Neurological complications of varicella zoster virus reactivation

Varicella‑zoster virus‑associated meningitis followed peripheral facial palsy: A case report

Although central nervous system infection following varicella zoster virus infection is relatively common, subsequent peripheral nervous system infection is comparatively rare. The present case documents a case of meningitis after varicella-zoster virus (VZV) infection, which was then followed by peripheral facial palsy. Specifically, a 54-year-old female patient was first admitted to Shengli Oilfield Central Hospital (Dongying, China) with headache and fever. Physical examination revealed herpes that formed along the intercostal nerve in the left forebreast, armpit and back. Subsequently, neurological examination found cervical resistance in more than three fingers (neck resistance of less than two transverse fingers is not evidence of meningeal irritation; the neck resistance of this patient was approximately three transverse fingers, so the patient was presumed to be positive for meningeal irritation, highly suggestive of meningitis) and Kernig sign was positive. There were no significant abnormalities according to brain MRI and lumbar puncture pressure was 330 mmH2O. In addition, the leukocyte count was 734x106/l, 50% monocyte count, 50% multinucleated cells, chloride levels of 109.1 mmol/l, protein levels of 235 mg/dl and glucose levels of 4.18 mmol/l in the cerebrospinal fluid. DNA and RNA metagenomic detection of pathogenic microorganisms in the cerebrospinal fluid revealed the presence of VZV. The patient was therefore treated with acyclovir, ceftriaxone, mannitol and methylprednisolone, but then developed right peripheral facial palsy at 10 days after treatment. This complication was not found in the literature, and the occurrence of facial neuritis was unexpected. The active period of VZV virus was 21 days, and the patient had herpes 5 days before admission. The active period of the virus was considered to have subsided and the patient was in the recovery period. Moreover, the results of lumbar puncture showed that the white blood cells, the proportion of neutrophils and the protein in cerebrospinal fluid were all decreasing, which also indicated that the patient had entered the recovery period. The patient was discharged 18 days after admission. In conclusion, observations from the present case suggested that the clinical manifestations of VZV infection can be complex and varied, requiring the clinician to have an accurate understanding of its disease progression and treatment.

Identifying and Evaluating Biological Markers of Postherpetic Neuralgia: A Comprehensive Review

Postherpetic neuralgia (PHN) manifests as persistent chronic pain that emerges after a herpes zoster outbreak and greatly diminishes quality of life. Unfortunately, its treatment efficacy has remained elusive, with many therapeutic efforts yielding less than satisfactory results. The research to discern risk factors predicting the onset, trajectory, and prognosis of PHN has been extensive. However, these risk factors often present as nonspecific and diverse, indicating the need for more reliable, measurable, and objective detection methods. The exploration of potential biological markers, including hematological indices, pathological insights, and supportive tests, is increasing. This review highlights potential biomarkers that are instrumental for the diagnosis, management, and prognosis of PHN while also delving deeper into its genesis. Drawing from prior research, aspects such as immune responsiveness, neuronal injury, genetic makeup, cellular metabolism, and pain signal modulation have emerged as prospective biomarkers. The immune spectrum spans various cell subtypes, with an emphasis on T cells, interferons, interleukins, and other related cytokines. Studies on nerve injury are directed toward pain-related proteins and the density and health of epidermal nerve fibers. On the genetic and metabolic fronts, the focus lies in the detection of predisposition genes, atypical protein manifestations, and energy-processing dynamics, with a keen interest in vitamin metabolism. Tools such as functional magnetic resonance imaging, electromyography, and infrared imaging have come to the forefront in the pain signaling domain. This review compiles the evidence, potential clinical implications, and challenges associated with these promising biomarkers, paving the way for innovative strategies for predicting, diagnosing, and addressing PHN.

Clinical spectrum and possible pathogenesis of progressive outer retinal necrosis

OBJECTIVE

Progressive outer retinal necrosis (PORN) is an alphaherpesvirus-caused panuveitis with devastating consequences for the eye. Our study aims to describe new findings in the clinical spectrum and propose a mechanism for the pathogenesis of PORN.

METHODS

Observational, consecutive case series. Seven eyes from five patients diagnosed with PORN were enrolled. Detailed case histories, ocular examination findings and multimodal images of retina were collected. Optic nerve and brain imaging were obtained by MRI.

RESULTS

All eyes were confirmed human alphaherpesviruses positive in ocular fluid by qPCR. Optic nerve oedema was observed on MRI in all eyes. A relative afferent pupillary defect was recorded in the affected eye for the unilateral cases. Two patients with unilateral involvement had a history of viral encephalitis and focal encephalomalacia found in the temporal lobe on brain MRI. The affected eyes were characterised by sensory retinal necrosis sparing retinal pigment epithelium, starting at the end of the retinal nerve fibre (horizontal raphe or peripheral area of the retina) and progressing rapidly along the nerve fibre. The wall of the retinal artery and vein was destroyed, resulting in blood flow interruption on fluorescein angiography and retinal haemorrhages along the large vessels.

CONCLUSIONS

Combination the neurotropic characteristics of alphaherpesviruses and the signs of PORN, we hypothesised that the reactivated PORN virus originated from the lateral geniculate nucleus, then propagated along the optic nerve and was released at the terminals, causing necrosis of the entire sensory retina rather than just affecting the outer segment.

Rare case of postherpetic abdominal pseudohernia in a patient on peritoneal dialysis

Patients affected by chronic kidney disease, especially those requiring maintenance dialysis therapy, are particularly susceptible to infections, including reactivation of herpes zoster and are also at increased risk of herpes zoster complications. Postherpetic abdominal pseudohernia is a rare sequela of the infection, caused by motor neuropathy with muscle paresis, that manifests as an abdominal protrusion. In patients receiving peritoneal dialysis who may often present slight abdominal distension, the diagnosis of this complication may be challenging. We present a case of this rare neurological complication in a patient on peritoneal dialysis and discuss its etiology and management. To the best of our knowledge, this is the first report of postherpetic abdominal pseudohernia in a patient receiving kidney replacement therapy.

Challenges in Diagnosing Varicella-Zoster Virus Encephalitis in an Immunocompromised Patient

Varicella-zoster virus (VZV) is a virus of the alphaherpesvirus family that is one of the common causes of infectious encephalitis worldwide, especially among those who are immunocompromised. In this case report, we discuss a case of a 55-year-old female with end-stage renal disease presenting with altered mental status and weakness. She was recently diagnosed with herpes zoster on oral acyclovir and multiple scattered dermatomal rashes on presentation. Cerebral spinal fluid analysis showed neutrophilic pleocytosis, high glucose and protein, and anti-VZV Immunoglobulin G (IgG) antibodies. She was started on treatment early with acyclovir and demonstrated good clinical improvement afterward two weeks. This case highlights to importance of performing lumbar puncture and looking for anti-VZV antibodies to rule out encephalitis in patients with altered mental status and starting acyclovir treatment early.

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.

New Insights Into the Therapeutic Management of Varicella Zoster Virus Meningitis: A Series of 123 Polymerase Chain Reaction-Confirmed Cases

Background

Varicella zoster virus (VZV) can reactivate and cause meningitis, but few studies have distinguished it from meningoencephalitis regarding treatment recommendations.The objective of this study was to assess the outcomes of a large series of patients with VZV meningitis according to their therapeutic management.

Methods

We conducted a bicentric retrospective cohort study, in Paris, France, including all adult patients with a cerebrospinal fluid sample positive for VZV by polymerase chain reaction between April 2014 and June 2022. We distinguished meningitis from encephalitis according to the International Encephalitis Consortium criteria. Unfavorable outcome was defined as mortality or functional sequelae defined by a loss of 2 points on the modified Rankin Scale.

