Detection of varicella zoster virus DNA in tear fluid and saliva of patients with Ramsay Hunt syndrome

Sialadenitis as chickenpox complication in a 6-year-old girl

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In the 6.year old girl with chickenpox we diagnosed an typical complication in the shape of sialadenitis (especially submaxillitis).

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Within the last twenty years, only in one child the relationship between sialadenitis and varicella-zoster virus infection has been suggested.

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Our observation has important clinical significance.

Chickenpox is considered as a mild disease, but sometimes it is associated with complications. Among them sialadenitis is mentioned sporadically. We describe a case of the 6-year-old girl suffering from complicated chickenpox. On the basis of clinical data and ultrasound image we diagnosed in her inflammation of both submandibular glands. Moreover, the ultrasound image suggested possibility of an inflammation developing in the left parotid gland.

Varicella-zoster DNA in saliva of patients with meningoencephalitis: a preliminary study

OBJECTIVES

Since the routine use of polymerase chain reaction testing (PCR) in diagnosing herpes infections, varicella-zoster virus is increasingly recognized as a cause of varicella-zoster meningoencephalitis (VZV ME) among immunocompetent patients. We were interested to determine whether patients with VZV ME had VZV DNA in their saliva during the acute phase of the illness.

MATERIALS AND METHODS

Forty-five consecutive patients who underwent a lumbar puncture for diagnostic purposes were included in the study. The cerebrospinal fluid was examined for the presence of VZV DNA by PCR, and patients with positive findings were treated with acyclovir. The saliva was later analyzed in a blinded fashion for the presence of VZV DNA.

RESULTS

VZV DNA was found in saliva in four of five (80%) patients with PCR confirmed VZV ME (sensitivity 0.8, specificity 0.84, and likelihood ratio 5). This was significantly more than in patients with non-zoster viral ME (0%, P = 0.009), parainfectious headache (12%, P = 0.03) and controls (9.5%, P = 0.007). In immunocompromised patients with systemic lymphoma and AIDS, VZV DNA was present at a similar rate (67%, P = 0.6).

CONCLUSIONS

We have found VZV DNA in saliva of patients with PCR confirmed VZV ME at a higher proportion than in controls and patients with non-VZV viral ME. This finding might be of clinical importance, especially in immunocompetent individuals with suspected VZV ME where the results of genetic and immunological testing are not conclusive.

Varicella-zoster virus keratitis with asymptomatic conjunctival viral shedding in the contralateral eye

Purpose

To report a case of varicella-zoster virus (VZV) keratitis with detection of VZV DNA in the tear fluid of not only the symptomatic eye but also the contralateral asymptomatic eye by polymerase chain reaction (PCR).

Methods

This is a case report. A 63-year-old otherwise healthy woman presented with circular corneal ulcer and stromal opacity with infiltration accompanied by mild conjunctival and ciliary injections in the left eye. Bacterial cultures of the corneal scrapings and virus PCR analyses of tear fluid from both eyes were performed.

Results

No pathogen was found by bacterial cultures. PCR was negative for Acanthamoeba, herpes simplex virus and cytomegalovirus, but positive for VZV. VZV DNA was also detected in the unaffected eye. Based on the diagnosis of VZV keratitis, oral valacyclovir and acyclovir eye ointment were administered to the corneal infected eye. The infected eye was healed and VZV DNA turned negative in the tear fluid of the treated eye after 6 months of treatment; however, VZV DNA was still positive in the tear fluid of the contralateral eye.

Conclusions

To our knowledge, this is the first case report of the detection of VZV DNA in the tear fluid of both affected and unaffected eyes in a patient with VZV keratitis. Asymptomatic conjunctival shedding of VZV may continue in the healthy unaffected eye in VZV keratitis patients.

Favorable Outcome of Ramsay Hunt Syndrome under Dexamethasone

A 20-year-old student under chronic stress developed a painful reddish left ear, vesicles on the left ear, severe left-sided peripheral facial-nerve palsy, and hypoesthesia of the left upper lip, after exposure to a ventilator. Ramsay Hunt syndrome was diagnosed. Instead of prednisolone she received dexamethasone (40 mg/d) but nonetheless recovered completely after 12 weeks.

Herpes zoster oticus (Ramsay Hunt syndrome) in children: case report and literature review

INTRODUCTION

Approximately 10% of patients with peripheral facial nerve palsy are children. Facial nerve palsy is usually idiopathic. An uncommon cause is herpes zoster oticus (Ramsay Hunt syndrome). This syndrome usually affects adults and is rare in children.

METHODS

We reviewed the literature and describe the cause, clinical manifestations, and treatment of Ramsay Hunt syndrome. We also report a case of the syndrome in a 12-year-old boy.

CONCLUSION

Ramsay Hunt syndrome is characterized by peripheral facial paralysis associated with herpetic eruption on the auricula and external ear, and by vestibulocochlear dysfunction. It occurs by reactivation of latent varicella-zoster virus (VZV) in the geniculate ganglion, affecting the seventh and eighth cranial nerves. The diagnosis is based on history and physical findings. Treatment of Ramsay Hunt syndrome uses a combination of high-dose corticosteroids and acyclovir. Although the prognosis is better in children than in adults, it is not good enough.

