Herpes zoster

A Case Report of Herpes Zoster After Botulinum Toxin Injections

This case report presents a rare occurrence of herpes zoster (HZ) outbreak in a 50-year-old male following botulinum toxin (BTX) type A injections. The patient developed burning swollen lesions on the left forehead four days after receiving BTX injections. Physical examination revealed papules and erosions in a dermatomal distribution. He was diagnosed with HZ and promptly treated with oral acyclovir. The lesions resolved within two weeks without complications. Previous literature reports a few similar HZ outbreaks following aesthetic treatments with BTX injections. The exact mechanism triggering varicella reactivation in these cases remains unclear. Prompt diagnosis and treatment of HZ are crucial in order to minimize outbreak duration and reduce complications. Physicians should maintain awareness of HZ as a potential complication following BTX injections.

Varicella pneumonia in an immunocompetent child: A case report

Varicella-zoster virus (VZV) is a type of herpes virus that causes varicella (primary infection) and herpes zoster/shingles (due to reactivation of latent infection). Usually a benign and a self-limited illness, the illness sometimes can result in severe complications in both immunocompetent and immunocompromised persons. Varicella Pneumonia as a complication of herpes zoster is a rare event, with reports primarily concerning immunocompromised individuals. Here we report a 14-year-old female who developed a secondary bacterial infection of the skin lesions and varicella pneumonia associated with VZV infection. The patient presented with multiple painful vesicles that later turned into pustular lesions over the right cheek with erosions and hemorrhagic crusting. Swelling involving the right half of both upper and lower lips was present. She developed a fever, cough, and shortness of breath after two days of the presence of vesico-pustular lesions. A diagnosis of Pneumonia was made based on symptoms of fever and cough and findings on chest x-ray. This case highlights, though rare, varicella pneumonia has a high rate of respiratory failure, but early diagnosis with prompt administration of antiviral medications can improve outcomes.

The Spectrum of Neurological Manifestations of Varicella-Zoster Virus Reactivation

Varicella-Zoster virus (VZV) is a pathogenic human alpha herpes virus that causes varicella (chicken pox) as a primary infection and, following a variable period of latency in different ganglionic neurons, it reactivates to produce herpes zoster (shingles). The focus of this review is on the wide spectrum of the possible neurological manifestations of VZV reactivation. While the most frequent reactivation syndrome is herpes zoster, this may be followed by the serious and painful post-herpetic neuralgia (PHN) and by many other neurological conditions. Prominent among these conditions is a VZV vasculopathy, but the role of VZV in causing giant cell arteritis (GCA) is currently controversial. VZV reactivation can also cause segmental motor weakness, myelitis, cranial nerve syndromes, Guillain-Barre syndrome, meningoencephalitis, and zoster sine herpete, where a neurological syndrome occurs in the absence of the zoster rash. The field is complicated by the relatively few cases of neurological complications described and by the issue of causation when a neurological condition is not manifest at the same time as the zoster rash.

Value and Implementation of the Aggregate Safety Assessment Plan

Aggregate safety assessment involves evaluation of the totality of safety data to characterize the emerging safety profile of a product. The Drug Information Association-American Statistical Association Interdisciplinary Safety Evaluation scientific working group recently published an approach to developing an Aggregate Safety Assessment Plan (ASAP). Creation of an ASAP facilitates a consistent approach to safety data collection and analysis across studies and minimizes important missing data at the time of regulatory submission. A critical aspect of the ASAP is identification of the Safety Topics of Interest (STOI). The STOI, as defined in the ASAP, comprises adverse events (AEs), which have the potential to impact the benefit: risk profile of a product and typically require specialized data collection or analyses. While there are clear benefits to developing an ASAP for a drug development program, multiple concerns may be encountered with implementation. This article uses the examples of two STOIs to demonstrate the benefits and efficiencies gained with implementation of the ASAP in safety planning as well as in optimally characterizing the emerging safety profile of a product.

Efficacy of local anaesthetic and steroid combination in prevention of post-herpetic neuralgia: A meta-analysis

Objective

The objective was to provide synthesized evidence on the efficacy of local anaesthetics and steroid injections for prevention and management of PHN, compared to the standard treatment using anti-viral and analgesic medications. The primary outcomes of interest were incidence of PHN and duration of neuralgic pain.

Methods

Comprehensive searches were done systematically through PubMed, Scopus, Cochrane Central Register of Controlled Trials and Google scholar databases. Randomized controlled trials that compared the efficacy of local anaesthetics and steroid injections for preventing and managing PHN were included for this meta-analysis. A comprehensive search was done for papers published until 15th July 2021.