Results

We included 123 patients with meningitis. Among them, 14% received no antivirals, while 20% were treated with oral valacyclovir alone, 41% with a short course of intravenous (IV) acyclovir before switch to valacyclovir, and 25% with a long course of IV acyclovir. Outcomes were favorable regardless of antiviral regimen. In multivariate analysis, only age, underlying immunosuppression, and cranial radiculitis appear to be predictive factors for longer IV therapy, based on the Akaike information criterion.

Conclusions

In this study, patients with VZV meningitis had a good outcome, with no evidence of any impact of the treatment strategy. However, further studies are needed to support the possibility of milder treatment in immunocompetent patients, avoiding cost and side effects of IV acyclovir.

Varicella-Zoster Virus-Induced Neurologic Disease After COVID-19 Vaccination: A Multicenter Observational Cohort Study

Background

Early reports described an increased risk of herpes zoster following receipt of mRNA-based COVID-19 vaccines. The objective was to assess whether COVID-19 vaccine is associated with varicella-zoster virus-induced neurologic disease (VZV-ND).

Methods

This multicenter retrospective case-control study with a test-negative design was conducted at 12 hospitals in Israel. We included all patients admitted with VZV-ND between January 2020 and December 2021 and matched controls with a negative polymerase chain reaction result for VZV in cerebrospinal fluid.

Results

We identified 188 patients meeting the case definition of VZV-ND who were admitted during the study period. Cases were matched with 376 controls. There was no significant variation in the incidence of VZV-ND between 1 year preceding and 1 year following the deployment of BNT162b2 in Israel. Analysis of persons who had received at least 1 dose of COVID-19 vaccine (n = 259) showed similar proportions of VZV-ND and non-VZV-ND in 4 intervals (30, 42, 50, 60 days) following the last vaccine dose. The median time from the last vaccine dose to hospitalization with a neurologic syndrome was 53 days (IQR, 25-128) and 82 days (IQR, 36-132) for VZV-ND and non-VZV-ND, respectively, not reaching statistical significance (P = .056). The rate of VZV-ND in vaccinated patients was no different from the rate in the unvaccinated group (30.9% vs 35.4%, P = .2).

Conclusions

We did not find an association between COVID-19 vaccine and VZV-ND. Since COVID-19 vaccine is now recommended yearly, every fall and winter, establishing the safety of the vaccine is of great importance.

Comparing the efficacy and safety of high-voltage and standard-voltage pulsed radiofrequency for the treatment of postherpetic neuralgia: A pooled analysis from randomized controlled trials

Postherpetic neuralgia (PHN) is one of the most common and serious complications of herpes zoster infection. Pulsed radiofrequency (PRF) therapy has emerged to be a neuromodulation technique for the treatment of PHN. Two therapeutic options are available for PRF, including high-voltage and standard-voltage PRF. Some studies suggested that the former one had better clinical efficacy than the latter one. For the first time, this pooled analysis compared the efficacy and safety of these two surgeries for the treatment of PHN. Five commonly used databases were applied to identify the eligible studies. This study was registered on the PROSPERO (ID: CRD42023460236), which provided more relevant information. Finally, four randomized controlled trials (RCTs) with 285 participants were included. The combined odds ratios (OR) showed that high-voltage PRF exhibited a significantly higher treatment efficiency than the standard PRF (OR = 1.4, 95%CI: 1.16 to 1.69, P < 0.001). Additionally, the visual analogue scale (VAS) in the high-voltage PRF group was significantly lower than that of the standard PRF group at one week (SMD = -0.776, 95%CI: -1.408 to -0.145, P = 0.016), one month (SMD = -0.544, 95%CI: -0.907 to -0.180, P = 0.003), and three months (SMD = -1.096, 95%CI: -1.504 to -0.687, P < 0.001) after treatment, particularly at the three months after surgery. However, the VAS was comparable between the two groups (SMD = -0.94, 95%CI: -1.985 to 0.104, P = 0.077). Patients who underwent high-voltage PRF did not have a significantly higher incidence of adverse events than those with standard PRF (OR = 1.56, 95%CI: 0.78 to 3.13, P = 0.208). In summary, the current study revealed that high-voltage PRF is superior to standard-voltage PRF in improving analgesic efficacy in patients with PHN. Additionally, it does not increase the incidence of treatment-related adverse effects. Further studies are still warranted to determine the optimal voltage and duration of PRF treatment for patients with PHN.

Varicella Zoster Virus Vasculopathy: An Under-Recognized Entity

Varicella zoster virus (VZV) vasculopathy is a rare yet potentially severe neurological manifestation resulting from VZV reactivation, primarily affecting immunocompromised individuals. We present a case report of a 61-year-old male with VZV vasculopathy who initially presented with herpes zoster ophthalmicus, subsequently complicated by meningoencephalitis and an acute infarct in the territory of the left middle cerebral artery (MCA). Imaging revealed acute and chronic infarcts in the capsuloganglionic regions, accompanied by thickening and enhancement of the left MCA wall. Treatment involved a 14-day course of intravenous acyclovir, supplemented with oral prednisolone, resulting in modest clinical improvement. VZV vasculopathy represents an infrequently acknowledged neurological syndrome, particularly prevalent among immunocompromised individuals. Early recognition and appropriate intervention offer promise in ameliorating outcomes for affected patients. This case emphasizes the importance of including VZV vasculopathy in the differential diagnosis of neurological deficits, especially within high-risk populations.

Laboratory diagnosis of CNS infections in children due to emerging and re-emerging neurotropic viruses

Recent decades have witnessed the emergence and re-emergence of numerous medically important viruses that cause central nervous system (CNS) infections in children, e.g., Zika, West Nile, and enterovirus/parechovirus. Children with immature immune defenses and blood-brain barrier are more vulnerable to viral CNS infections and meningitis than adults. Viral invasion into the CNS causes meningitis, encephalitis, brain imaging abnormalities, and long-term neurodevelopmental sequelae. Rapid and accurate detection of neurotropic viral infections is essential for diagnosing CNS diseases and setting up an appropriate patient management plan. The addition of new molecular assays and next-generation sequencing has broadened diagnostic capabilities for identifying infectious meningitis/encephalitis. However, the expansion of test menu has led to new challenges in selecting appropriate tests and making accurate interpretation of test results. There are unmet gaps in development of rapid, sensitive and specific molecular assays for a growing list of emerging and re-emerging neurotropic viruses. Herein we will discuss the advances and challenges in the laboratory diagnosis of viral CNS infections in children. This review not only sheds light on selection and interpretation of a suitable diagnostic test for emerging/re-emerging neurotropic viruses, but also calls for more research on development and clinical utility study of novel molecular assays. IMPACT: Children with immature immune defenses and blood-brain barrier, especially neonates and infants, are more vulnerable to viral central nervous system infections and meningitis than adults. The addition of new molecular assays and next-generation sequencing has broadened diagnostic capabilities for identifying infectious meningitis and encephalitis. There are unmet gaps in the development of rapid, sensitive and specific molecular assays for a growing list of emerging and re-emerging neurotropic viruses.

Kaempferol: A Review of Current Evidence of Its Antiviral Potential

Kaempferol and its derivatives are flavonoids found in various plants, and a considerable number of these have been used in various medical applications worldwide. Kaempferol and its compounds have well-known antioxidant, anti-inflammatory and antimicrobial properties among other health benefits. However, the antiviral properties of kaempferol are notable, and there is a significant number of experimental studies on this topic. Kaempferol compounds were effective against DNA viruses such as hepatitis B virus, viruses of the alphaherpesvirinae family, African swine fever virus, and pseudorabies virus; they were also effective against RNA viruses, namely feline SARS coronavirus, dengue fever virus, Japanese encephalitis virus, influenza virus, enterovirus 71, poliovirus, respiratory syncytial virus, human immunodeficiency virus, calicivirus, and chikungunya virus. On the other hand, no effectiveness against murine norovirus and hepatitis A virus could be determined. The antiviral action mechanisms of kaempferol compounds are various, such as the inhibition of viral polymerases and of viral attachment and entry into host cells. Future research should be focused on further elucidating the antiviral properties of kaempferol compounds from different plants and assessing their potential use to complement the action of antiviral drugs.

