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Drăgoi AL, Nemeș RM. A unique case of double meningitis with enterovirus and reactivated varicella-zoster virus in a male teenager. Diagn Microbiol Infect Dis 2024; 110:116409. [PMID: 38964071 DOI: 10.1016/j.diagmicrobio.2024.116409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Revised: 06/17/2024] [Accepted: 06/19/2024] [Indexed: 07/06/2024]
Abstract
This paper presents a unique case of double meningitis with enterovirus and reactivated varicella-zoster virus without shingles in an immunocompetent male teenager, a case that offers many important medical lessons, all "gravitating" around physiopathological reasoning of any clinical case in general.
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Affiliation(s)
- Andrei-Lucian Drăgoi
- The Medical Doctoral School of University "Titu Maiorescu", Bucharest, Romania; The Emergency County Hospital Târgoviște (Romania) (SJUT), Street General Ion Emanoil Florescu, nr. 9, bl. D11, sc. B, ap. 9 (2nd floor), Targoviste, Dambovita county, Romania, 130056.
| | - Roxana-Maria Nemeș
- Medical Doctoral School of University "Titu Maiorescu", Bucharest, Romania; Institute of Pneumophthisiology "Marius Nasta", Bucharest, Romania
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2
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Ramachandran P, Grose C. Serious neurological adverse events in immunocompetent children and adolescents caused by viral reactivation in the years following varicella vaccination. Rev Med Virol 2024; 34:e2538. [PMID: 38658176 PMCID: PMC11170866 DOI: 10.1002/rmv.2538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/05/2024] [Accepted: 04/15/2024] [Indexed: 04/26/2024]
Abstract
Serious adverse events following vaccination include medical complications that require hospitalisation. The live varicella vaccine that was approved by the Food and Drug Administration in the United States in 1995 has an excellent safety record. Since the vaccine is a live virus, adverse events are more common in immunocompromised children who are vaccinated inadvertently. This review includes only serious adverse events in children considered to be immunocompetent. The serious adverse event called varicella vaccine meningitis was first reported in a hospitalised immunocompetent child in 2008. When we carried out a literature search, we found 15 cases of immunocompetent children and adolescents with varicella vaccine meningitis; the median age was 11 years. Eight of the children had received two varicella vaccinations. Most of the children also had a concomitant herpes zoster rash, although three did not. The children lived in the United States, Greece, Germany, Switzerland, and Japan. During our literature search, we found five additional cases of serious neurological events in immunocompetent children; these included 4 cases of progressive herpes zoster and one case of acute retinitis. Pulses of enteral corticosteroids as well as a lack of herpes simplex virus antibody may be risk factors for reactivation in immunocompetent children. All 20 children with adverse events were treated with acyclovir and recovered; 19 were hospitalised and one child was managed as an outpatient. Even though the number of neurological adverse events remains exceedingly low following varicella vaccination, we recommend documentation of those caused by the vaccine virus.
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Affiliation(s)
- Prashanth Ramachandran
- Peter Doherty Institute for Infection and Immunity, University of Melbourne; Department of Neurology, Royal Melbourne Hospital; and Department of Neurology, St. Vincent’s Hospital, Melbourne, Victoria, Australia
| | - Charles Grose
- Division of Infectious Diseases, Virology Laboratory, Department of Pediatrics, University of Iowa, Iowa City, Iowa, United States
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3
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Abstract
Here, we present a previously healthy adolescent with aseptic meningitis without skin rash caused by varicella vaccine derived from the Oka/Biken strain; the patient received a single dose of varicella vaccine at 1 year of age. Pediatricians should be aware of the potential for reactivation of varicella vaccine derived from the Oka/Biken strain, which can cause aseptic meningitis in vaccinated children even in the absence of a skin rash.
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4
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Safety surveillance of varicella vaccine using tree-temporal scan analysis. Vaccine 2021; 39:6378-6384. [PMID: 34561139 DOI: 10.1016/j.vaccine.2021.09.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/03/2021] [Accepted: 09/13/2021] [Indexed: 11/20/2022]
Abstract
IMPORTANCE Passive surveillance systems are susceptible to the under-reporting of adverse events (AE) and a lack of information pertaining to vaccinated populations. Conventional active surveillance focuses on predefined AEs. Advanced data mining tools could be used to identify unusual clusters of potential AEs after vaccination. OBJECTIVE To assess the feasibility of a novel tree-based statistical approach to the identification of AE clustering following the implementation of a varicella vaccination program among one-year-olds. SETTING AND PARTICIPANTS This nationwide safety surveillance was based on data from the Taiwan National Health Insurance database and National Immunization Information System for the period 2004 through 2014. The study population was children aged 12-35 months who received the varicella vaccine. EXPOSURE First-dose varicella vaccine. OUTCOMES AND MEASURES All incident ICD-9-CM diagnoses (emergency or inpatient departments) occurring 1-56 days after the varicella vaccination were classified within a hierarchical system of diagnosis categories using Multi-Level Clinical Classifications Software. A self-controlled tree-temporal data mining tool was then used to explore the incidence of AE clustering with a variety of potential risk intervals. The comparison interval consisted of days in the 56-day follow-up period that fell outside the risk interval. RESULTS Among 1,194,189 varicella vaccinees with no other same-day vaccinations, nine diagnoses with clustering features were categorized into four safety signals: fever on days 1-6 (attributable risk [AR] 38.5 per 100,000, p < 0.001), gastritis and duodenitis on days 1-2 (AR 5.9 per 100,000, p < 0.001), acute upper respiratory infection on days 1-5 (AR 11.0 per 100,000, p = 0.006), and varicella infection on days 1-9 (AR 2.7 per 100,000, p < 0.001). These safety profiles and their corresponding risk intervals have been identified in previous safety surveillance studies. CONCLUSIONS Unexpected clusters of AEs were not detected after the mass administration of childhood varicella vaccines in Taiwan. The tree-temporal statistical method is a feasible approach to the safety surveillance of vaccines in populations of young children.