Results

A total of 10 RCTs were included in the meta-analysis. In the overall pooled analyses, compared to standard care/placebo, those receiving a combination of local anaesthetic and steroid injection had 55% lower risk of PHN at 3 months from onset of rash (RR 0.45; 95% CI, 0.29; 0.70). Out of the different modes of intervention delivery i.e., intravenous, subcutaneous and nerve block, maximum beneficial effect in reducing the incidence of PHN was noted in nerve block (RR 0.55; 95% CI, 0.34, 0.89).

Conclusions

The meta-analysis provides some evidence to support the use of combined local anaesthetic and steroids in reducing risk of post-herpetic neuralgia and duration of neuralgic pain in patients with herpes zoster rash.

Herpes zoster in outpatient departments of healthcare centers in India: a review of literature

In India, although incidence of Herpes zoster has not been assessed, regional cases have been reported. We revisited the peer-reviewed literature on clinical cases of HZ to depict the trends in population characteristics, disease presentation, and predisposing factors for the disease in India. Systematically conducted literature search yielded 27 studies, published between January 2011 and May 2020, reporting 3124 HZ clinical cases, with high proportions in older adults (>50 years of age: 15.0-81.3%). Thoracic dermatome was consistently reported as the most frequent site affected by HZ (38.9-71.0%). Post-herpetic neuralgia and secondary bacterial infections were the two most frequent complications (10.2-54.7% and 3.5-21.0%, respectively). Despite the paucity of data and gaps in the reporting of HZ cases, available evidence indicate that the disease causes an important burden to older adults in India, suggesting that preventive strategies, along with recommendations to healthcare practitioners, can help mitigate the burden of HZ.

Sciatic Herpes Zoster Suspected of Lumbar Disc Herniation: An Infrequent Case Report and Literature Review

Background: The symptoms of sciatic herpes zoster are sometimes difficult to distinguish from sciatica caused by lumbar disc herniation. We describe a case of suspected lumbar disc herniation with sciatic herpes zoster to reduce the rate of misdiagnosis.

Case Report: A 55-year old man, male, developed low back pain after carrying heavy items 20 years ago. Characteristics of symptoms: 1. Symptoms were aggravated in the upright lumbar forward flexion position; 2. The VAS (leg) score was 8–9 points and the VSA (lumbar) score was 0 point; 3. It can be relieved when rested in the supine position; 4. It came on intermittently with radiation pain in the right lower limb. There were several attacks every year. One month ago, there was radiating pain in the right lower limb. The pain was from the back of the right hip, behind the thigh, in lateral crural region, to the back of the foot. And Symptoms worsened for 10 days. The VAS score was 8 points. Pain could not be relieved by rest or changing posture. There was no back pain, no lower limbs, weak walking, no claudication and other symptoms. Analgesics and neurotrophic drugs are ineffective. After the application of antiviral drugs, the radiation pain in the right lower extremity was significantly relieved.

Conclusion: We describe this case in detail and discuss how to make an authentic diagnosis, with a concomitant literature review.

Dermatologic aspects of bed bug epidemic: an atlas of differential diagnosis

Bed bug infestation rate has gone through an unforeseen increase in the past decades worldwide. Their resurgence is a consequence of numerous factors, including growing population density, increased international travel and the spread of insecticide resistance. Bed bug infestation is often revealed by skin symptoms appearing after their bite in sensitive patients. Medical professionals encountering patients with bed bug bites have responsibility for recognizing the condition and for instructing patients about the necessary measures for eradication. Setting the correct diagnosis, however, is not unequivocal as several skin diseases with autoimmune, immune-mediated aetiology or other arthropod stings and bites may present with similar symptoms. In this review we provide a differential diagnostic guide and an atlas of clinical pictures assigned to the diagnoses. We highlight those dermatological findings where the possibility of bed bug bite arises and identify key elements that help in the differentiation so as to avoid unnecessary diagnostic tests and force early start of extermination.

An unusual distribution of herpes zoster mandibularis post total parotidectomy

This case report highlights an unusual presentation of herpes zoster mandibularis in an immunocompromised patient with previous head and neck surgery, with relative sparing of the cheek. It demonstrates the importance of critically considering past medical and surgical history in clinical diagnosis and management of the disease.

Insights into the pathogenesis of varicella viruses

Purpose of review

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

Recent findings

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

Summary

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

Determinants of neurological syndromes caused by varicella zoster virus (VZV)

Varicella zoster virus (VZV) is a pathogenic human herpes virus which causes varicella as a primary infection, following which it becomes latent in peripheral autonomic, sensory, and cranial nerve ganglionic neurons from where it may reactivate after decades to cause herpes zoster. VZV reactivation may also cause a wide spectrum of neurological syndromes, in particular, acute encephalitis and vasculopathy. While there is potentially a large number of coding viral mutations that might predispose certain individuals to VZV infections, in practice, a variety of host factors are the main determinants of VZV infection, both disseminated and specifically affecting the nervous system. Host factors include increasing age with diminished cell-mediated immunity to VZV, several primary immunodeficiency syndromes, secondary immunodeficiency syndromes, and drug-induced immunosuppression. In some cases, the molecular immunological basis underlying the increased risk of VZV infections has been defined, in particular, the role of POL III mutations, but in other cases, the mechanisms have yet to be determined. The role of immunization in immunosuppressed individuals as well as its possible efficacy in preventing both generalized and CNS-specific infections will require further investigation to clarify in such patients.