Serum Inflammatory Cytokine Levels in Herpes Zoster Patients and Their Association with Postherpetic Neuralgia: A Prospective Study

BACKGROUND This study aimed to investigate the serum levels of inflammatory cytokines in patients with herpes zoster (HZ) and to assess their correlation with the development of postherpetic neuralgia (PHN). Understanding this relationship may offer insight into the mechanisms of PHN and provide avenues for targeted treatment. MATERIAL AND METHODS We selected 169 patients diagnosed with HZ and 43 healthy controls (HCs) for the study. Serum levels of inflammatory cytokines were measured in all participants. Pain severity was evaluated using the visual analog scale (VAS). Based on follow-up data, the 169 HZ patients were categorized into 2 groups: those who developed PHN (HZ-PHN) and those who did not (HZ-Con). We then analyzed the differences in cytokine levels and their correlation with PHN development. RESULTS Compared to the HCs group, HZ patients exhibited a significant decrease in TNF-a levels and an increase in IL-10 levels (P<0.05, P<0.01). The VAS score was negatively correlated with TNF-alpha levels and positively correlated with IL-10 levels in HZ patients (r=-0.3081, P<0.01; r=0.5619, P<0.01). Distinctive levels of TNF-alpha, IL-6, IL-8, and IL-10 were observed among different pain groups (P<0.05, P<0.01). The HZ-PHN group showed lower TNF-alpha and higher IL-10 levels compared to the HZ-Con group (P<0.05, P<0.01). IL-10 level was identified as an independent risk factor for PHN, with a sensitivity and specificity of 76.4% and 54.3%, respectively. CONCLUSIONS Abnormal levels of inflammatory cytokines are present in HZ patients, and the IL-10 level may serve as a valuable indicator for predicting the risk of developing PHN.

Cerebrospinal fluid proteomics in meningitis patients with reactivated varicella zoster virus

OBJECTIVE

This study investigated the proteomic characteristics of cerebrospinal fluid (CSF) in patients with varicella zoster virus (VZV) meningitis to understanding the pathogenesis of central nervous system (CNS) infection by reactivated VZV.

METHOD

We used data-independent acquisition model to analyze the CSF proteomic differences of 28 patients with VZV meningitis and 11 herpes zoster (HZ) patients. According to the clinical manifestations at discharge, 28 VZV meningitis patients were divided into favorable outcome group and unfavorable outcome (UO) group and their differences in CSF proteome were also analyzed.

RESULTS

Compared with the HZ group, the proteins (CXCL10, ELANE, IL-1RN, MPO, PRTN3, etc.) related to inflammation and immune cell activation were significantly upregulated in the VZV meningitis group (p < .01). The protein related to the nerve function and energy metabolism (CKMT1B, SLITRK3, Synaptotagmin-3, KIF5B, etc.) were significantly downregulated (p < .05). The levels of a pro-inflammatory factor, IL-18, in CSF were significantly higher in patients in the UO group as compared to patients with favorable prognosis (p < .05).

CONCLUSION

Inflammatory immune response is an important pathophysiological mechanism of CNS infection by VZV, and the CSF IL-18 levels might be a potential prognostic indicator of the outcomes of VZV meningitis.

Therapeutic Strategies for Postherpetic Neuralgia: Mechanisms, Treatments, and Perspectives

PURPOSE OF REVIEW

Postherpetic neuralgia is an annoying pain that mainly affects older people. In order to give patients more options, this review summarizes the pharmacological and interventional treatments for postherpetic neuralgia and updates the research on the efficacy, thereby providing doctors with more treatment options. The adverse effects and effective doses of its various treatments are also presented so that the therapy can be prescribed according to their concrete physical conditions. In a word, this review is dedicated to providing a comprehensive overview of the treatment options for postherpetic neuralgia and offering patients more choices.

RECENT FINDINGS

Combinational therapy is more excellent than monotherapy. The local anesthesia and gabapentin comprised outstanding compatibility. In addition, two therapeutic tools for PHN patients, especially for the intractable ones, electroacupuncture (EA), and osteopathic manipulative treatment (OMT), show their efficacy and become potential options to alleviate pain. In terms of treatment, guidelines recommend patients use tricyclic antidepressants (TCAs), gabapentin, pregabalin, and 5% lidocaine patches as the first-line medications, and gabapentin is investigated most, especially the gabapentin enacarbil (GEn). And drug efficacy can be limited by adverse effects and tolerated doses. Interventional treatments, with their invasiveness and operational difficulty, are usually considered for intractable patients. Combinational therapies may be used when a single therapy cannot achieve the desired effect. Therapies such as OMT and EA have also been proposed to palliate pain in some cases, and future directions of treatment may be investigated in Chinese medicine and acupuncture.

Clinical features of varicella-zoster virus caused neurological diseases detected by metagenomic next-generation sequencing

Clinical presentation of central nervous system (CNS) infections caused by varicella-zoster virus (VZV) is highly sophisticated, making identification challenging. We retrospectively reported 18 cases of VZV neurologic disease confirmed by metagenomic next-generation sequencing (mNGS). The detection rate of mNGS was higher than that of PCR assay (100 vs 66.7%, p < 0.05) and serum IgM antibody (100 vs 68.8%, p < 0.05) measurement. Of the 18 cases, five patients were diagnosed with acute meningitis, three with acute meningitis combined with facial neuritis, three with acute meningitis combined with polycranial neuritis, and the remaining seven with various clinical diagnoses. Typical clinical symptoms included headache (15), fever (9), and rash (11). Cranial or spinal MRI showed abnormalities in 12 patients, and 17 patients had obvious neurological symptoms. The predominant genotype of VZV in this study was genotype J (100%, 10/10). All patients were treated with acyclovir/penciclovir and dexamethasone, 16 recovered and 2 died. Our study highlights the good performance of mNGS in diagnosing CNS infection caused by VZV. It could provide additional diagnostic evidence in patients with diverse clinical spectrum and variable manifestations.

Jugular Foramen Syndrome Caused by Varicella Zoster Virus Infection

Jugular foramen syndrome (JFS) is a lower cranial neuropathy syndrome characterized by dysphonia and dysphagia. The syndrome is caused by dysfunction of the glossopharyngeal, vagus, and spinal accessory nerves at the level of the pars nervosa and pars vascularis within the jugular foramen. There are numerous etiologies for JFS, including malignancy, trauma, vascular, and infection. Here, we present the case of a healthy adult man who developed JFS secondary to an atypical presentation of Varicella Zoster meningitis, and was promptly diagnosed and treated with rapid symptom resolution. We diagnosed the patient using specialized skull-based imaging which detailed the jugular foramen, as well as CSF analysis. This case highlights the clinical value of detailed structural evaluation, consideration for infection in the absence of systemic symptoms, and favorable outcomes following early identification and treatment.

Top 100 Most-Cited Papers in Herpes Zoster from 2000 to 2022: A Bibliometric Study

Background

In recent years, the incidence of herpes zoster has risen steeply, the exact pathogenesis of the acute pain and the transformation into postherpetic neuralgia are still obscure, and the absence of effective management remains a major therapeutic challenge. The purpose of this study was to perform a qualitative and quantitative bibliometric analysis of the 100 most cited papers on herpes zoster.

Materials and methods

Related literature were retrieved from the Web of Science Core Collection. Excel and VOSviewer software were applied to quantitatively analyze, and construct the bibliometric network charts.

