelium with viral cytopathic effects were noted. A varicella zoster virus (VZV)-specific immunostain was positive in the areas of interest confirming the diagnosis of the VZV infection limited to the hemorrhoids. Combined herpes simplex virus type 1 and 2 (HSV 1 and HSV 2) immunostain was also performed and was negative. Anal herpes has been widely described in the literature, particularly in immunocompromised patients. However, isolated VZV infection in hemorrhoids to the best of our knowledge has never been reported.

Atypical Complications during the Course of COVID-19: A Comprehensive Review

COVID-19 is primarily a respiratory disease, but numerous studies have indicated the involvement of various organ systems during the course of illness. We conducted a comprehensive review of atypical complications of COVID-19 with their incidence range (IR) and their impact on hospitalization and mortality rates. We identified 97 studies, including 55 research articles and 42 case studies. We reviewed four major body organ systems for various types of atypical complications: (i) Gastro-intestinal (GI) and hepatobiliary system, e.g., bowel ischemia/infarction (IR: 1.49-83.87%), GI bleeding/hemorrhage (IR: 0.47-10.6%), hepatic ischemia (IR: 1.0-7.4%); (ii) Neurological system, e.g., acute ischemic stroke/cerebral venous sinus thrombosis/cerebral hemorrhage (IR: 0.5-90.9%), anosmia (IR: 4.9-79.6%), dysgeusia (IR: 2.8-83.38%), encephalopathy/encephalitis with or without fever and hypoxia (IR: 0.19-35.2%); (iii) Renal system, e.g., acute kidney injury (AKI)/acute renal failure (IR: 0.5-68.8%); (iv) Cardiovascular system, e.g., acute cardiac injury/non-coronary myocardial injury (IR: 7.2-55.56%), arrhythmia/ventricular tachycardia/ventricular fibrillation (IR: 5.9-16.7%), and coagulopathy/venous thromboembolism (IR: 19-34.4%). This review encourages and informs healthcare practitioners to keenly monitor COVID-19 survivors for these atypical complications in all major organ systems and not only treat the respiratory symptoms of patients. Post-COVID effects should be monitored, and follow-up of patients should be performed on a regular basis to check for long-term complications.

Herpes Zoster in Hospitalized Patients With Inflammatory Bowel Disease: National Analysis of Disease Presentation and Age Distribution

BACKGROUND

Studies have demonstrated an increased risk of herpes zoster (HZ) in patients with inflammatory bowel disease (IBD). Most recently, the Advisory Committee on Immunization Practices recommended HZ vaccination for adults aged 19 years and older who are at increased risk of shingles due to their disease or drug-related immunosuppression. We aimed to assess the burden of HZ in IBD inpatients and contribute with scientific evidence for an appropriate age cut-off vaccination recommendation.

MATERIALS AND METHODS

Population-based cross-sectional analysis using the 2014 US National Inpatient Sample (NIS). We measured the frequencies and demographics of adult patients with IBD admitted to the hospital with an HZ diagnosis. Age-stratification analysis was performed, and age groups were compared with non-IBD inpatients with an HZ diagnosis.

RESULTS

From 307,260 IBD discharges, 1110 (0.35%) patients were found to have HZ as follows: shingles 63%; post-herpetic neuralgia 26%; HZ with ophthalmic involvement 7%; HZ with neurological involvement 4%. Women with IBD were more likely to have shingles ( P =0.002) and post-herpetic neuralgia ( P =0.001) than men with IBD. The shingles distribution by age in IBD inpatients was 18 to 39 (13%), 40 to 49 (19%), 50 to 59 (18%), 60 to 99 (50%) compared with 18 to 39 (8%), 40 to 49 (6%), 50 to 59 years (14%), 60 to 99 (72%) in non-IBD inpatients ( P =0.0004).

CONCLUSIONS

Hospitalized patients with IBD were found to have a higher frequency of shingles at younger ages when compared with hospitalized patients without IBD. Shingles is more frequent in women, and their prevalence steadily increases with aging though 32% of cases were seen in patients younger than age 50.

Guillain-Barré Syndrome Associated with SARS-CoV-2 in Two Pediatric Patients

Guillain-Barré syndrome (GBS) is a recognised complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We report two children with GBS associated with SARS-CoV-2 who presented to a tertiary centre in Muscat, Oman in 2021: The first patient was a three-month-old female infant who presented with bradypnea, encephalopathy, and generalised weakness that required mechanical ventilation. Polymerase chain reaction (PCR) testing of the nasopharyngeal swabs (NPS) was positive for SARS-CoV-2. She had axonal variant GBS based on a nerve conduction study, cerebrospinal fluid analysis, and neuroimaging findings. The second patient was a six-year-old girl with fever, vomiting, and diarrhea followed by ascending weakness who presented with quadriplegia and facial weakness. Subsequently, she developed respiratory muscle weakness and required mechanical ventilation. PCR testing of NPS was negative for SARS-Cov-2, however IgG serology analysis was positive. The clinical course of these two patients was rapidly progressive and both of them required mechanical ventilation. The patient with axonal variant GBS made an incomplete recovery.