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Shang BS, Hung CJJ, Lue KH. Herpes Zoster in an Immunocompetent Child without a History of Varicella. Pediatr Rep 2021; 13:162-167. [PMID: 33916031 PMCID: PMC8167658 DOI: 10.3390/pediatric13020022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 11/30/2022] Open
Abstract
Herpes zoster is a relatively rare infectious disease in the pediatric population, as compared with adults, which is due to the reactivation of latent Varicella-Zoster virus. We report a 7-year-old child without any history of varicella, who first experienced skin pain and later presented skin lesions in dermatomal distribution. Finally, the patient was diagnosed with herpes zoster. We aim to emphasize that herpes zoster could occur in immunocompetent children and may be due to the reactivation of the vaccine strain or previous subclinical infection.
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Affiliation(s)
- Bing-Shiau Shang
- Department of Pediatrics, Chung Shan Medical University Hospital, Taichung City 402, Taiwan;
- Department of Medicine, Chung Shan Medical University, Taichung City 402, Taiwan;
| | - Cheng-Jui Jamie Hung
- Department of Medicine, Chung Shan Medical University, Taichung City 402, Taiwan;
| | - Ko-Huang Lue
- Department of Pediatrics, Chung Shan Medical University Hospital, Taichung City 402, Taiwan;
- Department of Medicine, Chung Shan Medical University, Taichung City 402, Taiwan;
- Correspondence:
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6
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Advances and Perspectives in the Management of Varicella-Zoster Virus Infections. Molecules 2021; 26:molecules26041132. [PMID: 33672709 PMCID: PMC7924330 DOI: 10.3390/molecules26041132] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/10/2021] [Accepted: 02/12/2021] [Indexed: 02/06/2023] Open
Abstract
Varicella-zoster virus (VZV), a common and ubiquitous human-restricted pathogen, causes a primary infection (varicella or chickenpox) followed by establishment of latency in sensory ganglia. The virus can reactivate, causing herpes zoster (HZ, shingles) and leading to significant morbidity but rarely mortality, although in immunocompromised hosts, VZV can cause severe disseminated and occasionally fatal disease. We discuss VZV diseases and the decrease in their incidence due to the introduction of live-attenuated vaccines to prevent varicella or HZ. We also focus on acyclovir, valacyclovir, and famciclovir (FDA approved drugs to treat VZV infections), brivudine (used in some European countries) and amenamevir (a helicase-primase inhibitor, approved in Japan) that augur the beginning of a new era of anti-VZV therapy. Valnivudine hydrochloride (FV-100) and valomaciclovir stearate (in advanced stage of development) and several new molecules potentially good as anti-VZV candidates described during the last year are examined. We reflect on the role of antiviral agents in the treatment of VZV-associated diseases, as a large percentage of the at-risk population is not immunized, and on the limitations of currently FDA-approved anti-VZV drugs. Their low efficacy in controlling HZ pain and post-herpetic neuralgia development, and the need of multiple dosing regimens requiring daily dose adaptation for patients with renal failure urges the development of novel anti-VZV drugs.
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Amaral V, Shi JZ, Tsang AMC, Chiu SSS. Primary varicella zoster infection compared to varicella vaccine reactivation associated meningitis in immunocompetent children. J Paediatr Child Health 2021; 57:19-25. [PMID: 33295075 DOI: 10.1111/jpc.15303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/30/2020] [Accepted: 11/19/2020] [Indexed: 12/24/2022]
Abstract
We diagnosed varicella zoster virus (VZV) meningitis in a healthy adolescent boy who presented without a rash or fever. We aim to compare VZV reactivation meningitis in children after primary VZV infection and VZV vaccination. We reviewed the literature up until June 2020 using Pubmed/MEDLINE and EMBASE databases using 'varicella zoster', 'meningitis' and 'children' as keywords. Only English articles were included. Twenty-five cases were included in this review. Children who had VZV reactivation meningitis after vaccination were younger (7 ± 3.4 years vs. 11.9 ± 3.6 years, P = 0.0038), had a shorter interval between first exposure to reactivation (5.6 ± 2.9 years vs. 8.8 ± 3.2 years, P = 0.018) and more likely to have a rash (100% vs. 55%, P = 0.04). VZV reactivation meningitis occurs after both primary VZV infection and VZV vaccination. The absence of exanthem, fever or meningism does not rule out VZV meningitis.