Results

The Top 100 most-cited papers published between 2000 and 2018 showed a fluctuating downward trend. The most studies were published in the year of 2000 (n = 12). The article entitled "A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults" from Oxman MN, was the most-cited publication. The United States was the most contributing country, followed by the United Kingdom, and Italy. Finland occupied the highest citations per publication (CPP). The University of Colorado topped the list of institutions with the most publications with 18 articles and also had the most citations (average citations: 281.78 per article). Myron J Levin from the University of Colorado School of Medicine is the most published and most cited researcher overall, whereas Duke University's John W Gnann tops the list in terms of average CPP.

Conclusion

In terms of the quantity of T100 articles, researchers, and organizations, the US is the predominant country. The most T100 papers were published in the special journal Clinical Infectious Diseases. The most academic focus remain the remedies for postherpetic neuralgia and vaccine development for individualized groups.

How viral infections cause neuronal dysfunction: a focus on the role of microglia and astrocytes

In recent decades, a number of infectious viruses have emerged from wildlife or reemerged that pose a serious threat to global health and economies worldwide. Although many of these viruses have a specific target tissue, neurotropic viruses have evolved mechanisms to exploit weaknesses in immune defenses that eventually allow them to reach and infect cells of the central nervous system (CNS). Once in the CNS, these viruses can cause severe neuronal damage, sometimes with long-lasting, life-threatening consequences. Remarkably, the ability to enter the CNS and cause neuronal infection does not appear to determine whether a viral strain causes neurological complications. The cellular mechanisms underlying the neurological consequences of viral infection are not fully understood, but they involve neuroimmune interactions that have so far focused mainly on microglia. As the major immune cells in the brain, reactive microglia play a central role in neuroinflammation by responding directly or indirectly to viruses. Chronic reactivity of microglia leads to functions that are distinct from their beneficial roles under physiological conditions and may result in neuronal damage that contributes to the pathogenesis of various neurological diseases. However, there is increasing evidence that reactive astrocytes also play an important role in the response to viruses. In this review article, we summarize the recent contributions of microglia and astrocytes to the neurological impairments caused by viral infections. By expanding knowledge in this area, therapeutic approaches targeting immunological pathways may reduce the incidence of neurological and neurodegenerative disorders and increase the therapeutic window for neural protection.

Case report: Varicella associated neuropsychiatric syndrome (VANS) in two pediatric cases

Background

Viral or bacterial infections can trigger auto-immune inflammatory reactions and conditions in children. Self-reactivity arises due to similarities in molecular structures between pathogenic microorganisms and regular body structures with consequent immune-cross reactions. Reactivation of latent Varicella Zoster Virus (VZV) infections can cause neurological sequalae, including cerebellitis, post-herpetic neuralgias, meningo/encephalitis, vasculopathy and myelopathy. We propose a syndrome caused by auto-immune reactivity triggered by molecular mimicry between VZV and the brain, culminating in a post-infectious psychiatric syndrome with childhood VZV infections.

Case presentation

Two individuals, a 6-year-old male and 10-year-old female developed a neuro-psychiatric syndrome 3-6 weeks following a confirmed VZV infection with intrathecal oligoclonal bands. The 6-year-old male presented with a myasthenic syndrome, behavior deterioration and regression in school, he was poorly responsive to IVIG and risperidone, however had a pronounced response to steroid treatment. The 10-year-old female presented with marked insomnia, agitation, and behavioral regression as well as mild bradykinesia. A trial of neuroleptics and sedatives resulted in a mild unsustained reduction in psychomotor agitation and IVIG was also unsuccessful, however the patient was very responsive to steroid therapy.

Conclusion

Psychiatric syndromes with evidence of intrathecal inflammation temporally related to VZV infections that are responsive to immune modulation have not been described before. Here we report two cases demonstrating neuro-psychiatric symptoms following VZV infection, with evidence of persistent CNS inflammation following the resolution of infection, and response to immune modulation.

Mechanisms, Effects, and Management of Neurological Complications of Post-Acute Sequelae of COVID-19 (NC-PASC)

With a growing number of patients entering the recovery phase following infection with SARS-CoV-2, understanding the long-term neurological consequences of the disease is important to their care. The neurological complications of post-acute sequelae of SARS-CoV-2 infection (NC-PASC) represent a myriad of symptoms including headaches, brain fog, numbness/tingling, and other neurological symptoms that many people report long after their acute infection has resolved. Emerging reports are being published concerning COVID-19 and its chronic effects, yet limited knowledge of disease mechanisms has challenged therapeutic efforts. To address these issues, we review broadly the literature spanning 2020-2022 concerning the proposed mechanisms underlying NC-PASC, outline the long-term neurological sequelae associated with COVID-19, and discuss potential clinical interventions.

Epidemiology of Herpes Zoster in Adults in Mexico: A Retrospective Database Analysis

INTRODUCTION

The risk of herpes zoster (HZ) increases with age. In countries with an ageing population such as Mexico, a rise in the risk of HZ and complications is expected. The goal of this study was to provide an updated estimate of the potential burden of HZ and associated complications in Mexico.

METHODS

A retrospective database study was performed using data from the national surveillance database of the Ministry of Health (Secretaría de Salubridad y Asistencia/Dirección General de Información en Salud). HZ cases and associated complications were identified via the International Classification of Diseases 10th Revision codes. Emergency room (ER) visits, hospitalizations, and deaths were extracted and analyzed by age group and year. The observation period was between 2011 and 2020 for ER visits and hospitalizations and between 2011 and 2019 for deaths. Cumulative incidence per 1000 people and case fatality rate were estimated.

RESULTS

During the observation period, 53,030 ER visits, 4172 hospitalizations, and 263 deaths due to HZ were reported nationwide. The cumulative incidence of HZ based on ER visits was 1.04 per 1000 people aged ≥ 50 years but increased in older age groups (1.47 per 1000 people aged ≥ 65 years). The most common complications were neuralgia (10.9%), ocular disease (7.0%), meningoencephalitis (2.9%), and disseminated disease (3.1%). Patients ≥ 65 years accounted for 37% of hospitalizations and 81% of deaths.

CONCLUSION

In Mexico, HZ and its complications impose a considerable burden on the population and the healthcare system. Prospective surveillance studies are required to obtain an accurate picture of the current epidemiology of HZ in Mexico and to estimate the benefits of future vaccination strategies against HZ.

Dysphagia with Unilateral Vocal Cord Paralysis in Herpes Zoster: A Case Report

Herpes zoster is caused by the varicella-zoster virus, which becomes latent in ganglia after primary infection. When the varicella-zoster virus reactivates on the cranial nerve, the patient can suffer from cranial nerve palsy, pain, and skin lesions on the head and neck area. A 57-year-old immunocompetent male presented with dysphagia lasting 10 days. Computed tomography and other neurological findings were normal. However, laryngoscopy showed right vocal cord paralysis, which might be the reason for dysphagia in this patient. There was a grouped crusted lesion on the right posterior auricular area that appeared 5 days after the dysphagia. After famciclovir and prednisolone combination therapy, the patient was cured with no sequelae. This is a rare case of herpes zoster in an immunocompetent patient who presented with dysphagia. In addition, it was difficult to make an accurate diagnosis because his skin lesion appeared several days after dysphagia.

A Case of Varicella-Zoster Virus Meningomyelitis in an HIV-1-Infected Patient: Facing the Challenges Related to Its Management and Prognosis

Varicella-zoster virus (VZV) myelitis is a rare complication of herpes zoster. Diagnosing and treating this entity may be challenging. Clinical outcomes vary and neurological sequelae may be seen despite treatment. We report a case of a 43-year-old woman with human immunodeficiency virus type 1 (HIV-1) infection (CD4 cell count 191 cells/µL - 14%; undetectable viral load) who was started on antiretroviral treatment eight months before. She presented with VZV meningitis and transverse myelitis and concomitant thoracic vesicular rash at the dermatomal level T6. Neurological examination revealed neck stiffness, paraplegia, sensory level below T4, and autonomic dysfunction. Magnetic resonance imaging (MRI) revealed signs of myelitis from C4 to T10 and VZV DNA by polymerase chain reaction (PCR) was positive (20,00,000 cp/mL) in the cerebrospinal fluid (CSF). The patient completed four weeks of intravenous acyclovir and systemic corticosteroids. Repeat lumbar puncture returned negative for VZV PCR and MRI showed spinal cord improvement. However, only partial neurological improvement was observed after six months. Some features of the present case may be associated with an unfavorable outcome, including high VZV viral load in the CSF and rapid progression of neurological deficits to paraplegia and sphincter dysfunction. Moreover, the recovery of CD4+ cells from 4% to 14% after starting antiretroviral treatment might also have contributed to the extension of myelopathy. Further studies are needed to improve the understanding of VZV myelitis course and optimize its treatment.