Zoster Sine Herpete: two unusual cases of varicella-zoster reactivation with atypical complaints of acute chest pain and severe headache

In this case report, we describe two unusual presentations of varicella-zoster virus (VZV) reactivation without rash, a condition known as Zoster Sine Herpete (ZSH). In Case 1, a 58-year-old woman presented with severe right-sided chest pain under her breast that radiated to the ipsilateral back. After the initial workup ruled out cardiac and musculoskeletal etiologies, the characteristic dermatomal distribution of pain made us suspect VZV reactivation. A diagnosis of ZSH was made with positive VZV IgG and IgM serologies and symptomatic relief after famciclovir treatment. In Case 2, a 43-year-old woman presented with a severe headache and resolved sharp right flank pain. She was diagnosed with varicella meningitis after cerebrospinal fluid showed positive VZV DNA. Intravenous acyclovir treatment resulted in symptom resolution. The most common presentation of VZV reactivation is Herpes Zoster, or shingles, making ZSH a frequently missed diagnosis. High clinical suspicion is warranted to prevent life-threatening complications of ZSH.

Adjuvanted recombinant zoster vaccine decreases herpes zoster-associated pain and the use of pain medication across 3 randomized, placebo-controlled trials

ABSTRACT

Herpes zoster (HZ) and HZ-associated pain greatly affect patients' quality of life, particularly in older and immunocompromised adults, for whom comorbidities and polypharmacy are often reported. Three phase III, randomized, placebo-controlled clinical trials have reported the adjuvanted recombinant zoster vaccine (RZV) as highly efficacious in preventing HZ and reducing pain severity in healthy adults ≥50 years old (Zoster Efficacy Study [ZOE]-50 study, NCT01165177) and ≥70 years old (ZOE-70; NCT01165229) and in immunocompromised adults ≥18 years old undergoing autologous hematopoietic stem cell transplantation (ZOE-HSCT; NCT01610414). Here, we investigated efficacy of RZV in reducing (i) the duration of clinically significant pain (Zoster Brief Pain Inventory pain score ≥3) and (ii) HZ-associated pain medication use and duration of use in participants with confirmed HZ ("breakthrough cases") from the 3 studies. Recombinant zoster vaccine effectively reduced the duration of clinically significant HZ-associated pain during HZ episodes by 38.5% ( P -value: 0.010) in the ZOE-HSCT study. Although a similar trend was observed in the ZOE-50 and ZOE-70 studies, the results were not statistically significant because of the high vaccine efficacy (VE) against HZ resulting in rare breakthrough cases. VE in reducing pain medication use (39.6%; P -value: 0.008) and duration of medication use (49.3%, P -value: 0.040) was reported in the ZOE-70 study; corresponding positive VE estimates were observed in the ZOE-50 and ZOE-HSCT studies but were not statistically significant. Data reported here demonstrate efficacy of RZV in reducing HZ-associated pain duration and pain medication use in breakthrough cases, thereby improving quality of life of those with HZ.

Increased Stroke Risk Following Herpes Zoster Infection and Protection With Zoster Vaccine

BACKGROUND

Studies evaluating stroke following varicella zoster virus (VZV) infection are limited, and the utility of zoster vaccination against this phenomenon is unclear. This study aimed to determine the risk of stroke 30 days following zoster infection and to evaluate the impact of zoster vaccinations on the risk of stroke in VZV-infected patients.

METHODS

This retrospective case-control study was conducted from January 2010 to January 2020 utilizing nationwide patient data retrieved from the Veterans Affairs' Corporate Data Warehouse.

RESULTS

A total of 2 165 505 patients ≥18 years of age who received care at a Veterans Affairs facility were included in the study, of whom 71 911 had a history of zoster infection. Zoster patients were found to have 1.9 times increased likelihood of developing a stroke within 30 days following infection (odds ratio [OR], 1.93 [95% confidence interval {CI}, 1.57-2.4]; P < .0001). A decreased risk of stroke was seen in patients who received the recombinant zoster vaccine (OR, 0.57 [95% CI, .46-.72]; P < .0001) or the live zoster vaccine (OR, 0.77 [95% CI, .65-.91]; P = .002).

CONCLUSIONS

Patients had a significantly higher risk of stroke within the first month following recent herpes zoster infection. Receipt of at least 1 zoster vaccination was found to mitigate this increased risk. Vaccination may therefore be viewed as a protective tool against the risk of neurologic postinfection sequelae.

Safety and efficacy of recombinant and live herpes zoster vaccines for prevention in at-risk adults with chronic diseases and immunocompromising conditions

Compared with the general population, older adults with immune senescence and individuals who are immunocompromised (IC) due to disease or immunosuppressive therapy are at increased risk for herpes zoster (HZ) and its associated complications, which can be debilitating and life-threatening. Vaccination can be an effective strategy against HZ and studies have shown that HZ vaccination in IC individuals can elicit immune responses and provide protection from infection. Recently, the first approvals have been granted in the United States and the European Union for the recombinant HZ vaccine (RZV) in adults ≥ 18 years of age at risk of HZ due to immunodeficiency or immunosuppression. Existing systematic reviews have highlighted the risks for HZ in limited immunocompromising conditions and have only examined clinical data for RZV. This review details the risks and burden of HZ in a broad range of clinically relevant IC populations and summarizes key efficacy and safety data for RZV and live HZ vaccine in these individuals. Research has shown IC individuals can benefit from HZ vaccination; however, these insights have yet to be fully incorporated into vaccination guidelines and clinical care. Clinicians should consider HZ vaccination in eligible at-risk populations to protect against HZ and its associated complications and thereby, reduce the burden that HZ poses on the healthcare system. Electronic health records and linked personal health records could be used to identify and contact patients eligible for HZ vaccination and provide clinical decision support-generated alerts for missing or delayed vaccinations. This review will help clinicians identify eligible IC individuals who may benefit from HZ vaccination. A video abstract linked to this article is available on Figshare https://doi.org/10.6084/m9.figshare.21517605.