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Affiliation(s)
- Vanessa Amaral
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Julia Zhuo Shi
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Anita Man-Ching Tsang
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Susan Shui-Seng Chiu
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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Heusel EH, Grose C. Twelve Children with Varicella Vaccine Meningitis: Neuropathogenesis of Reactivated Live Attenuated Varicella Vaccine Virus. Viruses 2020; 12:v12101078. [PMID: 32992805 PMCID: PMC7599892 DOI: 10.3390/v12101078] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/11/2020] [Accepted: 09/22/2020] [Indexed: 12/22/2022] Open
Abstract
Varicella vaccine is a live attenuated varicella-zoster virus (VZV). Like its parental strain called VZV pOka, the vaccine virus vOka retains some neurotropic properties. To better understand vOka neuropathogenesis, we reassessed 12 published cases of vOka meningitis that occurred in once-immunized and twice-immunized children, all of whom had bouts of herpes zoster preceding the central nervous system infection. Eight of the 12 meningitis cases occurred in children who had received only one immunization. There was no pattern to the time interval between varicella vaccination and the onset of herpes zoster with meningitis. Four of the meningitis cases occurred in children who had received two immunizations. Since all four children were 14 years old when meningitis was diagnosed, there was a strong pattern to the interval between the first vaccination at age 1 year and onset of meningitis, namely, 13 years. Knowledge of pathogenesis requires knowledge of the location of herpes zoster; the majority of dermatomal rashes occurred at sites of primary immunization on the arm or thigh, while herpes zoster ophthalmicus was uncommon. Based on this literature review, currently there is no consensus as to the cause of varicella vaccine meningitis in twice-immunized children.
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Faluk MA, Makadia S, Abdelmaseih R, Hasan SM, Abusaada K. A Rare Case of an Immunocompetent Male With Zoster Meningitis. J Investig Med High Impact Case Rep 2020; 8:2324709620952212. [PMID: 32830563 PMCID: PMC7448257 DOI: 10.1177/2324709620952212] [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] [Indexed: 11/30/2022] Open
Abstract
Varicella zoster meningitis is an uncommon complication of herpes zoster,
especially in immunocompetent patients. We report a case of a healthy
45-year-old male who developed aseptic meningitis as a result of reactivated
varicella zoster virus infection. This case highlights the importance of
remaining cognizant of varicella zoster virus as a cause of meningitis in not
only the elderly or immunocompromised patients but also in patients who are
healthy.
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Affiliation(s)
- Mohammed Ali Faluk
- University of Central Florida, Orlando, FL, USA.,Ocala Regional Medical Center, Ocala, FL, USA
| | - Shraddhadevi Makadia
- University of Central Florida, Orlando, FL, USA.,Ocala Regional Medical Center, Ocala, FL, USA
| | - Ramy Abdelmaseih
- University of Central Florida, Orlando, FL, USA.,Ocala Regional Medical Center, Ocala, FL, USA
| | - S Mustajab Hasan
- University of Central Florida, Orlando, FL, USA.,Ocala Regional Medical Center, Ocala, FL, USA
| | - Khalid Abusaada
- University of Central Florida, Orlando, FL, USA.,Ocala Regional Medical Center, Ocala, FL, USA
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10
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Ciancia S, Crisafi A, Fontana I, De Fanti A, Amarri S, Iughetti L. Encephalitis due to herpes zoster without rash in an immunocompetent 12-year-old girl: case report and review of the literature. BMC Pediatr 2020; 20:348. [PMID: 32682414 PMCID: PMC7368762 DOI: 10.1186/s12887-020-02244-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 07/13/2020] [Indexed: 12/27/2022] Open
Abstract
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.
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Affiliation(s)
- Silvia Ciancia
- Post-graduated School of Pediatrics, Department of Medical and Surgical Sciences for Mother, Children and Adults, University of Modena and Reggio Emilia, via del Pozzo 71, 41124, Modena, Italy
| | - Antonella Crisafi
- Pediatrics Unit, Arcispedale Santa Maria Nuova, via Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Ilaria Fontana
- Pediatrics Unit, Arcispedale Santa Maria Nuova, via Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Alessandro De Fanti
- Pediatrics Unit, Arcispedale Santa Maria Nuova, via Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Sergio Amarri
- Pediatrics Unit, Arcispedale Santa Maria Nuova, via Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Lorenzo Iughetti
- Post-graduated School of Pediatrics, Department of Medical and Surgical Sciences for Mother, Children and Adults, University of Modena and Reggio Emilia, via del Pozzo 71, 41124, Modena, Italy. .,Pediatrics Unit, Department of Medical and Surgical Sciences for Mother, Children and Adults, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy.