Varicella-Zoster virus ORF9 is an antagonist of the DNA sensor cGAS

Varicella-Zoster virus (VZV) causes chickenpox and shingles. Although the infection is associated with severe morbidity in some individuals, molecular mechanisms that determine innate immune responses remain poorly defined. We found that the cGAS/STING DNA sensing pathway was required for type I interferon (IFN) induction during VZV infection and that recognition of VZV by cGAS restricted its replication. Screening of a VZV ORF expression library identified the essential VZV tegument protein ORF9 as a cGAS antagonist. Ectopically or virally expressed ORF9 bound to endogenous cGAS leading to reduced type I IFN responses to transfected DNA. Confocal microscopy revealed co-localisation of cGAS and ORF9. ORF9 and cGAS also interacted directly in a cell-free system and phase-separated together with DNA. Furthermore, ORF9 inhibited cGAMP production by cGAS. Taken together, these results reveal the importance of the cGAS/STING DNA sensing pathway for VZV recognition and identify a VZV immune antagonist that partially but directly interferes with DNA sensing via cGAS.

Efficacy and Safety of Electroacupuncture for Pain Control in Herpes Zoster: A Systematic Review and Meta-Analysis

Introduction

Herpes zoster is caused by the reactivation of the latent varicella-zoster virus, which leads to acute pain that may disturb routine activities and affect patients' quality of life. Electroacupuncture (EA) has been commonly used for treating herpetic pain in clinical treatment. However, no relevant studies have been performed to evaluate the efficacy and safety of EA for acute control in herpetic neuralgia patients. The purpose of the current study was to conduct a systematic review and meta-analysis to address the deficiencies of the current research.

Methods

Three English (PubMed, Cochrane Library, and Web of Science) and four Chinese (China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature database (CBM), Wan-fang database, and the Chinese Scientific Journals Full-text Database (VIP)) were comprehensively searched from inception to 31 December 2021. Two independent reviewers evaluated the retrieved data based on the eligibility criteria in advance. In addition, the Cochrane Risk of Bias Tool was used to assess the methodological quality of the included studies. Outcome indexes in this study included the visual analog scale, the time to cessation of pustules, the time to scabs, the time to rash healing, adverse reactions, and the incidence of postherpetic neuralgia. Sensitivity and subgroup analyses were also performed to evaluate the intervention effect specifically. In addition, publication bias was analyzed.

Results

Six randomized controlled trials (167 participants in the experimental groups and 174 participants in the control groups) were identified as reporting the application of EA for acute herpes zoster pain and were included in this study. The results from our meta-analysis revealed that EA was superior to control treatment according to visual analog scale, the time of rash healing, and the incidence of postherpetic neuralgia. However, in terms of the time to cessation of pustules, scabs, and adverse reactions, the results showed that EA compared with the control group showed no significant difference. In addition, subgroup analyses indicated that 2/100 Hz-EA has more significant effects on herpetic pain. Sensitivity analyses revealed that the results of EA for acute pain control and the rash healing time in herpetic neuralgia patients were stable. However, a publication bias was observed.

Conclusion

Our meta-analysis results showed that EA could offer certain advantages in treating acute pain in herpetic neuralgia patients. However, small sample sizes, heterogeneity in study design, and variable methodological quality weaken these inferences. In addition, weak evidence was found for the safety of EA.

Cross-Sectional Retrospective Study to Identify Clinical and Radiographic Features Associated With VZV Reactivation in Cryptogenic Stroke Patients With CSF Testing

BACKGROUND AND PURPOSE

A large proportion of ischemic stroke patients lack a definitive stroke etiology despite extensive diagnostic testing. Varicella-Zoster Virus (VZV) can directly invade blood vessels causing vasculitis and may be associated with cryptogenic stroke (CS).

METHODS

We conducted a retrospective cross-sectional study of CS patients tested for VZV. The following were considered evidence of VZV reactivation (VZV+): positive CSF VZV PCR, anti-VZV IgM in CSF, or anti-VZV IgG CSF/serum ratio of 1:10 or higher. We describe the cohort, report VZV+ proportion with 95% confidence intervals (CI) determined with the Wald method, and compare patient groups using standard statistical tests.

RESULTS

A total of 72 CS patients met full study inclusion criteria. Most of the patients were <65 years old, had few traditional vascular risk factors, and had multifocal infarcts. Mean age was 49 years (SD ±13) and 47% were women. A total of 14 patients (19.4%; CI: 11.4-30.8%) had evidence of CNS VZV reactivation. There was no difference in evaluated demographic or radiographic features between those with versus without evidence of VZV reactivation. History of ischemic stroke in the past year (11/14 vs 25/43, P<.05) and hypertension (13/14 vs 35/58 and P<.05) were associated with VZV+.

CONCLUSION

We found a high proportion of CNS VZV reactivation in a cross-sectional cohort of CS patients selected for CSF testing. Testing for VZV might be reasonable in CS patients who are young, have multifocal infarcts, or had an ischemic stroke within the past year, but additional research is needed.

Cellular metabolism changes in bilateral hippocampi in patients with herpes zoster

OBJECTIVES

Herpes zoster (HZ) has been found to be associated with arisk of developing dementia. However, changes of cellular metabolism in the hippocampus in HZ have received little attention. This study aimed to investigate the cellular metabolism changes in bilateral hippocampi in acute HZ.

METHODS

¹H-MRS (magnetic resonance spectroscopy) was used to detect the cellular metabolism of bilateral hippocampi in 62 patients with acute HZ and 12 volunteers (control group) from July 2020 to December 2021. Mini-Mental State Examination (MMSE), Hamilton Depression Scale (HAMD), Hamilton Anxiety Scale (HAMA) and Numerical Rating Scale (NRS) were used to evaluate their cognitive function, depression, anxiety and pain intensity, as well as a the correlation between them.

RESULTS

The MMSE score in patients with HZ was not significantly different from that of controls (P>0.05), while the scores of HAMD and HAMA were significantly higher (P<0.05) than those of controls. Also 12.9% and 21.0% of the patients with acute HZ had depression and anxiety disorders, respectively. The level of Cho/Cr in the left/right hippocampi of HZ patients was significantly lower than that of the control group (P<0.05). The level of Cho/Cr in the right hippocampus, duration of disease and NRS score in HZ patients with anxiety/depression were significantly higher than those without anxiety/depression, but the level of NAA/Cr in the right hippocampus was lower (P<0.05). The NRS score and duration of disease in HZ patients were positively correlated with the scores of HAMD and HAMA.

CONCLUSION

The cellular metabolism of bilateral hippocampi in patients with acute HZ is altered. Those with longer duration of disease and severe pain are more likely to have depression and anxiety disorder, and the changes in cellular metabolism of hippocampi in those with depression and anxiety were more prominent.

Varicella Zoster meningitis as a mimicker of pseudotumor cerebri in an immunocompetent patient: A case report and literature review

Varicella-zoster (VZ) meningitis is uncommon in patients with immunocompetence and usually presents with typical rash and fever. However, VZ meningitis can rarely present with symptoms of intracranial hypertension without the classic manifestations. Herein, we describe a 17-year-old female teen who presented with intractable headache and vomiting and diagnosed with VZ meningitis. Her symptoms remarkably improved after a lumbar puncture and acyclovir therapy.