Recurrent herpes zoster in a rheumatoid arthritis patient treated with tofacitinib: A case report and review of the literature

BACKGROUND

Tofacitinib is an oral Janus kinase (JAK) inhibitor that is currently approved by the United States Food and Drug Administration for the treatment of rheumatoid arthritis (RA). Varicella zoster virus reactivation leading to herpes zoster (HZ) is an adverse effect of this drug; however, recurrent HZ at the same site is a rare clinical condition.

CASE SUMMARY

A 70-year-old female RA patient had undergone 1-year of tofacitinib treatment (10 mg daily). About 1 mo after initiation of oral tofacitinib, she developed blisters on the left flank and abdomen and was diagnosed with HZ; antiviral therapy with acyclovir was resolutory. However, 5 d prior to presentation at our hospital, erythema and blisters with severe pain recurred at the same site. Small clustered blisters and bullous were visible on the left lumbar abdomen and perineum, with a pain score of 8 (visual analogue scale). Antiviral, nutritional supplement, analgesic and other treatments led to healing but over an atypically long period (approximately 26 d, vs approximately 1 wk). HZ is a common and serious adverse reaction of JAK inhibitors, but it rarely recurs. Our patient’s experience of HZ recurrence at the same site, with a wider affected area, more severe pain and longer healing period, is inconsistent with previous reports.

CONCLUSION

Same-anatomical site HZ recurrence may occur during oral tofacitinib treatment, with more severe clinical manifestations than in the initial occurrence.

A Case of Aseptic Meningitis Without Rash Possibly Associated With Varicella Vaccine

Varicella-zoster virus (VZV) may cause aseptic meningitis in the pediatric age group. We describe a pediatric case of aseptic meningitis with a substantial increase of the paired serum antibody to VZV in which the child did not have skin rash during the course of illness. The patient was a 13-year-old boy without any history of exposure to VZV who was admitted with headache, vomiting, and low-grade fever. He had received one dose of varicella vaccine derived from the Oka/Biken strain (vOka) at the age of one year. Cerebrospinal fluid (CSF) analysis on admission revealed an elevated white blood cell count at 609/mm³ with 99.6% mononuclear cells. As his symptoms resolved after lumbar puncture alone, he was discharged on the seventh day of hospitalization without receiving any specific medication. Serum VZV-IgG titer was found to be substantially elevated after two weeks. VZV infection and reactivations associated with vaccination, as well as past infections, should be included in the differential diagnoses of pediatric aseptic meningitis, even in the absence of skin rash in the entire course. Polymerase chain reaction (PCR) testing for VZV DNA in CSF should be performed in all cases, if available.

Rational Design of a Skin- and Neuro-Attenuated Live Varicella Vaccine: A Review and Future Perspectives

Primary varicella-zoster virus (VZV) infection causes varicella, which remains a prominent public health concern in children. Current varicella vaccines adopt the live-attenuated Oka strain, vOka, which retains the ability to infect neurons, establish latency and reactivate, leading to vaccine-associated zoster in some vaccinees. Therefore, it is necessary to develop a safer next-generation varicella vaccine to help reduce vaccine hesitancy. This paper reviews the discovery and identification of the skin- and neuro-tropic factor, the open reading frame 7 (ORF7) of VZV, as well as the development of a skin- and neuro-attenuated live varicella vaccine comprising an ORF7-deficient mutant, v7D. This work could provide insights into the research of novel virus vaccines based on functional genomics and reverse genetics.

Decline in hospitalization rates for herpes zoster in Italy (2003-2018): reduction in the burden of disease or changing of hospitalization criteria?

BACKGROUND

Herpes Zoster (HZ) is a very demanding disease caused by the reactivation of latent Varicella Zoster Virus. The main aim of this study was to estimate the burden of the HZ hospitalizations in Italy from 2003 to 2018 evaluating temporal trends.

METHODS

Retrospective population-based study analyzing Hospital Discharge Records. Hospitalization records reporting the ICD-9 CM 053.X code in the principal diagnosis or in any of the five secondary diagnoses were considered as cases. Trends of hospitalization rates have been evaluated by Joinpoint analyses.

RESULTS

Overall, 99,036 patients were hospitalized with HZ in the 16-year period of the study, and 83,720 (84.5%) of these patients were over 50 years. Hospitalization rate was 10.4 per 100,000 persons/year with a significant decreasing trend from 13.9 in 2003-2006 to 7.8 in 2015-2018 (p < 0.001). Hospitalization rates showed a 20-fold higher risk among subjects aged over 80 years and 11-fold higher risk among 70-79-year-old subjects with respect to those aged less than 50 years. Over time, a statistically significant increase was observed for the case fatality rate (from 1.2 to 1.7%; p < 0.001) and the median length of stay (from 7 to 8 days; p < 0.001).

CONCLUSIONS

Zoster is a disease that causes hospitalization as relatively frequent complication and the observed reduced trend over time could be due to a restriction in hospitalization criteria instead of a reduced burden of disease. The decreasing trend should be carefully interpreted, since it could have an impact on promoting herpes zoster vaccination.