A case of Ramsay Hunt syndrome in living-kidney transplant recipient

A 36-year-old woman underwent ABO-incompatible living-donor kidney transplantation. Immunosuppression was achieved by quadruple therapy with tacrolimus, basiliximab, mycophenolate mofetil (MMF), and prednisone. Desensitization and removal of anti-ABO antibody was achieved by administration of MMF for 4 weeks before transplantation followed by intravenous administration of rituximab, double-filtered plasmapheresis, and plasma exchange. At 1 month after transplantation, she complained of left ear pain without vesicle rash, tinnitus, and vertigo. Physical examination revealed left facial paralysis and nystagmus. T2 fluid-attenuated inversion recovery magnetic resonance imaging (MRI) visualized swelling of the left facial nerve. Real-time polymerase chain reaction showed the existence of varicella zoster virus DNA in the patient's tears and saliva. The final diagnosis was Ramsay Hunt syndrome without vesicle rash, which is called zoster sine herpete. The patient was treated by intravenous administration of acyclovir (3 mg/kg, 3 times per day) in addition to the reduction of the MMF dose. For facial nerve palsy, prednisolone was prescribed for 3 days and then gradually tapered. These treatments improved the symptoms of tinnitus and vertigo after a month; the facial nerve palsy completely disappeared after 10 months. This case demonstrated MRI to be a useful modality for the early diagnosis of Ramsay Hunt syndrome without vesicle eruption.

Tear IgA-ELISA: a novel and sensitive method for diagnosis of ophthalmic cysticercosis

For the first time, presence of locally secreted specific IgA antibodies in tear specimen from human with ophthalmic cysticercosis is documented in the present study. The ELISA using Taenia solium metacestode excretory secretory (ES) antigen demonstrated a diagnostic level of IgA antibodies in tears with 100% sensitivity (6 out of 6 confirmed cases of ophthalmic cysticercosis) whereas, 25 of 34 (73.52%) clinically suspected cases were diagnosed positive. The ELISA using T. solium metacestode somatic antigen detected a diagnostic titre of IgA antibody in tears with a sensitivity of 50% (3 out of 6 confirmed cases). The specificity of the tear IgAELISA using T. solium metacestode somatic and ES antigens is observed to be 94.87% and 92.3%, respectively. Overall in tears, the ELISA using T. solium metacestode ES antigens for detection of IgA antibodies shows a higher diagnostic efficiency (93.33%) compared to that using T. solium metacestode somatic antigen (88.88%). The sensitivities of the ELISA for detection of IgA antibodies in tears is observed to be higher than that for detection of IgG antibodies in serum using either somatic or ES antigens of the parasite.

Cornea as a tissue reservoir of Trypanosoma cruzi

Trypanosoma cruzi causal agent of Chagas' disease is a paninfective parasite of mammals transmitted through skin fecal contamination by Triatominae vectors. Studies of alternative routes for infection are scarce; therefore, eye infection should be important, because of the eye's high blood irrigation and brain proximity, as port of entry of the parasite. Trypanosoma cruzi parasites and/or their genetic material in ocular and adjacent muscle tissues were studied in batches of six NMRI mice (15 g) and Trichomys apereoides, an ancient caviomorph (250 g) inoculated with T. cruzi metacyclics from Brazilian (2) and Venezuelan (3) isolates genetically typified as T. cruzi I and II. Two animals/batch in the acute or chronic phase were killed and necropsies of cardiac and skeletal muscles, eyeball, and surrounding ocular muscle were processed for hematoxylin-eosine staining. Tissue parasitism was determined. DNA of the digested sections of the eyeball (5-10 mum) was extracted for T. cruzi k-DNA amplification by PCR, with S35 and S36 primers. The PCR products were analyzed. The average of maximum values of parasitemia of all infected animals was of 10(5) trypomastigotes/ml blood. Skeletal muscle and heart were colonized in patent infection for all isolates. Amastigote nests were found in corneal tissue of 2/3 of the used isolates and adjacent ocular muscle and connective tissue were parasitized. Trypanosoma cruzi k-DNA (330-bp band) was observed in ocular tissue of 4/6 of the isolates studied in both animal models. Investigations concerning infection of the eye globe tissues by T. cruzi are extremely scarce. The presence of stages of T. cruzi and/or its genetic products in ocular tissues indicate a broad colonization from a systemic infection. The results show the ocular environment as a possible appropriate microniche for T. cruzi and emphasize the risk of transmitting T. cruzi by ocular fluids and by parasitized cornea through transplants.

Molecular diagnosis of infectious diseases in dermatology

The molecular diagnosis of infectious disease has been growing considerably over the past decade. Nucleic acid amplification techniques, such as polymerase chain reaction, ligase chain reaction, transcription-mediated amplification, and nucleic acid sequence-based amplification, provide highly accurate diagnosis of numerous bacterial, viral, fungal, and parasitic infections involved in a variety of dermatologic diseases. In addition, signal amplification with hybrid capture, branched-DNA assays, and in situ hybridization have been used to detect numerous viral pathogens with high degrees of sensitivity and specificity. New technology that involves the use of DNA and protein microarrays has also enabled the detection of a variety of genes and gene mutations. With time, these diagnostic assays are decreasing in cost, gaining approval of the U.S. Food and Drug Administration, and becoming easier and more efficient to use. In the future, these assays will be able to deliver rapid and accurate diagnosis of infectious diseases within a single clinic visit.