Anti-varicella zoster virus and related anti-inflammation effects of ethanolic extract of Elaeocarpus sylvestris

ETHNOPHARMACOLOGICAL RELEVANCE

Elaeocarpus sylvestris var. ellipticus (ES), a plant that grows in Taiwan, Japan, and Jeju Island in Korea. ES root bark, known as "sanduyoung," has long been used in traditional oriental medicine. ES is also traditionally used to treat anxiety, asthma, arthritis, stress, depression, palpitation, nerve pain, epilepsy, migraine, hypertension, liver diseases, diabetes, and malaria. However, lack of efficacy and mechanism studies on ES.

AIM OF THE STUDY

In the present study, we aim to investigate the VZV-antiviral efficacy, pain suppression, and the anti-inflammatory and antipyretic effects of ES.

METHODS

and methods: Inhibition of VZV was evaluated by hollow fiber assays. Analgesic and antipyretic experiments were conducted using ICR mice and SD Rats, and anti-inflammatory experiments were conducted using Raw264.7 cells.

RESULTS

To evaluate the efficacy of ESE against VZV, we conducted antiviral tests. ESE inhibited cell death by disrupting virus and gene expression related to invasion and replication. In addition, ESE suppressed the pain response as measured by writhing and formalin tests and suppressed LPS-induced inflammatory fever. Further, ESE inhibited the phosphorylation of IκB and NF-κB in LPS-induced Raw264.7 cells and expression of COX-2, iNOS, IL-1β, IL-6, and TNF-α.

CONCLUSION

E. sylvestris shows potential as a source of medicine. ESE had a direct effect on VZV and an inhibitory effect on the pain and inflammation caused by VZV infection.

A case of ischemic stroke secondary to varicella-zoster virus meningoencephalitis

Varicella-zoster virus (VZV) lurks in cranial nerves and other brain ganglias after infection. Because middle cerebral artery (MCA) receives the ipsilateral trigeminal ganglia afferent innervations, the reactivated VZV infects the adventitia and intima of cerebral artery wall probably through this way and causes vascular inflammation, finally resulting in artery remodeling, vessel occlusion, and ischemia. In fact, there is a growing clinical recognition that there is an association between VZV reactivation and subsequent stroke. Here, we showed a case of ischemic stroke secondary to varicella-zoster virus meningoencephalitis and reviewed the literature to emphasize the importance of VZV-associated vasculopathy.

Post-Varicella Neurological Complications: A Preliminary Observation from a Tertiary Care Centre of Eastern India

Objectives:

The objective of this study is to analyse detailed clinical presentations, imaging findings, and outcome in a series of 17 cases (n = 17) with neurological complications following acute varicella infection.

Methods:

It is an observational study on the patients who presented to the neurology outpatient department of our institute with neurological abnormalities following acute varicella infection within the last 3 months.

Results:

Neuroimaging, either computed tomography or magnetic resonance imaging, cerebrospinal fluid analysis, electroencephalography and nerve conduction studies were performed in all the patients along with other specialized investigations as per clinical context. The age of presentation varied from childhood to middle age (median age was 23 years) and range of clinical spectrum was also wide. Peripheral nervous system involvement was more common in the form of Guillain–Barré syndrome (29.4%) and isolated lower motor neuron facial nerve palsy (23.5%) compared to central nervous system (CNS) involvement. CNS involvement was documented in the form of ataxia (11.76%), myelopathy (17.6%), stroke (5.88%) and encephalitis (5.88%).

Conclusion:

Chickenpox is a common viral disease and most patients recover without any complication. Although rare, neurological complications following acute varicella infection may have myriad presentations ranging from lower motor neuron facial palsy to life-threatening encephalitis. Compared to other studies, varicella encephalitis and ataxia were not so common in our study group. Response to therapy was uniformly good except in the patients presenting with ataxia. Response was particularly good to central and peripheral demyelinating disorders.

A Case Report of Varicella Zoster Meningitis as Co-Infection With Breakthrough COVID-19 in an Immunocompetent Patient

There are several previous reports that infection or reactivation of varicella zoster virus (VZV) can occur after coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Herein, we report a rare case of VZV meningitis in breakthrough COVID-19. An 18-years-old male visited the emergency room, presenting with a headache and fever of up to 38.4°C for 5 days. He received the second dose of BNT162b2 mRNA SARS-CoV-2 vaccine 7 weeks prior to symptom onset. The symptoms persisted with headache, fever, and nausea. His cerebrospinal fluid (CSF) showed an elevated opening pressure of 27 cm H₂O, 6/µL red blood cells, 234/µL white blood cells (polymorphonuclear leukocytes 3%, lymphocytes 83%, and other 14%), 43.9 mg/dL protein, and 59 mg/dL glucose, and CSF polymerase chain reaction (PCR) test was positive for VZV. Also, he was diagnosed with COVID-19 by reverse transcriptase-PCR examining upper and lower respiratory tract. We administered intravenous acyclovir for 12 days, and he was discharged without any neurologic complication.

Acute myelitis with multicranial neuritis caused by Varicella zoster virus: a case report

Background

Varicella zoster virus (VZV) can remain lifelong in the latent state in ganglionic neurons and adrenal glands after the initial infection. However, it can be reactivated anytime and can trigger several severe neurological manifestations such as encephalitis, meningitis, Ramsay-Hunt syndrome, cerebellitis, myelitis, and stroke. In addition, due to the diversity of clinical manifestations, clinical diagnosis of VZV can be difficult, especially in the absence of varicella. Here, we describe the case of a 52-year-old male who presented with symptoms of acute myelitis as well as polycranial neuritis, and was finally diagnosed with VZV infection through metagenomic next-generation sequencing (mNGS).

Case presentation

A 52-year-old male came to our hospital with complaint of headache, fever, weakness of right lower limb, abdominal distension, and hearing loss. T2-weighted MRI revealed a hyperintense lesion in the spinal cord extending from T8 to T11. In addition, enhanced MRI showed small patches and strips hyperintensities in both the spinal cord and meninges. Plain abdominal radiographs and abdominal computed tomography (CT) scan displayed air-fluid levels and incomplete bowel obstruction. Moreover, electrophysiological evaluation of the peripheral neuropathy in the extremities was found to be normal. Finally, by using metagenomic next-generation sequencing (mNGS) we found that the copy number of VZV DNA in cerebrospinal fluid (CSF) was significantly increased and IgG antibody against VZV in CSF was also noted to be positive. Hence, VZV infection was identified in patient’s central neuron system. Finally, after a few days of low dose steroid treatment, the patient's symptoms were found to be significantly improved.

Conclusions

The findings indicate that we should pay proper attention to the various symptoms caused by VZV infection due to the clinical heterogeneity, especially in the absence of cutaneous lesions.

Neurological complications of varicella zoster virus reactivation: Prognosis, diagnosis, and treatment of 72 patients with positive PCR in the cerebrospinal fluid

BACKGROUND

VZV infection can involve every level of the neurologic system: from the central nervous system (CNS) to the peripheral nervous system (PNS), including aseptic meningitis. Prognosis seems to differ between these neurological involvements. Prognostic factors remain unknown.

METHODS

This is a retrospective multicenter study including all patients with a positive VZV polymerase chain reaction (PCR) in the cerebrospinal fluid (CSF) from eight centers in Paris (France) between 2011 and 2018. Unfavorable outcome was defined as mortality linked to VZV or incomplete recovery. Modified Rankin Scale (mRS) evaluated disability before and after the infection, with the difference designated as Rankin Delta.