Development of a skin- and neuro-attenuated live vaccine for varicella

Varicella caused by the primary infection of varicella-zoster virus (VZV) exerts a considerable disease burden globally. Current varicella vaccines consisting of the live-attenuated vOka strain of VZV are generally safe and effective. However, vOka retains full neurovirulence and can establish latency and reactivate to cause herpes zoster in vaccine recipients, raising safety concerns. Here, we rationally design a live-attenuated varicella vaccine candidate, v7D. This virus replicates like wild-type virus in MRC-5 fibroblasts and human PBMCs, the carrier for VZV dissemination, but is severely impaired for infection of human skin and neuronal cells. Meanwhile, v7D shows immunogenicity comparable to vOka both in vitro and in multiple small animal species. Finally, v7D is proven well-tolerated and immunogenic in nonhuman primates. Our preclinical data suggest that v7D is a promising candidate as a safer live varicella vaccine with reduced risk of vaccine-related complications, and could inform the design of other herpes virus vaccines.

Current varicella vaccines retain neurovirulence and can establish latency and reactivate. Here, the authors present preclinical results of a rationally-designed, skin- and neuro-attenuated varicella vaccine candidate, v7D, showing its attenuation in human skin and neuronal cells and its immunogenicity in small animal models and nonhuman primates

Cerebral venous sinus thrombosis as a complication of primary varicella infection in a child, case report

INTRODUCTION AND IMPORTANCE

Chickenpox (Varicella) is a benign illness caused by varicella-zoster virus, predominant in childhood.Chicken pox related neurological complications are seen in less than 1% cases of chickenpox.Cerebral Venous thrombosis due to primary (VZV) infection is very rare, and it may occurs secondary to primary or re-activation the virus.

CASE PRESENTATION

We report a case of 5-year-old female complained of ataxia, vomiting, headache, and drowsiness 7 days after the onset varicella zoster infection. She had vesicular lesions with scab over the trunk and limbs.

CLINICAL DISCUSSION

Neurological examination revealed left hemiparesis.Her blood counts and metabolic parameters were normal.Computed tomography brain showed hemorrhagic infarct in the left temporo-parietal region. Coagulation profile was normal. Magnetic resonance imaging (MRI) brain revealed hemorrhagic infarct in the same region. Magnetic resonance Venogram showed thrombosis of left transverse sinus and sigmoid sinus and internal jugular vein.VZV- IgG antibody was positive but CSF VZV PCR (Polymerase chain reaction) was found to be negative.Intravenous acyclovir for 15 days, and low-molecular-weight heparin for 3 days overlapped with oral Warfarin for 3months,. After 3 months follow up, the patient experienced a complete recovery. MRI repeated after 3 months showed recanalization of the sinuses.

CONCLUSION

The pathogenic link of occurrence of CSVT after VZV infection is unclear, but some articles showed that it is related to direct endothelial damage by the virus.Early recognition of this complication of VZV infection and prompt treatment is essential to prevent catastrophic complications.

Non-dermatomal cutaneous herpes zoster infection in a solid-organ transplant patient

Diagnosis of atypical generalized forms of herpes zoster can be a challenge and may lead to a delay in treatment. Herpes zoster can present with atypical clinical manifestations, some with higher risk of complications that are potentially life-threatening. We describe a patient that presented with several ulcerated papules and plaques in a non-dermatomal distribution in whom disseminated cutaneous herpes zoster was proven by molecular amplification testing. Patients with disseminated herpes zoster should be treated initially with intravenous antiviral therapy, followed by oral acyclovir, valacyclovir, or famciclovir in most adults, with close follow-up. Earlier treatment may reduce the risk of developing complications and progression of visceral involvement. This case adds to the evolving literature related to herpes zoster, especially regarding patients with immunosuppressed status.

Shingles: a harbinger of chronic HIV infection

Early diagnosis and treatment are essential to reduce the risk of community transmission and morbidity and mortality of individuals infected with HIV. A 49-year-old woman presented with a painful, vesicular rash on the left side of her neck after being treated with valacyclovir for a separate perianal rash. She admitted recent weight loss and diffuse lymphadenopathy. She reported one family member with HIV but denied intravenous drug use or recently new sexual partners. Serum HIV-1 antibody screen was positive. Herpes zoster reactivation is associated with waning immunity in chronic HIV and should prompt testing. Delays in treatment impacts short-term and long-term prognosis for patients infected with HIV.

A case of paraplegia due to asymptomatic varicella-zoster virus infection in AIDS patient unexpectedly diagnosed by CSF metagenomic next-generation sequencing

BACKGROUND

Varicella-zoster virus (VZV) infection may induce central nervous system complications in HIV/AIDS patients. However, it is rare to have paraplegia caused by VZV infection but no herpes zoster clinically. Asymptomatic VZV infection in HIV/AIDS patient increased the difficulty of diagnosis.

CASE PRESENTATION

We reported a 41-year-old male AIDS patient with rare asymptomatic VZV infection-induced paraplegia after his anti-retroviral therapy initiation. MRI of the spinal cord showed the morphology of the thoracic spinal cord was irregular and locally inflated. The patient was confirmed as VZV induced thoracic myelomyelitis by using the cerebrospinal fluid for metagenomic next-generation sequencing (mNGS).