Higher risk of herpes zoster in stroke patients

Background

Stroke is a leading cause of death, morbidity and disability worldwide. Infection is a common complication in the acute phase after stroke. Herpes zoster is a common viral disease, in which the most debilitating complication is post-herpetic neuralgia, which can have a very large negative impact on quality of life. The aim of this study was to investigate whether stroke increases the risk of herpes zoster.

Methods

This cohort study compared patients who had herpes zoster with and without a first incident of stroke. The Taiwan National Health Insurance Research Database was utilized to identify 20,551 stroke patients and 20,551 controls matched for age, gender, age categories and Charlson Comorbidity Index (CCI) score categories at a one-to-one ratio. Cox proportional-hazards regression models were employed to estimate herpes zoster risk in the stroke group relative to general population.

Results

Compared to the control group, the stroke group had a greater risk for herpes zoster, especially within 1 year after stroke (adjust HR = 25.27). Both hemorrhagic stroke and ischemic stroke were significantly associated with herpes zoster (hemorrhagic type (IRR = 2.31, 95% CI, 1.67–3.20); ischemic type (IRR = 2.51, 95% CI 2.09–3.02)). However, the hemorrhagic stroke patients had a higher risk of herpes zoster ophthalmicus (IRR = 12.46, 95% CI 4.00–38.76) whereas the ischemic stroke patients had a higher risk of post-herpetic neuralgia (IRR = 2.24, 95% CI 1.56–3.20).

Conclusion

Physicians should know about that adults with stroke have a higher than normal risk of herpes zoster. Thus, physicians must be acquainted with proper antiviral therapy and pain control to bring down the morbidity that ensues from herpes zoster. Use of herpes zoster vaccine may be considered in stroke patients.

Pressure ulcer following circumferential head dressing

PURPOSE

To report four patients with forehead pressure ulcer (PU) following encircling head dressing and review the literature.

METHODS

Uneventful endoscopic forehead lift procedure was performed with moderate skin elevation in three patients. Left upper eyelid crease incision was made to remove the sub-brow dermoid cyst uneventfully in one patient. All procedures were performed under general anesthesia. Mixed topical antibiotic and steroid ointments were placed on the incision sites before putting the encircling forehead dressing (using gauze and elastic bandage). The dressing was then removed on the first postoperative examination.

RESULTS

Forehead and eyebrow PUs were observed on the first follow-up visit (16-72 h) after removing the dressing. Patients were otherwise healthy. They did not have significant pain or burning postoperatively. Management included pressure release, wound debridement, daily dressing, topical antibiotic and steroid, and silicone-based anti-scar cream. None had infected ulcer and all except one ended up with atrophic scar in the last follow-up (2-14 months). External pressure and shearing forces were assumed to be the main causative factors, even though reperfusion injury could contribute in the development of PU.

CONCLUSION

Encircling head dressing can cause PU and result in scar formation in healthy immunocompetent patients. If there is a low risk of postoperative hematoma, encircling dressing should be avoided. Early loosening of the dressing and frequent examination of the skin are the best preventive and diagnostic measures. Treatment includes pressure removal, daily debridement, and topical medications.

Epidemiology and clinical characteristics of herpes zoster in a tertiary care hospital in Brazil

Background

There is little information on herpes zoster from hospital registries in South America. The aim of this study was to describe the epidemiological and clinical aspects of herpes zoster (HZ) in hospitalized patients.’

Methods

We searched for hospital-based records during the period from March 2000 to January 2017 in a 700-bed tertiary-care hospital located in southern Brazil. The medical records of all eligible patients were reviewed, and data regarding demographics, medical history, clinical and laboratory characteristics, treatment regimens, and clinical outcomes were collected. Patients were also evaluated for mortality.

Results

There were 801 records of herpes zoster according to the proposed criteria. Most patients with HZ presented a cutaneous clinical form of the disease with involvement of a single dermatome (n = 589, 73.5%). Additional clinical characteristics included postherpetic neuralgia (22.1%), ophthalmic HZ (7.6%) and meningoencephalitis (2.7%). Most patients presented immunocompromised conditions (64.9%) including HIV, administration of immunosuppressive agents, and malignant neoplasms. During this period, there were 105 (13.1%) deaths, which were mostly unrelated to HZ. Five deaths were related to HZ meningoencephalitis.