RESULTS

Seventy-two patients were included (53% male, median age 51 years, median mRS 0). Immunosuppression was reported in 42%. The clinical spectrum included 26 cases of meningitis, 27 instances of CNS involvement, 16 of PNS involvement, and 3 isolated replications (positive PCR but no criteria for neurological complications from VZV). Antiviral treatment was administered to 69 patients (96%). Sixty-two patients completed follow-up. Death linked to VZV occurred in eight cases. Unfavorable outcome (UO) occurred in 60% and was significantly associated with a higher prior mRS (Odd-ratio (OR) 3.1 [1.4-8.8] p = .012) and the presence of PNS or CNS manifestations (OR 22 [4-181] p = .001, OR 6.2 [1.3-33] p = .03, respectively, compared to meningitis). In the CSF, higher protein level (p < .0001) was also significantly associated with a higher Rankin Delta.

CONCLUSIONS

Neurological complications of VZV with evidence of CSF viral replication are heterogeneous: aseptic meningitis has a good prognosis, whereas presence of CNS and PNS involvement is associated with a higher risk of mortality and of sequelae, respectively.

Clinical Management of Herpes Zoster in Patients With Rheumatoid Arthritis or Psoriatic Arthritis Receiving Tofacitinib Treatment

INTRODUCTION

Risk of herpes zoster (HZ) is increased with Janus kinase inhibitor use. We evaluated clinical study data relating to HZ management in patients with rheumatoid arthritis (RA) or psoriatic arthritis (PsA) receiving tofacitinib.

METHODS

This post hoc analysis included data from 21 RA and 3 PsA clinical studies; data were pooled for tofacitinib doses. Outcomes of HZ events (serious and non-serious) and tofacitinib treatment changes were evaluated in response to first and second HZ events. Median time to resolution was stratified by dermatomal involvement, history of HZ prior to tofacitinib, changes to tofacitinib treatment, anti-viral and corticosteroid use, and tofacitinib dose.

RESULTS

Seven hundred eighty-three (11.1%, N = 7061) patients with RA experienced ≥ 1 HZ event, 63 (8.0%) of whom had ≥ 2 HZ events. In patients with PsA, 36 (4.6%, N = 783) experienced ≥ 1 HZ event, 1 (2.8%) of whom had ≥ 2 HZ events. For most HZ events, tofacitinib treatment was unchanged or temporarily discontinued. The majority of patients received anti-viral treatment, most within 3 days of onset. Post-herpetic neuralgia developed in 6.9% and 3.2% of patients with RA with first and second events, respectively, and in 2.8% of patients with PsA with a first event. Most first and second events resolved (RA: 97.6% and 96.8%, respectively; PsA: 94.4% and 100%, respectively). Median time to resolution was 22.0 days for first and 15.0 days for second events for RA and 20.5 days for first and 11.0 days for second events (n = 1) for PsA. Time to resolution of first events for RA and PsA was generally numerically shorter for patients with single dermatomal HZ, history of HZ, or anti-viral use versus those without.

CONCLUSION

Among patients receiving tofacitinib, recurrent events were more common in patients with RA versus PsA; HZ duration was shorter for repeat events.

TRIAL REGISTRATION

NCT01262118, NCT01484561, NCT00147498, NCT00413660, NCT00550446, NCT00603512, NCT00687193, NCT01164579, NCT00976599, NCT01059864, NCT01359150, NCT02147587, NCT00960440, NCT00847613, NCT00814307, NCT00856544, NCT00853385, NCT01039688, NCT02187055, NCT00413699, NCT00661661, NCT01877668, NCT01882439, NCT01976364.

Meningitis/meningoencephalitis caused by varicella zoster virus reactivation: a retrospective single-center case series study

Recent clinical studies showed that central nervous system (CNS) infection caused by varicella zoster virus (VZV) reactivation was more than previously reported. The clinical manifestations were often diverse and complex, and the outcome often varied among different patients. A systematic study is needed to provide clinical characteristics of the CNS VZV infection to help clinicians with clinical diagnosis and management. Toward that end, we retrospectively analyzed the clinical presentations, laboratory results, imaging findings, treatment and outcomes in74 patients with meningitis or meningoencephalitis caused by VZV reactivation in our center from August 2018 to December 2020. Fever, headache, cranial nerve involvement, cognitive changes, meningeal irritation, nausea, vomiting, and Ramsay-Hunt syndrome (RHS) were the most common clinical manifestations of VZV meningitis or meningoencephalitis. Brain MRI analysis showed no obvious abnormal manifestation. Compared to VZV meningoencephalitis, patients with VZV meningitis were younger (56.9±13.8 vs 66.1±8.5 years; P=0.01), and more likely to develope in winter (P=0.04), had lower cerebrospinal fluid (CSF) glucose content (3.68±0.79 vs 4.21±0.94 mmol/L, P=0.02), and a better outcome at discharge (P=0.00). The outcome at discharge was worse in male patients and when longer than 1.5 days passed between onset of the neurological symptoms to initiation of the antiviral treatment.Early intravenous antiviral treatment for VZV meningitis and meningoencephalitis is important and is expected for a good outcome.

Varicella-zoster virus-associated meningitis, encephalitis, and myelitis with sporadic skin blisters: A case report

BACKGROUND

Varicella-zoster virus (VZV) generally causes chickenpox at first infection in childhood and then establishes latent infection in the dorsal root ganglia of the spinal cord or other nerves. Virus reactivation owing to an impaired immune system causes inflammation along spinal nerves from the affected spinal segment, leading to skin manifestations (herpes zoster). Viremia and subsequent hematogenous transmission and nerve axonal transport of the virus may lead to meningitis, encephalitis, and myelitis. One such case is described in this study.

CASE SUMMARY

A 64-year-old man presented with dysuria, pyrexia, and progressive disturbance in consciousness. He had signs of meningeal irritation, and cerebrospinal fluid (CSF) analysis revealed marked pleocytosis with mononuclear predominance and a CSF/serum glucose ratio of 0.64. Head magnetic resonance imaging revealed hyperintense areas in the frontal lobes. He had four isolated blisters with papules and halos on his right chest, right lumbar region, and left scapular region. Infected giant cells were detected using the Tzanck test. Degenerated epidermal cells with intranuclear inclusion bodies and ballooning degeneration were present on skin biopsy. Serum VZV antibody titers suggested previous infection, and the CSF tested positive for VZV-DNA. He developed paraplegia, decreased temperature perception in the legs, urinary retention, and fecal incontinence. The patient was diagnosed with meningitis, encephalitis, and myelitis and was treated with acyclovir for 23 days and prednisolone for 14 days. Despite gradual improvement, the urinary retention and gait disturbances persisted as sequelae.

CONCLUSION

VZV reactivation should be considered in differential diagnoses of patients with sporadic blisters and unexplained central nervous system symptoms.

Detection of Circulating VZV-Glycoprotein E-Specific Antibodies by Chemiluminescent Immunoassay (CLIA) for Varicella-Zoster Diagnosis

Varicella and herpes zoster are mild symptoms-associated diseases caused by varicella–zoster virus (VZV). They often cause severe complications (disseminated zoster), leading to death when diagnoses and treatment are delayed. However, most commercial VZV diagnostic tests have low sensitivity, and the most sensitive tests are unevenly available worldwide. Here, we developed and validated a highly sensitive VZV diagnostic kit based on the chemiluminescent immunoassay (CLIA) approach. VZV-glycoprotein E (gE) was used to develop a CLIA diagnostic approach for detecting VZV-specific IgA, IgG, and IgM. The kit was tested with 62 blood samples from 29 VZV-patients classified by standard ELISA into true-positive and equivocal groups and 453 blood samples from VZV-negative individuals. The diagnostic accuracy of the CLIA kit was evaluated by receiver-operating characteristic (ROC) analysis. The relationships of immunoglobulin-isotype levels between the two groups and with patient age ranges were analyzed. Overall, the developed CLIA-based diagnostic kit demonstrated the detection of VZV-specific immunoglobulin titers depending on sample dilution. From the ELISA-based true-positive patient samples, the diagnostic approach showed sensitivities of 95.2%, 95.2%, and 97.6% and specificities of 98.0%, 100%, and 98.9% for the detection of VZV-gE-specific IgA, IgG, and IgM, respectively. Combining IgM to IgG and IgA detection improved diagnostic accuracy. Comparative analyses on diagnosing patients with equivocal results displaying very low immunoglobulin titers revealed that the CLIA-based diagnostic approach is overall more sensitive than ELISA. In the presence of typical VZV symptoms, CLIA-based detection of high titer of IgM and low titer of IgA/IgG suggested the equivocal patients experienced primary VZV infection. Furthermore, while no difference in IgA/IgG level was found regarding patient age, IgM level was significantly higher in young adults. The CLIA approach-based detection kit for diagnosing VZV-gE-specific IgA, IgG, and IgM is simple, suitable for high-throughput routine analysis situations, and provides enhanced specificity compared to ELISA.