CONCLUSIONS

mNGS may contribute to disease diagnosis for asymptomatic VZV infection-induced myelitis.

Waning Effectiveness of One-dose Universal Varicella Vaccination in Korea, 2011-2018: a Propensity Score Matched National Population Cohort

BACKGROUND

Despite high coverage (~98%) of universal varicella vaccination (UVV) in the Republic of Korea since 2005, reduction in the incidence rate of varicella is not obvious. The study aimed to evaluate the vaccine effectiveness (VE) of one-dose UVV by timeline and severity of the disease.

METHODS

All children born in Korea in 2011 were included for this retrospective cohort study that analyzed insurance claims data from 2011-2018 and the varicella vaccination records in the immunization registry. Adjusted hazard ratios by Cox proportional hazard models were used to estimate the VE through propensity score matching by the month of birth, sex, healthcare utilization rate, and region.

RESULTS

Of the total 421,070 newborns in the 2011 birth cohort, 13,360 were matched for age, sex, healthcare utilization rate, and region by the propensity score matching method. A total of 55,940 (13.29%) children were diagnosed with varicella, with the incidence rate 24.2 per 1000 person-year; 13.4% of vaccinated children and 10.4% of unvaccinated children. The VE of one-dose UVV against any varicella was 86.1% (95% confidence interval [CI], 81.4-89.5) during the first year after vaccination and 49.9% (95% CI, 43.3-55.7) during the 6-year follow-up period since vaccination, resulting in a 7.2% annual decrease of VE. The overall VE for severe varicella was 66.3%. The VE of two-dose compared to one-dose was 73.4% (95% CI, 72.2-74.6).

CONCLUSION

We found lower long-term VE in one-dose vaccination and waning of effectiveness over time. Longer follow ups of the vaccinated children as well as appropriately designed studies are needed to establish the optimal strategy in preventing varicella in Korea.

Update on Viral Infections Involving the Central Nervous System in Pediatric Patients

Infections of the central nervous system (CNS) are mainly caused by viruses, and these infections can be life-threatening in pediatric patients. Although the prognosis of CNS infections is often favorable, mortality and long-term sequelae can occur. The aims of this narrative review were to describe the specific microbiological and clinical features of the most frequent pathogens and to provide an update on the diagnostic approaches and treatment strategies for viral CNS infections in children. A literature analysis showed that the most common pathogens worldwide are enteroviruses, arboviruses, parechoviruses, and herpesviruses, with variable prevalence rates in different countries. Lumbar puncture (LP) should be performed as soon as possible when CNS infection is suspected, and cerebrospinal fluid (CSF) samples should always be sent for polymerase chain reaction (PCR) analysis. Due to the lack of specific therapies, the management of viral CNS infections is mainly based on supportive care, and empiric treatment against herpes simplex virus (HSV) infection should be started as soon as possible. Some researchers have questioned the role of acyclovir as an empiric antiviral in older children due to the low incidence of HSV infection in this population and observed that HSV encephalitis may be clinically recognizable beyond neonatal age. However, the real benefit-risk ratio of selective approaches is unclear, and further studies are needed to define appropriate indications for empiric acyclovir. Research is needed to find specific therapies for emerging pathogens. Moreover, the appropriate timing of monitoring neurological development, performing neuroimaging evaluations and investigating the effectiveness of rehabilitation during follow-up should be evaluated with long-term studies.

Safety Profile of the Adjuvanted Recombinant Zoster Vaccine in Immunocompromised Populations: An Overview of Six Trials

Introduction

The adjuvanted recombinant zoster vaccine (RZV) has demonstrated high efficacy against herpes zoster in older adults and immunocompromised populations. We present comprehensive safety data from six clinical trials in immunocompromised populations (autologous hematopoietic stem cell transplant and renal transplant recipients, patients with hematologic malignancies, patients with solid tumors, and human immunodeficiency virus-infected adults) who are at an increased risk of herpes zoster.

Methods

In all trials, immunocompromised adults ≥ 18 years of age were administered RZV or placebo. Safety was evaluated in the total vaccinated cohort. Solicited adverse events (AEs) were collected for 7 days and unsolicited AEs for 30 days after each dose. Serious AEs, fatal serious AEs, and potential immune-mediated diseases were collected from dose 1 until 12 months post-last dose or study end. Data were pooled for solicited AEs; unsolicited AEs, (fatal) serious AEs, and potential immune-mediated diseases were analyzed for each individual trial. All AEs were analyzed for sub-strata of adults 18–49 years of age and ≥ 50 years of age.

Results

In total, 1587 (RZV) and 1529 (placebo) adults were included in the pooled total vaccinated cohort. Solicited AEs were more common after RZV than placebo, were generally more common in the younger age stratum, and were mostly mild to moderate and resolved within 3 days (median duration). Unsolicited AEs and serious AEs were in line with underlying diseases and therapies. Across studies, the percentage of adults reporting one or more unsolicited AE was comparable between RZV and placebo, irrespective of age stratum. The percentage of adults reporting one or more serious AE, fatal serious AE, or potential immune-mediated diseases was generally similar for RZV and placebo, irrespective of age stratum. Overall, no safety concerns were identified.

Conclusions

Recombinant zoster vaccine has a clinically acceptable safety profile. With the previously published vaccine efficacy and immunogenicity results, these data support a favorable benefit-risk profile of RZV vaccination in immunocompromised populations who are at an increased risk of herpes zoster.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40264-021-01076-w.