Conclusion

The results of this study demonstrate a high burden of HZ disease in a Brazilian tertiary care hospital in the HZ vaccination era. Awareness of the incidence and comorbidity factors associated with HZ in Latin American countries such as Brazil contribute for adoption and implementation of strategies for immunization in this area.

Evaluation of Varicella-zoster virus-specific cell-mediated immunity by interferon-γ Enzyme-Linked Immunosorbent Assay in adults ≥50 years of age administered a herpes zoster vaccine

Varicella-zoster virus (VZV)-specific cell-mediated immunity (CMI) is critical for preventing and controlling the onset of herpes zoster (HZ). To assess VZV CMI, an interferon-γ (IFN-γ) enzyme-linked immunosorbent assay (ELISA) was validated by examining the influence of VZV-specific antigen content, incubation time, and interval from whole blood collection on the assay. In phase II clinical trial, VZV-specific CMI in adults ≥50 years of age administered an HZ vaccine were evaluated by IFN-γ ELISA, as determined by measuring IFN-γ production in the whole blood in response to stimulation with ultraviolet light-inactivated VZV. The VZV-specific IFN-γ levels varied among individuals from prevaccination (baseline) to 6 weeks postvaccination. In most subjects, VZV-specific CMI was increased at 6 weeks postvaccination. The HZ vaccine elicited a significant increase in the VZV-specific CMI response as measured by ELISA; the geometric mean fold-rises from baseline to 6 weeks postvaccination were 3.50, 4.22, and 5.24 in the 4.3, 4.7, and 4.9 log plaque-forming unit vaccine groups, respectively, which was significantly higher than in the placebo group (P < 0.05). These results indicate that vaccination enhances the VZV-specific CMI responses in subjects; IFN-γ ELISA is an effective method for evaluating the CMI response and may be useful for identifying individuals at a high risk of HZ infection.

Varicella Virus-Host Interactions During Latency and Reactivation: Lessons From Simian Varicella Virus

Varicella zoster virus (VZV) is a neurotropic alphaherpesvirus and the causative agent of varicella (chickenpox) in humans. Following primary infection, VZV establishes latency in the sensory ganglia and can reactivate to cause herpes zoster, more commonly known as shingles, which causes significant morbidity, and on rare occasions mortality, in the elderly. Because VZV infection is highly restricted to humans, the development of a reliable animal model has been challenging, and our understanding of VZV pathogenesis remains incomplete. As an alternative, infection of rhesus macaques with the homologous simian varicella virus (SVV) recapitulates the hallmarks of VZV infection and thus constitutes a robust animal model to provide critical insights into VZV pathogenesis and the host antiviral response. In this model, SVV infection results in the development of varicella during primary infection, generation of an adaptive immune response, establishment of latency in the sensory ganglia, and viral reactivation upon immune suppression. In this review, we discuss our current knowledge about host and viral factors involved in the establishment of SVV latency and reactivation as well as the important role played by T cells in SVV pathogenesis and antiviral immunity.

Pharmacokinetics and Safety of Amenamevir in Healthy Subjects: Analysis of Four Randomized Phase 1 Studies

Introduction

Amenamevir (ASP2151) is a nonnucleoside antiherpesvirus compound available for the treatment of varicella–zoster virus infections. In this article we summarize the findings of four phase 1 studies in healthy participants.

Methods

Four randomized phase 1 studies investigated the safety and pharmacokinetics of single and multiple doses of amenamevir, including the assessment of age group effect (nonelderly vs elderly), food effect, and the relative bioavailability of two formulations. Amenamevir was administered orally at various doses as a single dose (5–2400 mg) or daily (300 or 600 mg/day) for 7 days.

Results

Following single and multiple oral doses, amenamevir demonstrated a less than dose proportional increase in the pharmacokinetic parameters area under the plasma drug concentration versus time curve from time zero to infinity (AUC_inf) and C_max. After single and multiple oral 300-mg doses of amenamevir, no apparent differences in pharmacokinetics were observed between nonelderly and elderly participants. In contrast, with the amenamevir 600-mg dose both the area under the plasma drug concentration versus time curve from time zero to 24 h and C_max were slightly increased and renal clearance was decreased in elderly participants. The pharmacokinetics of amenamevir was affected by food, with AUC_inf increased by about 90%. In the bioavailability study, AUC_inf and C_max were slightly lower following tablet versus capsule administration (decreased by 14 and 12%, respectively), with relative bioavailability of 86%. The different amenamevir doses and formulations were safe and well tolerated; no deaths or serious adverse events were reported.

Conclusion

Amenamevir had less than dose proportional pharmacokinetic characteristics. Age may have an influence on amenamevir pharmacokinetics; however, the effect was considered minimal. The pharmacokinetics of amenamevir were affected by food, with AUC_inf almost doubling when amenamevir was administered with food. The concentration versus time profile of the tablet was slightly lower than that of the capsule; the relative bioavailability of the tablet versus the capsule was 86%. Amenamevir was safe and well tolerated in the dose range investigated.