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11
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Harrington WE, Mató S, Burroughs L, Carpenter PA, Gershon A, Schmid DS, Englund JA. Vaccine Oka Varicella Meningitis in Two Adolescents. Pediatrics 2019; 144:peds.2019-1522. [PMID: 31776194 PMCID: PMC6889945 DOI: 10.1542/peds.2019-1522] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2019] [Indexed: 11/24/2022] Open
Abstract
The live-attenuated varicella vaccine, a routine immunization in the United States since 1995, is both safe and effective. Like wild-type varicella-zoster virus, however, vaccine Oka (vOka) varicella can establish latency and reactivate as herpes zoster, rarely leading to serious disease, particularly among immunocompromised hosts. Previous cases of reactivated vOka resulting in meningitis have been described in young children who received a single dose of varicella vaccine; less is known about vOka reactivation in older children after the 2-dose vaccine series. We present 2 adolescents with reactivated vOka meningitis, 1 immunocompetent and 1 immunocompromised, both of whom received 2 doses of varicella vaccine many years before as children. Pediatricians should be aware of the potential of vOka varicella to reactivate and cause clinically significant central nervous system disease in vaccinated children and adolescents.
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Affiliation(s)
- Whitney E. Harrington
- Seattle Children’s Hospital, Seattle, Washington;,Department of Pediatrics, University of Washington, Seattle, Washington
| | - Sayonara Mató
- Randall Children’s Hospital at Legacy Emanuel, Portland, Oregon
| | - Lauri Burroughs
- Seattle Children’s Hospital, Seattle, Washington;,Department of Pediatrics, University of Washington, Seattle, Washington;,Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Paul A. Carpenter
- Seattle Children’s Hospital, Seattle, Washington;,Department of Pediatrics, University of Washington, Seattle, Washington;,Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Anne Gershon
- Department of Pediatrics, Vagelos School of Physicians and Surgeons, Columbia University, New York, New York; and
| | - D. Scott Schmid
- Viral Vaccine Preventable Diseases Branch, Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Janet A. Englund
- Seattle Children’s Hospital, Seattle, Washington;,Department of Pediatrics, University of Washington, Seattle, Washington
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12
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Woodward M, Marko A, Galea S, Eagel B, Straus W. Varicella Virus Vaccine Live: A 22-Year Review of Postmarketing Safety Data. Open Forum Infect Dis 2019; 6:5544864. [PMID: 31392326 PMCID: PMC6685817 DOI: 10.1093/ofid/ofz295] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 07/15/2019] [Indexed: 01/13/2023] Open
Abstract
Background Varicella, a contagious infectious disease caused by varicella zoster virus (VZV), can result in hospitalization and, occasionally, death. Varicella virus vaccine live (VVVL [VARIVAX]) was introduced in the United States in 1995. Methods This comprehensive review of the VVVL safety profile is based on 22 years of postmarketing adverse event (AE) data received through spontaneous and noninterventional study reports submitted by health care providers and on a review of the published literature (cumulatively from March 17, 1995, through March 16, 2017, during which period >212 million doses were distributed globally). Results The VVVL safety profile was consistent with previous publications, with common AEs including varicella, rash, and pyrexia. AE reports have decreased over time, from ~500 per million doses in 1995 to ~40 per million doses in 2016; serious AEs comprise 0.8 reports per million doses. Secondary transmission was rare (8 confirmed cases); polymerase chain reaction analysis indicated that 38 of the 66 reported potential secondary transmission cases of varicella were attributable to wild-type VZV. The prevalence of major birth defects in the Pregnancy Registry was similar to that in the general US population. In total, 86 cases of death were reported after vaccination with VVVL; immunocompromised individuals appeared to be most at risk for a fatal varicella- or herpes zoster–related outcome. Conclusions This comprehensive 22-year review confirms the overall safety profile for VVVL, with no new safety concerns identified. Since VVVL’s introduction in 1995, notable declines in varicella cases and in varicella-related deaths have occurred compared with the prevaccination period.
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Affiliation(s)
| | - Ann Marko
- Merck & Co., Inc., Kenilworth, New Jersey
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13
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Yasuda R, Minami K, Ogawa A, Okada H, Terakawa R, Koike Y, Ogura S, Takeuchi K, Higuchi T. Herpes zoster and meningitis in an immunocompetent child: a case report. J Med Case Rep 2019; 13:182. [PMID: 31200772 PMCID: PMC6570968 DOI: 10.1186/s13256-019-2082-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 04/12/2019] [Indexed: 12/18/2022] Open
Abstract
Background Development of neurological complications of varicella zoster virus reactivation is relatively uncommon, particularly in an immunocompetent child. Case presentation An 11-year-old Asian girl presented with headache and skin rash on her left chest. She was diagnosed with meningitis, and herpes zoster was confirmed by polymerase chain reaction using cerebrospinal fluid. Acyclovir was administered intravenously. Given the favorable evolution of the clinical course, she was discharged from the hospital on day 8 of her illness. She had no apparent sequelae or comorbidities at the time of the 6-week follow-up. Conclusions Neurological complications such as meningitis due to varicella zoster virus reactivation are uncommon, especially in an immunocompetent child; no specific immune deficiency was identified in our patient. We conclude that, although rare, varicella zoster virus should be recognized as a potential cause of viral meningitis in immunocompetent children.