Varicella zoster virus leads to chickenpox after primary infection and herpes zoster upon reactivation of the latent virus. Older adults and immunocompromised people, whose immune system is impaired because of the age-related decline in immunity and their underlying disease and/or treatment, respectively, are at an increased risk of herpes zoster and its complications. Recombinant zoster vaccine has been approved to prevent herpes zoster and its complications in adults aged ≥ 50 years in over 30 countries. In Europe, the vaccine has recently received approval to expand its use in adults aged 18 years or older who are at an increased risk of herpes zoster. We present an overview of the safety data from six clinical trials in immunocompromised patients vaccinated with recombinant zoster vaccine. We found that solicited adverse events were more common after the vaccine than placebo but that these were mild to moderate in intensity. Furthermore, the frequency of unsolicited adverse events was similar between the vaccine and placebo, and most of the reported adverse events and severe adverse events (e.g., infections or tumors) could be attributed to the pre-existent diseases and/or therapies. As such, no safety concern was identified following the review of the available clinical data. This overview, together with the published efficacy data in the prevention of herpes zoster and the vaccine immunogenicity, provides useful medical information and supports the use of the recombinant zoster vaccine in an immunocompromised population at an increased risk of herpes zoster.

Varicella-Zoster Meningitis in an Immunocompetent Male without Fever or Rash

Varicella-Zoster virus (VZV) is a human herpesvirus that primarily causes chickenpox and can reactivate later in life. Chickenpox occurs mostly in children and is characterized by a typical generalized vesicular rash. Following the primary infection, VZV can remain latent and can reactivate decades later to produce Zoster, being more common in the elderly as well as immunosuppressed individuals. The diagnosis of both the primary and reactivation is mostly clinical from the typical rash. However, when presentations are atypical, it leads to diagnostic challenges. We report an unusual case of VZ reactivation in an immunocompetent young adult presenting without fever, zoster rash, or neuralgia. The diagnosis was established by a positive polymerase chain reaction (PCR) performed on cerebrospinal fluid samples. The patient was treated with acyclovir and responded very well. The diagnosis of VZ meningitis is challenging in the absence of typical features of Zoster rash and requires a high index of suspicion.

Aging and Options to Halt Declining Immunity to Virus Infections

Immunosenescence is a process associated with aging that leads to dysregulation of cells of innate and adaptive immunity, which may become dysfunctional. Consequently, older adults show increased severity of viral and bacterial infections and impaired responses to vaccinations. A better understanding of the process of immunosenescence will aid the development of novel strategies to boost the immune system in older adults. In this review, we focus on major alterations of the immune system triggered by aging, and address the effect of chronic viral infections, effectiveness of vaccination of older adults and strategies to improve immune function in this vulnerable age group.

Chronic Headache and Cerebral Venous Sinus Thrombosis Due to Varicella Zoster Virus Infection: A Case Report and Review of the Literature

Patient: Male, 20-year-old

Final Diagnosis: Cerebral venous sinus thrombosis • varicella zoster virus infection

Symptoms: Fever • headache • skin rash

Medication: —

Clinical Procedure: —

Specialty: Infectious Diseases • Rheumatology

Varicella zoster meningitis in a pregnant woman with uncontrolled type 1 diabetes mellitus

We report the case of retrograde varicella zoster virus (VZV) reactivation presenting as aseptic meningitis without rash in a generally healthy pregnant patient. A 27-year-old nulliparous woman at 25 weeks of gestation presented to the emergency department with a 1-day history of severe headache associated with nausea, photophobia and neck stiffness. After ruling out a space-occupying lesion by brain imaging, lumbar puncture was performed. Cerebrospinal fluid analysis by PCR revealed the presence of VZV, making the diagnosis of acute varicella meningitis. The patient had immunoglobulin studies consistent with a history of primary VZV infection, thus confirming reactivation of VZV rather than primary infection. The patient was treated with acyclovir for 14 days and recovered fully. Her neonate was delivered full term without any evidence of vertical transmission. This is only the second reported case of VZV meningitis in a pregnant patient in the medical literature, and the first case in the US that was reported.

An atypical presentation of multidermatomal herpes zoster: a case report

Background

Herpes zoster (HZ) also known as shingles is a common dermatological pathology seen in the emergency department. Multidermatomal involvement is an uncommon presentation and usually is linked to immunocompromised individuals. However, it is rarely reported in the immunocompetent population.

Case presentation

We report a 30-year-old Emirati male complaining of low-grade fever for 3 days, sore throat and an uncomfortable pruritic erythematous rash over his chest and back for 2 days. He was treated the day preceding his presentation in another facility for a presumed allergic reaction after taking ibuprofen. On physical examination, he was found to have exudative tonsillitis and influenza and was treated for both and discharged. He returned to the emergency department reporting increasing pain and was referred to be seen in the dermatology clinic where a biopsy was obtained, and he was discharged with a steroid topical cream. Fourteen days later, he returned to the clinic reporting crusting of the rash; the biopsy results were positive for herpes zoster. The diagnosis of multidermatomal herpes zoster was made, and he was then treated with antivirals.

Conclusions

Herpes zoster can present with atypical manifestations. Multidermatomal HZ is a rare dermatological manifestation in the immunocompetent adult. It is characterised by a rash spread over two or more adjacent dermatomes. This case highlights the challenging diagnosis of this dermatological presentation.