Funding

Astellas Pharma.

Trial registration

ClinicalTrials.gov identifiers NCT02852876 (15L-CL-002) and NCT02796118 (15L-CL-003).

Electronic supplementary material

The online version of this article (10.1007/s12325-017-0642-4) contains supplementary material, which is available to authorized users.

Herpes Zoster in the Older Adult

Herpes zoster (HZ) is the result of reactivation of latent varicella zoster virus (VZV) and occurs most frequently in older adults. Classically, HZ presents as a unilateral, selflimited, dermatomal rash. Postherpetic neuralgia (PHN) is a common sequela, presenting as severe pain that persists after the rash has resolved. In the elderly, PHN can be debilitating and requires a prompt diagnosis, treatment with antivirals, and adequate pain control. A longer-term pain management strategy is required if PHN occurs. A modestly effective vaccine exists and is recommended for older individuals.

Decreased absolute numbers of CD3+ T cells and CD8+ T cells during aging in herpes zoster patients

Herpes zoster (HZ) is an infectious dermatosis with high incidence worldwide. Age is a key risk factor for HZ, and postherpetic neuralgia (PHN) is the main sequelae. Until now, no index has been available to predict the pathogenesis of PHN, and rare reports have focused on the immune response during aging and PHN. In this study, we selected immunoglobulin and complement proteins as markers for humoral immunity, while T lymphocyte subsets and natural killer (NK) cells were selected as markers for cell immunity, to systematically study the characteristics of immune responses in the peripheral blood of HZ patients. Our data showed that the absolute number of CD3⁺ T cells and CD8⁺ T cells decreased during aging and PHN. This implies that more attention should be paid to prevent the occurrence of PHN, especially in the aged population.

Acupuncture and Cutaneous Medicine: Is It Effective?

Background: In China, acupuncture has been used as a form of medical therapy for more than 2500 years. It is a part of traditional medical practice and is used to treat the entire spectrum of human and veterinary disease. Although dermatologic disease has received much less attention in worldwide acupuncture research than pain and musculoskeletal conditions, there is a growing body of evidence suggesting acupuncture's usefulness in this area. Objective: The aim of this article was to review the evidence in the literature regarding the usefulness of acupuncture in managing dermatologic illness. Results: Trials and case reports of patients using acupuncture have been published in the areas of atopic dermatitis and urticaria, herpes zoster, psoriasis, acne, melasma, and hyperhidrosis, as well as in promoting wound healing. Itch modulation by acupuncture has been the focus of recent research as itch is a predominant symptom in allergic skin diseases and leads to serious impairment of quality of life. Conclusions: Although more research is needed, acupuncture's use in cutaneous medicine is promising in the area of itch modulation, in treating atopic dermatitis and herpes zoster pain, and in promoting wound healing.

Impact of Underlying Conditions on Zoster-Related Pain and on Quality of Life Following Zoster

BACKGROUND

Chronic conditions have been investigated as risk factors for developing zoster, but in patients suffering from zoster, the impact of underlying conditions in zoster-related pain and quality of life (QOL) remains unclear.

METHODS

We performed a post hoc analysis of a prospective cohort study in immunocompetent zoster patients aged 50 years or older, conducted by general practitioners in Italy between 2009 and 2010. Zoster symptoms, pain intensity and characteristics, and physical and mental health scores were assessed at baseline (zoster diagnosis) and at 1, 3, and 6 months of follow-up.

RESULTS

Among 413 patients enrolled in the study, 73% (303/413) suffered from underlying conditions of which 69% (209/303) were aged 65 or older. Cardiovascular diseases (75%), diabetes (24%), and respiratory diseases (17%) were most frequent. One to three months after onset, zoster patients with underlying conditions experienced more intense zoster-related pain than those without. QOL scores were significantly lower in patients with underlying conditions, and age-adjusted difference in QOL scores between the groups increased over time, demonstrating a slower recovery for patients with underlying conditions.

CONCLUSIONS

In addition to age, the main risk factor of zoster occurrence and severity, the presence of underlying conditions results in more painful and impactful zoster episodes, creating a significant burden for these patients.

Herpes Zoster with Post Herpetic Neuralgia Involving the Right Maxillary Branch of Trigeminal Nerve: A Case Report and Review of Literature

Herpes Zoster (HZ) is an acute, self-limiting, neuro cutaneous viral infection caused by the reactivation of the Varicella Zoster Virus (VZV) that remains latent in the dorsal root ganglion. About 50% of occurrence is seen in older age groups and immunocompromised patients. Less than 5% occur in children. HZ is characterized by the unilateral pain, burning and tingling sensation followed by the vesicular eruptions limited to the single dermatome that are innervated by the single cranial ganglion, sometimes it leads to Post Herpetic Neuralgia (PHN). We report a case of a HZ in a 22-year-old young female patient involving the right maxillary branch of the trigeminal nerve along with PHN.