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Affiliation(s)
- Ryu Yasuda
- Department of General Pediatrics, Nagano Children's Hospital, Nagano, Japan. .,Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan.
| | - Kisei Minami
- Department of General Pediatrics, Nagano Children's Hospital, Nagano, Japan
| | - Akira Ogawa
- Department of General Pediatrics, Nagano Children's Hospital, Nagano, Japan
| | - Hideshi Okada
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Runa Terakawa
- Department of General Pediatrics, Nagano Children's Hospital, Nagano, Japan
| | - Yumi Koike
- Department of General Pediatrics, Nagano Children's Hospital, Nagano, Japan
| | - Shinji Ogura
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Kouichi Takeuchi
- Department of General Pediatrics, Nagano Children's Hospital, Nagano, Japan
| | - Tsukasa Higuchi
- Department of General Pediatrics, Nagano Children's Hospital, Nagano, Japan
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14
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Oliveira K, Fonseca J, Moreira D, Vila Real M. Varicella-zoster virus meningitis in an immunocompetent paediatric patient. NEUROLOGÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.nrleng.2016.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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15
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Meningitis causada por el virus varicela-zóster en un niño inmunocompetente. Neurologia 2018; 33:623-624. [DOI: 10.1016/j.nrl.2016.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 06/07/2016] [Accepted: 06/09/2016] [Indexed: 11/23/2022] Open
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16
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El Hamichi S, Messaoudi R, Moujahid B, Alsubari A, El Ouatassi N, Reda K, Oubaaz A. Orbital cellulitis due to ophthalmic herpes zoster in an immunocompetent child: A case report. J Fr Ophtalmol 2017; 40:e255-e256. [DOI: 10.1016/j.jfo.2016.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 06/17/2016] [Accepted: 07/07/2016] [Indexed: 10/19/2022]
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17
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Genotype analysis of ORF 62 identifies varicella-zoster virus infections caused by a vaccine strain in children. Arch Virol 2017; 162:1725-1730. [PMID: 28204894 DOI: 10.1007/s00705-017-3276-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 01/17/2017] [Indexed: 10/20/2022]
Abstract
This study was performed to differentiate vaccine-type strains from wild-type strains and determine the genotype of varicella-zoster virus (VZV) in 51 Korean children. A sequencing analysis of ORF 62 identified two cases of herpes zoster caused by the vaccine-type virus, without a previous history of varicella, 22 months and 5 months after VZV vaccination. The wild-type strain was identified in the remaining children. A genotype analysis of ORF 22 amino acids revealed genotype J in all children except one. Genotype E was identified in an infant with varicella imported from Egypt.
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Lee SK, Kim DJ, Lee UH, Kim MS, Choi JH. Herpes zoster with meningitis in a vaccinated, immunocompetent child. J Dermatol 2017; 44:1419-1420. [DOI: 10.1111/1346-8138.13729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Soo Kyung Lee
- Department of Dermatology; Sanggye Paik Hospital; Inje University College of Medicine; Seoul Korea
| | - Dong Joo Kim
- Department of Dermatology; Sanggye Paik Hospital; Inje University College of Medicine; Seoul Korea
| | - Un Ha Lee
- Department of Dermatology; Sanggye Paik Hospital; Inje University College of Medicine; Seoul Korea
| | - Myoung Shin Kim
- Department of Dermatology; Sanggye Paik Hospital; Inje University College of Medicine; Seoul Korea
| | - Jeong Hwan Choi
- Department of Otolaryngology Head and Neck Surgery; Sanggye Paik Hospital; Inje University College of Medicine; Seoul Korea
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Dysregulated Glycoprotein B-Mediated Cell-Cell Fusion Disrupts Varicella-Zoster Virus and Host Gene Transcription during Infection. J Virol 2016; 91:JVI.01613-16. [PMID: 27795423 DOI: 10.1128/jvi.01613-16] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 10/14/2016] [Indexed: 12/19/2022] Open
Abstract
The highly conserved herpesvirus glycoprotein complex gB/gH-gL mediates membrane fusion during virion entry and cell-cell fusion. Varicella-zoster virus (VZV) characteristically forms multinucleated cells, or syncytia, during the infection of human tissues, but little is known about this process. The cytoplasmic domain of VZV gB (gBcyt) has been implicated in cell-cell fusion regulation because a gB[Y881F] substitution causes hyperfusion. gBcyt regulation is necessary for VZV pathogenesis, as the hyperfusogenic mutant gB[Y881F] is severely attenuated in human skin xenografts. In this study, gBcyt-regulated fusion was investigated by comparing melanoma cells infected with wild-type-like VZV or hyperfusogenic mutants. The gB[Y881F] mutant exhibited dramatically accelerated syncytium formation in melanoma cells caused by fusion of infected cells with many uninfected cells, increased cytoskeleton reorganization, and rapid displacement of nuclei to dense central structures compared to pOka using live-cell confocal microscopy. VZV and human transcriptomes were concurrently investigated using whole transcriptome sequencing (RNA-seq) to identify viral and cellular responses induced when gBcyt regulation was disrupted by the gB[Y881F] substitution. The