Encephalitis with coinfection by Jamestown canyon virus (JCV) and varicella zoster virus (VZV)

We present the case of a 59-year-old Midwestern farmer who presented with altered mental status, dysarthria, urinary incontinence, and a right-sided L5 dermatomal rash; he had recently received a course of oral corticosteroids for treatment of radicular low back pain. Lumbar puncture revealed the presence of varicella zoster virus (VZV) and IgM antibodies against a California-group encephalitis virus, later confirmed as Jamestown Canyon virus (JCV). Unfortunately, the patient's health declined despite aggressive treatment, developing progressive subarachnoid hemorrhage. He died after withdrawal of supportive care following 3 weeks in the intensive care unit. To our knowledge, this is the first documented case of encephalitis associated with coinfection by VZV and JCV. While the relative contributions of these viral pathogens to the patient's illness are difficult to ascertain, the clinical features of this case are consistent with co-pathogenesis, possibly driven by antecedent corticosteroid use. This case highlights the emerging role of viral coinfections in the etiology of viral illnesses.

Insights into the pathogenesis of varicella viruses

Purpose of review

Varicella zoster virus (VZV) is a highly contagious, neurotropic alpha herpes virus that causes varicella (chickenpox). VZV establishes lifelong latency in the sensory ganglia from which it can reactivate to induce herpes zoster (HZ), a painful disease that primarily affects older individuals and those who are immune-suppressed. Given that VZV infection is highly specific to humans, developing a reliable in vivo model that recapitulates the hallmarks of VZV infection has been challenging. Simian Varicella Virus (SVV) infection in nonhuman primates reproduces the cardinal features of VZV infections in humans and allows the study of varicella virus pathogenesis in the natural host. In this review, we summarize our current knowledge about genomic and virion structure of varicelloviruses as well as viral pathogenesis and antiviral immune responses during acute infection, latency and reactivation. We also examine the immune evasion mechanisms developed by varicelloviruses to escape the host immune responses and the current vaccines available for protecting individuals against chickenpox and herpes zoster.

Recent findings

Data from recent studies suggest that infected T cells are important for viral dissemination to the cutaneous sites of infection as well as site of latency and that a viral latency-associated transcript might play a role in the transition from lytic infection to latency and then reactivation.

Summary

Recent studies have provided exciting insights into mechanisms of varicelloviruses pathogenesis such as the critical role of T cells in VZV/SVV dissemination from the respiratory mucosa to the skin and the sensory ganglia; the ability of VZV/SVV to interfere with host defense; and the identification of VLT transcripts in latently infected ganglia. However, our understanding of these phenomena remains poorly understood. Therefore, it is critical that we continue to investigate host-pathogen interactions during varicelloviruses infection. These studies will lead to a deeper understanding of VZV biology as well as novel aspects of cell biology.

Shingles (Herpes Zoster) Mimicking Acute Abdomen

Shingles is a very well-known viral infection caused by the varicella-zoster virus leading to painful skin rash. Although shingles can occur anywhere, it most often appears as a single stripe of blisters around the hypochondriac region. We are presenting a rare atypical presentation of shingles, as our patient presented with a picture of the acute abdomen a couple of days prior to the eruption of skin lesions.

Near-atomic cryo-electron microscopy structures of varicella-zoster virus capsids

Varicella-zoster virus (VZV) is a medically important human herpesvirus that causes chickenpox and shingles, but its cell-associated nature has hindered structure studies. Here we report the cryo-electron microscopy structures of purified VZV A-capsid and C-capsid, as well as of the DNA-containing capsid inside the virion. Atomic models derived from these structures show that, despite enclosing a genome that is substantially smaller than those of other human herpesviruses, VZV has a similarly sized capsid, consisting of 955 major capsid protein (MCP), 900 small capsid protein (SCP), 640 triplex dimer (Tri2) and 320 triplex monomer (Tri1) subunits. The VZV capsid has high thermal stability, although with relatively fewer intra- and inter-capsid protein interactions and less stably associated tegument proteins compared with other human herpesviruses. Analysis with antibodies targeting the N and C termini of the VZV SCP indicates that the hexon-capping SCP-the largest among human herpesviruses-uses its N-terminal half to bridge hexon MCP subunits and possesses a C-terminal flexible half emanating from the inner rim of the upper hexon channel into the tegument layer. Correlation of these structural features and functional observations provide insights into VZV assembly and pathogenesis and should help efforts to engineer gene delivery and anticancer vectors based on the currently available VZV vaccine.

Herpes Zoster in Kidney Transplant Recipients: A Series of Three Cases

Kidney transplant recipients require lifelong immunosuppression to prevent organ rejection. The need for this intervention, however, leads to decreased cellular immunity and, in turn, increased risk of developing herpes zoster (HZ) from reactivation of latent varicella zoster virus. HZ commonly presents as a painful rash in a dermatome presentation followed by post-herpetic neuralgia. In immunosuppressed individuals, the presentation can be atypical and vary in severity depending on degree of immunosuppression and host immune response. We present the clinical course of 3 kidney transplant recipients who developed HZ after transplantation at different times post-transplant with varying clinical manifestations. The balance between maintaining immunosuppression and preventing or subsequently treating disseminated disease is discussed.