Herpes zoster and the search for an effective vaccine

Primary infection with varicella zoster virus (VZV), an exclusively human neurotrophic alphaherpsesvirus, results in varicella, known more commonly as chickenpox. Like other alphaherpesviruses, VZV establishes latency in the sensory ganglia and can reactivate to cause herpes zoster (also known as shingles), a painful and debilitating disease, especially in elderly and immunocompromised individuals. The overall incidence of herpes zoster in Europe and the United States is three per 1000 people, but increases sharply after 60 years of age to 10 per 1000 people. Zostavax® is a vaccine approved by the Federal Drug Administration for the prevention of herpes zoster. Unfortunately, this vaccine reduces the incidence of disease by only 51% and the incidence of post-herpetic neuralgia by 66·5% when administered to those aged 60 and older. Moreover, it is contraindicated for individuals who are immunocompromised or receiving immunosuppressant treatments, although they are at higher risk for herpes zoster compared to immune-competent older individuals. This paper reviews VZV pathogenesis, host responses and current vaccines available to prevent herpes zoster.

Healthcare Resource Utilisation Associated with Herpes Zoster in a Prospective Cohort of Older Australian Adults

Background

Herpes zoster (HZ) is a common condition that increases in incidence with older age but vaccines are available to prevent the disease. However, there are limited data estimating the health system burden attributable to herpes zoster by age.

Methods

In this study, we quantified excess healthcare resource usage associated with HZ during the acute/sub-acute period of disease (21days before to 90 days after onset) in 5952 cases and an equal number of controls matched on age, sex, and prior healthcare resource usage. Estimates were adjusted for potential confounders in multivariable regression models. Using population-based estimates of HZ incidence, we calculated the age-specific excess number of health service usage events attributable to HZ in the population.

Results

Per HZ case, there was an average of 0.06 (95% CI 0.04–0.08) excess hospitalisations, 1.61 (95% CI 1.51–1.69) excess general practitioner visits, 1.96 (95% CI 1.86–2.15) excess prescriptions filled and 0.11 (95% CI 0.09–0.13) excess emergency department visits. The average number of healthcare resource use events, and the estimated excess per 100,000 population increased with increasing age but were similar for men and women, except for higher rates of hospitalisation in men. The excess annual HZ associated burden of hospitalisations was highest in adults ≥80 years (N = 2244, 95%CI 1719–2767); GP visits was highest in those 60–69 years (N = 50567, 95%CI 39958–61105), prescriptions and ED visits were highest in 70–79 years (N = 50524, 95%CI 40634–60471 and N = 2891, 95%CI 2319–3449 respectively).

Conclusions

This study provides important data to establish the healthcare utilisation associated with HZ against which detailed cost-effectiveness analyses of HZ immunisation in older adults can be conducted.

Issues in the Treatment of Neurological Conditions Caused by Reactivation of Varicella Zoster Virus (VZV)

Varicella zoster virus (VZV) is a ubiquitous neurotropic human herpesvirus. Primary infection usually causes varicella (chicken pox), after which virus becomes latent in ganglia along the entire neuraxis. Decades later, virus reactivates to produce herpes zoster (shingles), a painful dermatomally distributed vesicular eruption. Zoster may be further complicated by postherpetic neuralgia, VZV vasculopathy, myelitis, and segmental motor weakness. VZV reactivation has also been associated with giant cell arteritis. This overview discusses treatment of various conditions that often require both corticosteroids and antiviral drugs. Treatment for VZV-associated disease is often based on case reports and small studies rather than large-scale clinical trials. Issues that require resolution include the optimal duration of such combined therapy, more effective treatment for postherpetic neuralgia, whether some treatments should be given orally or intravenously, the widening spectrum of zoster sine herpete, and the role of antiviral therapy in giant cell arteritis.

Cost of Herpes Zoster in Patients With Selected Immune-Compromised Conditions in the United States

Among patients with common immune-compromised (IC) conditions in the United States, the healthcare cost associated with herpes zoster (HZ) was sizable and occurred mainly during the first quarter after diagnosis. And HZ-associated costs varied by age and underlying IC conditions.

Background. This retrospective study investigates the healthcare costs of herpes zoster (HZ) in patients with selected immune-compromised (IC) conditions in the United States (US).

Methods. Patients with incident HZ diagnosis (index date) were selected from nationwide administrative claims databases from 2005 to 2009. Baseline IC groups, analyzed separately, included adults aged 18–64 years with the following: human immunodeficiency virus infection (HIV), solid organ transplant (SOT), bone marrow or stem cell transplant (BMSCT), or cancer; and older adults (aged ≥65 years) with cancer. Herpes zoster patients (n = 2020, n = 1053, n = 286, n = 13 178, and n = 9089, respectively) were 1-to-1 matched to controls without HZ (with randomly selected index date) in the same baseline group. The healthcare resource utilization and costs (2014 US dollars) during the first 2 postindex quarters were compared between matched cohorts with continuous enrollment during the quarter.