expression of four vital VZV genes, ORF61 and the genes for glycoproteins gC, gE, and gI, was significantly reduced at 36 h postinfection for the hyperfusogenic mutants. Importantly, hierarchical clustering demonstrated an association of differential gene expression with dysregulated gBcyt-mediated fusion. A subset of Ras GTPase genes linked to membrane remodeling were upregulated in cells infected with the hyperfusogenic mutants. These data implicate gBcyt in the regulation of gB fusion function that, if unmodulated, triggers cellular processes leading to hyperfusion that attenuates VZV infection. IMPORTANCE The highly infectious, human-restricted pathogen varicella-zoster virus (VZV) causes chickenpox and shingles. Postherpetic neuralgia (PHN) is a common complication of shingles that manifests as prolonged excruciating pain, which has proven difficult to treat. The formation of fused multinucleated cells in ganglia might be associated with this condition. An effective vaccine against VZV is available but not recommended for immunocompromised individuals, highlighting the need for new therapies. This study investigated the viral and cellular responses to hyperfusion, a condition where the usual constraints of cell membranes are overcome and cells form multinucleated cells. This process hinders VZV and is regulated by a viral glycoprotein, gB. A combination of live-cell imaging and next-generation genomics revealed an alteration in viral and cellular responses during hyperfusion that was caused by the loss of gB regulation. These studies reveal mechanisms central to VZV pathogenesis, potentially leading to improved therapies.
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Iwasaki S, Motokura K, Honda Y, Mikami M, Hata D, Hata A. Vaccine-strain herpes zoster found in the trigeminal nerve area in a healthy child: A case report. J Clin Virol 2016; 85:44-47. [DOI: 10.1016/j.jcv.2016.10.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 09/07/2016] [Accepted: 10/31/2016] [Indexed: 10/20/2022]
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Amlie-Lefond C, Gilden D. Varicella Zoster Virus: A Common Cause of Stroke in Children and Adults. J Stroke Cerebrovasc Dis 2016; 25:1561-1569. [PMID: 27138380 DOI: 10.1016/j.jstrokecerebrovasdis.2016.03.052] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/27/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Varicella zoster virus (VZV) is a neurotropic, exclusively human herpesvirus. Primary infection causes varicella (chickenpox), after which the virus becomes latent in ganglionic neurons along the entire neuraxis. As cell-mediated immunity to VZV declines with advancing age and immunosuppression, VZV reactivates to produce zoster (shingles). One of the most serious complications of zoster is VZV vasculopathy. METHODS We reviewed recent studies of stroke associated with varicella and zoster, how VZV vasculopathy is verified virologically, vaccination to prevent varicella and immunization to prevent zoster, and VZV in giant cell arteritis (GCA). FINDINGS We report recent epidemiological studies revealing an increased risk of stroke after zoster; the clinical, laboratory, and imaging features of VZV vasculopathy; that VZV vasculopathy is confirmed by the presence of either VZV DNA or anti-VZV IgG antibody in cerebrospinal fluid; special features of VZV vasculopathy in children; vaccination to prevent varicella and immunization to prevent zoster; and the latest evidence linking VZV to GCA. CONCLUSION In children and adults, VZV is a common cause of stroke.
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Affiliation(s)
- Catherine Amlie-Lefond
- Department of Neurology, Seattle Children's Hospital, University of Washington, Seattle, Washington.
| | - Don Gilden
- Departments of Neurology and Immunology and Microbiology, University of Colorado School of Medicine, Aurora, Colorado
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Abstract
Varicella zoster virus (VZV) is a highly neurotropic human herpesvirus. Primary infection usually causes varicella (chicken pox), after which virus becomes latent in ganglionic neurons along the entire neuraxis. VZV reactivation results in zoster (shingles) which is frequently complicated by chronic pain (postherpetic neuralgia). VZV reactivation also causes meningoencephalitis, myelitis, ocular disorders, and vasculopathy, all of which can occur in the absence of rash. This review focuses on the association of VZV and stroke, and on the widening spectrum of disorders produced by VZV vasculopathy in immunocompetent and immunocompromised individuals, including recipients of varicella vaccine. Aside from ischemic stroke, VZV infection of cerebral arteries may lead to development of intracerebral aneurysms, with or without hemorrhage. Moreover, recent clinical-virological case reports and retrospective pathological-virological analyses of temporal arteries positive or negative for giant cell arteritis (GCA) indicate that extracranial VZV vasculopathy triggers the immunopathology of GCA. While many patients with GCA improve after corticosteroid treatment, prolonged corticosteroid use may potentiate VZV infection, leading to fatal vasculopathy in the brain and other organs.
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Affiliation(s)
- Maria A Nagel
- Department of Neurology, University of Colorado School of Medicine, 12700 E. 19th Avenue, Box B182, Aurora, CO, 80045, USA.
| | - Don Gilden
- Department of Neurology, University of Colorado School of Medicine, 12700 E. 19th Avenue, Box B182, Aurora, CO, 80045, USA.