Unusual presentation of fatal disseminated varicella zoster virus infection in a patient with lupus nephritis: a case report

Background

The risk of life-threatening complications, such as visceral disseminated varicella zoster virus (VZV) infection, is greater in immunosuppressed individuals, such as systemic lupus erythematosus (SLE) patients.

Case presentation

Here, a case is reported of a Caucasian woman diagnosed with lupus nephritis and anti-phospholipid syndrome, who was subjected to mycophenolate mofetil and high-dose steroid remission-induction therapy. Two months later she developed abdominal pain followed by a fatal rapid multi-organ failure. As no typical skin rashes were evident, death was initially attributed to catastrophic anti-phospholipid syndrome. However, autopsy and virological examinations on archival material revealed a disseminated VZV infection.

Conclusions

Overall, this case highlights the importance of having a high clinical suspicion of fatal VZV infections in heavily immunosuppressed SLE patients even when typical signs and symptoms are lacking.

Encephalitis due to herpes zoster without rash in an immunocompetent 12-year-old girl: case report and review of the literature

Background

Neurological complications due to reactivation of varicella-zoster virus (VZV) are very uncommon in immunocompetent patients. Generally a vesicular rash is present on one or more dermatomes, preceding or following the main manifestation. Few cases are reported in the international literature, but they concern mainly adult or elderly patients.

Case presentation

A 12-year-old girl was referred to our hospital for persisting headache, cough and rhinitis for six days. After first examination, diagnosis of anterior sinusitis was made by nasal endoscopy. The day after, the girl developed psychotic symptoms and altered mental status. Computed tomography (CT) scan was immediately performed but was unremarkable; lumbar puncture revealed leukocytosis with lymphocytic predominance and cerebrospinal fluid polymerase chain reaction (PCR) detected varicella-zoster virus DNA. The diagnosis of acute VZV encephalitis was made. The patient was promptly treated with acyclovir infused intravenously and her clinical conditions rapidly improved. Tests made did not show any condition of immunosuppression.

Conclusions

Although if rare, reactivation of VZV can occur in immunocompetent children and its complications can involve central nervous system. Among these complications, meningitis is more common, but cerebral parenchyma can also be involved leading to a severe medical condition that is defined meningoencephalitis. In rare cases vesicular rash may be absent; therefore high level of suspicion is required even in those patients in which suggestive clinical features are not present to guide the diagnosis. Intravenous acyclovir represents the treatment of choice to obtain a fast clinical response and to prevent the onset of late-term complications.

The Cost-Effectiveness of Universal Varicella Vaccination in Italy: A Model-Based Assessment of Vaccination Strategies

Background

In 2017, varicella vaccination became mandatory for all children in Italy, based on a two-dose schedule administered at 12–15 months of age and 5 to 6 years of age. Varicella vaccines are available in different formulations (as a single vaccine or as a combination vaccine together with measles, mumps, and rubella) and are made by multiple manufacturers with different effectiveness profiles. This study calculates the cost-effectiveness of a range of varicella vaccination strategies to identify the optimal strategy for Italy.

Methods

A dynamic transmission cost-effectiveness model was applied in Italy to simulate the long-term (50 years) costs and outcomes associated with different varicella vaccination strategies. Five vaccination strategies were evaluated using the model: two doses of two different combination Measles-Mumps-Rubella-Varicella vaccines (either Vaccine A (MSD) [denoted QQVa] or Vaccine B (GSK) [denoted QQVb]); a first dose of a single Varicella vaccine followed by a second dose of a combination vaccine (either Vaccine C (MSD) followed by Vaccine A [denoted MQVa] or Vaccine D (GSK) followed by Vaccine B [denoted MQVb]); or no vaccine at all (NV). The model was adapted for Italy using publicly available Italian data and expert opinion.

Results

Over the 50-year time-horizon, in the absence of universal varicella vaccination, there would be 34.8 million varicella cases, 142 varicella-infection-related deaths, and €23 billion in societal costs. The cost per capita from a societal perspective ranged from €164.55 to €392.18 with NV being the most expensive and QQVa the least expensive. The most effective strategy was QQVa, which resulted in a 66% decrease in varicella cases and 30% reduction in varicella-related deaths compared to NV strategy. QQVa led to a net saving in societal cost around €13 billion compared to NV as the cost of vaccination was more than offset by the savings that resulted from the reduced burden of illness.

Conclusion

Varicella vaccination has a major impact on reducing varicella incidence, prevalence, and societal costs. This analysis supports the policy for universal varicella vaccination in Italy as the NV strategy was the most expensive and resulted in the poorest outcomes. QQVa offers the greatest benefits at the lowest cost and should be considered as a potential priority strategy for Italian population.

Herpes-Zoster-Associated Voiding Dysfunction in an Immunocompromised Patient

During herpes zoster infection, immunocompromised hosts are especially vulnerable to complications, which include visceral organ involvement. Voiding dysfunction secondary to herpes zoster infection is an uncommon clinical presentation and has numerous enigmatic mechanisms. This case of herpes-zoster-associated voiding dysfunction occurred in a patient with nephrotic syndrome treated with immunosuppressives (prednisolone and mycophenolate mofetil). The patient presented with acute urinary retention and extensive lumbosacral herpetic infection. He responded positively to treatment and completely recovered following a 14-day course of intravenous acyclovir and intermittent self-catheterization (two to three times daily) for four weeks.