Results. Herpes zoster patients generally had greater use of inpatient, emergency room and outpatient services, and pain medications than matched controls (P < .05). The incremental costs of HZ during the first postindex quarter were $3056, $2649, $13 332, $2549, and $3108 for HIV, SOT, BMSCT, cancer in adults aged 18–64 years, and cancer in older adults, respectively (each P < .05). The incremental costs of HZ during the second quarter were only significant for adults aged 18–64 years with cancer ($1748, P < .05). The national incremental costs of HZ were projected to be $298 million annually across the 5 IC groups.

Conclusions. The healthcare cost associated with HZ among patients with studied IC conditions was sizable and occurred mainly during the first 90 days after diagnosis.

Current aspects on the management of viral uveitis in immunocompetent individuals

Viruses are a fundamental etiology of ocular inflammation, which may affect all structures of the organ. Advances in molecular diagnostics reveal an increasingly broader spectrum of virus-associated intraocular inflammation, including all members of the herpes family, rubella virus, and other more rare causes such as Epstein–Barr and chikungunya virus. In particular, viruses of the herpes family are important causes of anterior and posterior uveitis. Owing to their often fulminant clinical course and persistence in ocular tissues, a clear differential diagnosis between alpha- and beta-type herpes viruses is essential to guide acute and long-term treatment. Here, we review the epidemiology, clinical, and laboratory findings of virus-associated uveitis with emphasis on their therapy and management and include our own experience.

Increasing trends of herpes zoster in Australia

Background

Increasing trends in incidence of herpes zoster (HZ) have been reported in Australia and internationally. This may reflect the impact of childhood VZV vaccination programs introduced universally in Australia in late 2005. The objective of this study was to evaluate changes in incidence of HZ and PHN in Australia over time, and associated healthcare resource utilisation.

Methods

Australian data on general practice (GP) encounters for HZ, specific antiviral prescribing data from the pharmaceutical benefits scheme, emergency department presentations from the states of NSW and Victoria and national hospitalisation data for HZ were analysed for time trends using regression models. Two time periods (2000-2006 and 2006-2013) were compared which correspond broadly with the pre- and post- universal VZV vaccination period.

Results

All data sources showed increasing rates of HZ with age and over time. The GP database showed a significant annual increase in encounters for HZ of 2.5 per 100,000 between 1998 and 2013, and the rates of prescriptions for HZ increased by 4.2% per year between 2002 and 2012. In the 60+ population HZ incidence was estimated to increase from 11.9 to 15.4 per 1,000 persons using GP data or from 12.8 to 14.2 per 1,000 persons using prescription data (p<0.05, between the two periods). Hospitalisation data did not show the same increasing trend over time, except for the age group ≥80 years. Most emergency visits for HZ were not admitted, and showed significant increases over time.

Discussion

The burden of HZ in Australia is substantial, and continues to increase over time. This increase is seen both pre- and post-universal VZV vaccination in 2005, and is most prominent in the older population. The substantial burden of HZ, along with ageing of the Australian population and the importance of healthy ageing, warrants consideration of HZ vaccination for the elderly.

Reducing pain in acute herpes zoster with plain occlusive dressings: a case report

Introduction

The pain of acute herpes zoster (shingles) is severe and difficult to control. The medications used to control pain have a variety of important and potentially serious side effects. To the best of my knowledge, this is the first case report of using a plain topical occlusive dressing to reduce the pain of herpes zoster, avoiding the use of medication.

Case presentation

A 40-year-old Caucasian man and a qualified physician (the author), developed a dermatomal vesicular rash consistent with herpes zoster. Applying plain topical occlusive dressings reduced the severity of his pain to an ignorable level.

Conclusion

Plain topical occlusive dressings provide effective pain relief for acute herpes zoster, thereby avoiding the risks accompanying medication use.

A nationwide population-based cohort study to identify the correlation between heart failure and the subsequent risk of herpes zoster

Background

The association between heart failure (HF) and herpes zoster has rarely been studied. We investigated the hypothesis that HF may increase the risk of herpes zoster in Taiwan using a nationwide Taiwanese population-based claims database.

Method

Our study cohort consisted of patients who received a diagnosis of HF in 2001 ~ 2009 (N = 4785). For a comparison cohort, three age- and gender-matched control patients for every patient in the study cohort were selected using random sampling (N = 14,355). All subjects were tracked for 1 year from the date of cohort entry to identify whether or not they had developed herpes zoster. Cox proportional-hazard regressions were performed to evaluate 1-year herpes zoster-free survival rates.