- Department of Immunology & Microbiology, University of Colorado School of Medicine, 12700 E. 19th Avenue, Box B182, Aurora, CO, 80045, USA.
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Yamada N, Sanada Y, Okada N, Wakiya T, Ihara Y, Urahashi T, Mizuta K. Successful rescue of disseminated varicella infection with multiple organ failure in a pediatric living donor liver transplant recipient: a case report and literature review. Virol J 2015; 12:91. [PMID: 26081644 PMCID: PMC4480512 DOI: 10.1186/s12985-015-0311-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 05/15/2015] [Indexed: 12/28/2022] Open
Abstract
A 12-year-old female patient with biliary atresia underwent living donor liver transplantation (LDLT). Twelve months after the LDLT, she developed acute hepatitis (alanine aminotransferase 584 IU/L) and was diagnosed with disseminated varicella-zoster virus (VZV) infection with high level of serum VZV-DNA (1.5 × 105 copies/mL) and generalized vesicular rash. She had received the VZV vaccination when she was 5-years-old and had not been exposed to chicken pox before the LDLT, and her serum was positive for VZV immunoglobulin G at the time of the LDLT. Although she underwent treatment with intravenous acyclovir, intravenous immunoglobulin, and withdrawal of immunosuppressants, her symptoms worsened and were accompanied by disseminated intravascular coagulation, pneumonia, and encephalitis. These complications required treatment in the intensive care unit for 16 days. Five weeks later, her clinical findings improved, although her VZV-DNA levels remained high (8.5 × 103copies/mL). Oral acyclovir was added for 2 weeks, and she was eventually discharged from our hospital on day 86 after admission; she has not experienced a recurrence. In conclusion, although disseminated VZV infection with multiple organ failure after pediatric LDLT is a life-threatening disease, it can be cured via an early diagnosis and intensive treatment.
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Affiliation(s)
- Naoya Yamada
- Department of Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
| | - Yukihiro Sanada
- Department of Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
| | - Noriki Okada
- Department of Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
| | - Taiichi Wakiya
- Department of Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
| | - Yoshiyuki Ihara
- Department of Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
| | - Taizen Urahashi
- Department of Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
| | - Koichi Mizuta
- Department of Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
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Esposito S, Bosis S, Pinzani R, Morlacchi L, Senatore L, Principi N. A case of meningitis due to varicella zoster virus reactivation in an immunocompetent child. Ital J Pediatr 2013; 39:72. [PMID: 24224976 PMCID: PMC3832881 DOI: 10.1186/1824-7288-39-72] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 11/11/2013] [Indexed: 12/30/2022] Open
Abstract
Background The development of neurological complications due to varicella zoster virus (VZV) reactivation is relatively uncommon, particularly in the case of immunocompetent patients. Only a few cases have been described in the literature, most of which involved adult or elderly patients. Clinical presentation Two days after his pediatrician had diagnosed herpes zoster and prescribed oral acyclovir 400 mg three times a day, a 14-year-old boy was admitted to our hospital because of mild fever, severe headache, slowness, drowsiness and vomiting. A cerebrospinal fluid examination was performed and showed an increased protein concentration (95 mg/dL), normal glucose level (48 mg/dL; blood glucose level, 76 mg/dL) and lymphocytic pleocytosis (1,400 lymphocytes/μL), and VZV DNA was detected by means of polymerase chain reaction (1,250 copies/mL). The results of immunological screening for HIV, lymphocyte subpopulation counts, serum immunoglobulin and complement (C3 and C4) levels, vaccine responsiveness and lymphocytes stimulation tests were unremarkable. Acyclovir was administered intravenously at a dose of 10 mg/kg three times a day and continued for 10 days. The therapy was highly effective and the patient’s clinical condition rapidly improved: fever disappeared after two days, and all of the signs and symptoms of neurological involvement after four days. The skin lesions resolved in about one week, and no pain or dysesthesia was ever reported. Given the favourable evolution of the illness, the child was discharged without further therapy after the 10-day treatment. The findings of a magnetic resonance examination immediately after the discontinuation of the antiviral therapy were normal, and a control examination carried out about four weeks later did not find any sign or symptom of disease. Conclusion VZV reactivation can also lead to various neurological complications in immunocompetent children. Prompt therapy with acyclovir and the integrity of the immune system are important in conditioning outcome, but other currently unknown factors probably also play a role.