Transverse myelitis after infection with varicella zoster virus in patient with normal immunity: A case report

BACKGROUND

Varicella zoster virus (VZV) is a human neurotropic and double-stranded DNA alpha-herpes virus. Primary infection with VZV usually occurs during childhood, manifesting as chickenpox. Reactivation of latent VZV can lead to various neurological complications, including transverse myelitis (TM); although cases of the latter are very rare, particularly in newly active VZV infection.

CASE SUMMARY

We report here an unusual case of TM in a middle-aged adult immunocompetent patient that developed concomitant to an active VZV infection. The 46-year-old male presented with painful vesicular eruption on his left chest that had steadily progressed to involvement of his back over a 3-d period. Cerebrospinal fluid testing was denied, but findings from magnetic resonance imaging and collective symptomology indicated TM. He was administered antiviral drugs and corticosteroids immediately but his symptom improvement waxed and waned, necessitating multiple hospital admissions. After about a month of repeated treatments, he was deemed sufficiently improved for hospital discharge to home.

CONCLUSION

VZV myelitis should be suspected when a patient visits the outpatient pain clinic with herpes zoster showing neurological symptoms.

Treatment of Elsberg Syndrome Causes Fever of Unknown Origin Attributable to Drug Reaction

A 56-year-old male with a history of non-adherence to HIV anti-retroviral therapy (ART) presented with Elsberg syndrome - varicella reactivation causing fever, painful dermatomal rash, weakness of bilateral lower extremities, and urinary and bowel dysfunction. On the third day of hospitalization, the patient developed altered mental status. An investigation for encephalitis and myelitis revealed a CD4 count of 150 cells/uL, viral load of about 150,000 copies/mL, and MRI of the lumbar spine demonstrating thickening of the cauda equina. Cerebrospinal fluid (CSF) from lumbar puncture confirmed the presence of varicella-zoster virus (VZV). Treatment with acyclovir for 21 days was initiated. However, the patient developed a persistent fever. Evaluation for the source of the fever resulted in identification of anti-viral therapy as the cause. In conclusion, the present report provides a unique example of acyclovir-induced fever developed on treatment of Elsberg syndrome.

Varicella zoster virus-induced neurological disease after COVID-19 vaccination: a retrospective monocentric study

The description of every possible adverse effect or event related to vaccines is mandatory during the ongoing worldwide COVID-19 vaccination program. Although cases of cutaneous varicella zoster virus (VZV) reactivation after COVID-19 vaccination have been increasingly reported in literature and database sets, a description of VZV-induced neurological disease (VZV-ND) is still lacking. In the present study, we retrospectively evaluated patients admitted to our clinic and diagnosed with VZV-ND during the COVID-19 vaccination campaign (January-April 2021) and in the same months in the previous two years. We identified three patients with VZV-ND after COVID-19 vaccination and 19 unvaccinated VZV-ND cases as controls. In the case-control analysis, the two groups showed no difference in clinical features, results of diagnostic investigations, and outcome. Thus, VZV reactivation with neurological involvement might be a possible event triggered by COVID-19 vaccination, but the benefit following COVID-19 vaccination overcomes significantly the potential risk associated with a VZV reactivation.

Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease and Varicella Zoster Virus Infection - Frequency of an Association

To determine whether there is a correlation between myelin oligodendrocyte glycoprotein (MOG) antibody-associated diseases and varicella zoster virus (VZV) infection. We provide a case report and performed a study to determine the frequency of MOG antibodies (MOG-IgG) in neurological VZV infections. Patients admitted to the Medical University of Innsbruck from 2008-2020 with a diagnosis of a neurological manifestation of VZV infection (n=59) were included in this study; patients with neuroborreliosis (n=34) served as control group. MOG-IgG was detected using live cell-based assays. In addition, we performed a literature review focusing on MOG and aquaporin-4 (AQP4) antibodies and their association with VZV infection. Our case presented with VZV-associated longitudinally extensive transverse myelitis and had MOG-IgG at a titer of 1:1280. In the study, we did not detect MOG-IgG in any other patient neither in the VZV group (including 15 with VZV encephalitis/myelitis) nor in the neuroborreliosis group. In the review of the literature, 3 cases with MOG-IgG and additional 9 cases with AQP4 IgG associated disorders in association with a VZV infection were identified. MOG-IgG are rarely detected in patients with VZV infections associated with neurological diseases.

Approach to Neurologic Complications in the Immunocompromised Patient

Neurologic complications are common in immunocompromised patients, including those with advanced human immunodeficiency virus, transplant recipients, and patients on immunomodulatory medications. In addition to the standard differential diagnosis, specific pathogens and other conditions unique to the immunocompromised state should be considered in the evaluation of neurologic complaints in this patient population. A thorough understanding of these considerations is critical to the inpatient neurologist in contemporary practice, as increasing numbers of patients are exposed to immunomodulatory therapies. In this review, we provide a chief complaint-based approach to the clinical presentations and diagnosis of both infectious and noninfectious complications particular to immunocompromised patients.

Current Clinical Applications of Intracranial Vessel Wall MR Imaging

Intracranial vessel wall MR imaging (VWI) is increasingly being used as a valuable adjunct to conventional angiographic imaging techniques. This article will provide an updated review on intracranial VWI protocols and image interpretation. We review VWI technical considerations, describe common VWI imaging features of different intracranial vasculopathies and show illustrative cases. We review the role of VWI for differentiating among steno-occlusive vasculopathies, such as intracranial atherosclerotic plaque, dissections and Moyamoya disease. We also highlight how VWI may be used for the diagnostic work-up and surveillance of patients with vasculitis of the central nervous system and cerebral aneurysms.

Infections of the Spine and Spinal Cord

PURPOSE OF REVIEW

Infections of the spine and spinal cord are associated with a high risk of morbidity and mortality and, therefore, require prompt clinical recognition, efficient diagnostic evaluation, and interdisciplinary treatment. This article reviews the pathophysiology, epidemiology, clinical manifestations, diagnosis, and treatment of infections of the spine and spinal cord to help practicing clinicians recognize, evaluate, and manage patients with such infections.

RECENT FINDINGS

Aging of the population, increasing use of immunosuppressive medications, and other factors have contributed to increasing rates of spinal infections. Although the most common agents responsible for spinal infections remain bacteria and viruses, fungal infections occur in individuals who are immunocompromised, and parasitic infections are common in endemic regions, but patterns are in evolution with migration and climate change. Recent outbreaks of acute flaccid myelitis in children have been associated with enteroviruses A71 and D68.

SUMMARY

Infections of the spine and spinal cord can be challenging to diagnose, requiring a thorough history and neurologic examination, laboratory studies of serum and CSF, neuroimaging (particularly MRI), and, in some instances, biopsy, to establish a diagnosis and treatment regimen. Interdisciplinary management including collaboration with experts in internal medicine, infectious disease, and neurosurgery is important to improve clinical outcomes.