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be familiar with molecular diagnosis of infectious diseases in dermatology.

Bilateral Ramsay Hunt syndrome in a diabetic patient

BACKGROUND: Herpes zoster oticus accounts for about 10% cases of facial palsy, which is usually unilateral and complete and full recovery occurs in only about 20% of untreated patients. Bilateral herpes zoster oticus can sometime occur in immunocompromised patients, though incidence is very rare. CASE PRESENTATION: Diabetic male, 57 year old presented to us with bilateral facial palsy due to herpes zoster oticus. Patient was having bilateral mild to moderate sensorineural hearing loss. Patient was treated with appropriate metabolic control, anti-inflammatory drugs and intravenous acyclovir. Due to uncontrolled diabetes, glucocorticoids were not used in this patient. Significant improvement in hearing status and facial nerve functions were seen in this patient. CONCLUSIONS: Herpes zoster causes severe infections in diabetic patients and can be a cause of bilateral facial palsy and bilateral Ramsay Hunt syndrome. Herpes zoster in diabetic patients should be treated with appropriate metabolic control, NSAIDS and intravenous acyclovir, which we feel should be started at the earliest. Glucocorticoids should be avoided in diabetic patients.

Variable patterns of varicella-zoster virus reactivation in Ramsay Hunt syndrome

The mechanism by which reactivation of varicella-zoster virus (VZV) causes facial paralysis in Ramsay Hunt syndrome remains unclear. The relationship between VZV load and the onset of facial paralysis was analyzed in 42 patients with Ramsay Hunt syndrome. The patients were divided into three groups according to the times of appearance of zoster and of facial paralysis; group I (zoster preceding, n = 13), group II (simultaneous, n = 22), group III (paralysis preceding, n = 7). A real-time quantitative PCR assay was used to measure VZV DNA copy number in saliva, and paired sera were assayed for anti-VZV IgG and IgM antibodies. In group I, the VZV DNA-positive rate was low and virus load decreased gradually after the initial hospital visit around the time of onset of paralysis. The level of anti-VZV antibodies had in most cases already increased at that time. In group III, viral load tended to increase after the onset of paralysis and peaked around the time of appearance of zoster. The level of anti-VZV antibodies was low at the onset of paralysis but showed a significant increase when paired sera were tested. In group II, virus load and changes in level of anti-VZV antibodies either resembled group I or group III behavior. These results indicate that facial paralysis in Ramsay Hunt syndrome can occur at various times between the early and the regression phase of VZV reactivation, suggesting that there are variable patterns of development of facial nerve dysfunction caused by VZV reactivation and the progression of neuritis.

Specific detection and identification of herpes B virus by a PCR-microplate hybridization assay

Herpes B virus DNA was specifically amplified by PCR, targeting the regions that did not cross-react with herpes simplex virus (HSV). The amplified products, which were shown to be highly genetic polymorphisms among herpes B virus isolates, were identified by microplate hybridization with probes generated by PCR. The products immobilized in microplate wells were hybridized with the biotin-labeled probes derived from the SMHV strain of herpes B virus. The amplified products derived from the SMHV and E2490 strains of herpes B virus were identified by microplate hybridization. PCR products amplified from the trigeminal ganglia of seropositive cynomolgus macaques were identified as herpes B virus DNA. The utility of the PCR-microplate hybridization assay for genetic detection and identification of the polymorphic region of herpes B virus was determined.

Chronic varicella-zoster virus ganglionitis--a possible cause of postherpetic neuralgia

Postherpetic neuralgia (PHN) is dermatomal distribution pain that persists for months to years after the resolution of herpes zoster rash. The cause of PHN is unknown. Herein, we report clinical, molecular virological, and immunological findings over an 11-year period in an immunocompetent elderly woman with PHN. Initially, blood mononuclear cells (MNCs) contained varicella-zoster virus (VZV) DNA on two consecutive occasions. Random testing after treatment with famciclovir to relieve pain did not detect VZV DNA. However, the patient was reluctant to continue famciclovir indefinitely and voluntarily stopped drug treatment five times. Pain always recurred within 1 week, and blood MNCs contained many, but not all, regions of the VZV genome on all five occasions. Immunological analysis revealed increased cell-mediated immunity to VZV. Chronic VZV ganglionitis-induced PHN best explains the recurrence of VZV DNA in MNCs whenever famciclovir was discontinued; the detection of only some regions of the viral genome in MNCs, compared to the detection of all regions of the VZV genome in latently infected ganglia; the increased cell-mediated immunity to VZV; and a gratifying clinical response to famciclovir. The presence of fragments of VZV DNA in MNCs likely represents partial degradation of viral DNA in MNCs that trafficked through ganglia during productive infection.