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Affiliation(s)
- Susanna Esposito
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
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Gershon AA, Gershon MD. Pathogenesis and current approaches to control of varicella-zoster virus infections. Clin Microbiol Rev 2013; 26:728-43. [PMID: 24092852 PMCID: PMC3811230 DOI: 10.1128/cmr.00052-13] [Citation(s) in RCA: 127] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Varicella-zoster virus (VZV) was once thought to be a fairly innocuous pathogen. That view is no longer tenable. The morbidity and mortality due to the primary and secondary diseases that VZV causes, varicella and herpes zoster (HZ), are significant. Fortunately, modern advances, including an available vaccine to prevent varicella, a therapeutic vaccine to diminish the incidence and ameliorate sequelae of HZ, effective antiviral drugs, a better understanding of VZV pathogenesis, and advances in diagnostic virology have made it possible to control VZV in the United States. Occult forms of VZV-induced disease have been recognized, including zoster sine herpete and enteric zoster, which have expanded the field. Future progress should include development of more effective vaccines to prevent HZ and a more complete understanding of the consequences of VZV latency in the enteric nervous system.
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Goldman GS, King PG. Review of the United States universal varicella vaccination program: Herpes zoster incidence rates, cost-effectiveness, and vaccine efficacy based primarily on the Antelope Valley Varicella Active Surveillance Project data. Vaccine 2013; 31:1680-94. [PMID: 22659447 PMCID: PMC3759842 DOI: 10.1016/j.vaccine.2012.05.050] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 05/10/2012] [Accepted: 05/19/2012] [Indexed: 12/31/2022]
Abstract
In a cooperative agreement starting January 1995, prior to the FDA's licensure of the varicella vaccine on March 17, the Centers for Disease Control and Prevention (CDC) funded the Los Angeles Department of Health Services' Antelope Valley Varicella Active Surveillance Project (AV-VASP). Since only varicella case reports were gathered, baseline incidence data for herpes zoster (HZ) or shingles was lacking. Varicella case reports decreased 72%, from 2834 in 1995 to 836 in 2000 at which time approximately 50% of children under 10 years of age had been vaccinated. Starting in 2000, HZ surveillance was added to the project. By 2002, notable increases in HZ incidence rates were reported among both children and adults with a prior history of natural varicella. However, CDC authorities still claimed that no increase in HZ had occurred in any US surveillance site. The basic assumptions inherent to the varicella cost-benefit analysis ignored the significance of exogenous boosting caused by those shedding wild-type VZV. Also ignored was the morbidity associated with even rare serious events following varicella vaccination as well as the morbidity from increasing cases of HZ among adults. Vaccine efficacy declined below 80% in 2001. By 2006, because 20% of vaccinees were experiencing breakthrough varicella and vaccine-induced protection was waning, the CDC recommended a booster dose for children and, in 2007, a shingles vaccination was approved for adults aged 60 years and older. In the prelicensure era, 95% of adults experienced natural chickenpox (usually as children)-these cases were usually benign and resulted in long-term immunity. Varicella vaccination is less effective than the natural immunity that existed in prevaccine communities. Universal varicella vaccination has not proven to be cost-effective as increased HZ morbidity has disproportionately offset cost savings associated with reductions in varicella disease. Universal varicella vaccination has failed to provide long-term protection from VZV disease.
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Affiliation(s)
- G S Goldman
- Independent Computer Scientist, P.O. Box 847, Pearblossom, CA 93553, United States.
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Abstract
Varicella zoster virus (VZV) is a highly successful human pathogen, which is never completely eliminated from the host. VZV causes two clinically distinct diseases, varicella (chickenpox) during primary infection and herpes zoster (shingles) following virus reactivation from latency. Throughout its lifecycle the virus encounters the innate and adaptive immune response, and in order to prevent eradication it has developed many mechanisms to evade and overcome these responses. This review will provide a comprehensive overview of the host immune response to VZV infection, during the multiple stages of the virus lifecycle and at key sites of VZV infection. We will also briefly describe some of the strategies employed by the virus to overcome the host immune response and the ongoing challenges in further elucidating the interplay between VZV and the host immune response in an attempt to lead to better therapies and a ‘second generation’ vaccine for VZV disease.
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Affiliation(s)
- Megan Steain
- Discipline of Infectious Diseases & Immunology, The University of Sydney, NSW, Australia
- Centre for Virus Research, Westmead Millennium Institute, NSW, Australia
| | - Barry Slobedman
- Discipline of Infectious Diseases & Immunology, The University of Sydney, NSW, Australia
- Centre for Virus Research, Westmead Millennium Institute, NSW, Australia
| | - Allison Abendroth
- Discipline of Infectious Diseases & Immunology, The University of Sydney, NSW, Australia
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Differentiated neuroblastoma cells provide a highly efficient model for studies of productive varicella-zoster virus infection of neuronal cells. J Virol 2011; 85:8436-42. [PMID: 21632750 DOI: 10.1128/jvi.00515-11] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Varicella-zoster virus (VZV) is a highly species-specific herpesvirus that targets sensory ganglionic neurons. This species specificity has limited the study of many aspects of VZV pathogenesis, including neuronal infection. We report development of a highly efficient neuroblastoma cell model to study productive VZV infection of neuronal cells. We show that differentiation of SH-SY5Y neuroblastoma cells yields a homogenous population of neuron-like cells that are permissive to the full VZV replicative cycle. These cells supported productive infection by both laboratory and clinical VZV isolates, including the live varicella vaccine. This model may enable rapid identification of genetic determinants facilitating VZV neurotropism.
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