Results

The main finding of this study was that patients with HF seemed to be at an increased risk of developing herpes zoster. Of the total patients, 211 patients developed herpes zoster during the 1-year follow-up period, among whom 83 were HF patients and 128 were in the comparison cohort. The adjusted hazard ratio (AHR) of herpes zoster in patients with HF was higher (AHR: 2.07; 95% confidence interval (CI): 1.54 ~ 2.78; p < 0.001) than that of the controls during the 1-year follow-up. Our study also investigated whether HF is a gender-dependent risk factor for herpes zoster. We found that male patients with HF had an increased risk of developing herpes zoster (AHR: 2.30 95% CI: 1.51 ~ 3.50; p < 0.001).

Conclusions

The findings of our population-based study suggest that patients with HF may have an increased risk of herpes zoster. These health associations should be taken into consideration, and further studies should focused on the cost-effectiveness of the herpes zoster vaccine should be designed for HF patients.

Acute pancreatitis associated with herpes zoster: Case report and literature review

Varicella-zoster virus (VZV) is a type of herpes virus known to cause varicella, mainly in young children, and herpes zoster in adults. Although generally non-lethal, VZV infection can be associated with serious complications, particularly in adults. Acute pancreatitis caused by VZV infection is a rare event, with reports primarily concerning immunocompromised individuals. Here we report a 44-year-old immunocompetent female who developed acute pancreatitis associated with VZV infection. The patient presented with vomiting and persistent pain in the upper quadrant less than one week after diagnosis and treatment for a herpes zoster-related rash with stabbing pain on the abdomen and dorsal right trunk side. A diagnosis of acute pancreatitis was confirmed based on abdominal pain, elevated levels of urine and serum amylase, and findings of peri-pancreatic exudation and effusions by computed tomography and magnetic resonance cholangiopancreatography. This case highlights that, though rare, acute pancreatitis should be considered in VZV patients who complain of abdominal pain, especially in the epigastric area. Early detection and proper treatment are needed to prevent the condition from deteriorating further and to minimize mortality.

Orofacial pain syndromes: evaluation and management

Patients will often visit their primary medical practitioner with orofacial pain complaints. Hence, it is important to recognize and have an understanding of these conditions to properly evaluate and potentially manage these disorders. If the practitioner is uncertain or uncomfortable with these conditions, then patient referral to a knowledgeable health care practitioner should be considered for further evaluation and management. In this article, the evaluation and management of various neuropathic, neurovascular, and vascular pains are discussed.

Physician Attitudes toward the Herpes Zoster Vaccination in South Korea

This survey investigated Korean physician attitudes toward the herpes zoster (HZ) vaccine. A total of 400 physicians answered a self-reported questionnaire. Most physicians knew that HZ poses a significant socioeconomic burden and had good knowledge about HZ and its vaccine. Physicians who did not recommend HZ vaccine were concerned about costs (90.7%, 78/86) and doubted the effectiveness of the vaccine (58.1%, 50/86). Patient demand had a profound effect on physicians decisions; 84.9% (73/86) of them who said not recommending HZ vaccine reported that they would provide the vaccine upon patient request. In conclusion, educational initiatives should be targeted toward both physicians and patients.

Herpes zoster ophthalmicus following onabotulinumtoxinA administration for chronic migraine: a case report and literature review

BACKGROUND

There is a growing body of literature documenting local herpes zoster outbreak following procedures. The mechanism underlying these outbreaks remains elusive. We present a case of zoster following onabotulinumtoxinA (BTX) for migraine and a literature review.

METHODS

Chart and literature review.

CASE

A 72-year-old woman with chronic migraine received BTX injections for 3 years without incident. She had a history of thoracic zoster with subsequent post-herpetic neuralgia. In August 2013, 48 hours after receiving BTX injections, she developed a painful rash in the right V1 distribution consistent with herpes zoster ophthalmicus. One week later the rash had resolved without treatment.

LITERATURE REVIEW

We identified 65 (including 2 from Juel-Jenson) cases of zoster reactivation following minor procedures. These cases tend to be in young patients without specific risk factors. Outbreaks characteristically occur at the level of exposure to local trauma.

DISCUSSION

Our review suggests that local trauma, regardless of the nature of stimuli, may be sufficient for zoster reactivation. We hypothesize that the stressors in these reported cases exert a local epigenetic influence on viral transcription, allowing for viral reactivation.

CONCLUSION

Zoster is a potential complication of BTX administration for chronic migraine in adults. Physician awareness can reduce the significant morbidity associated with this disease.

No increased risk of herpes zoster found in cirrhotic patients: a nationwide population-based study in Taiwan

Background

The association between liver cirrhosis (LC) and herpes zoster has rarely been studied. We investigated the hypothesis that LC, known as an immunodeficiency disease, may increase the risk of herpes zoster using a national health insurance database in Taiwan.

Materials and Methods

The study cohort included cirrhotic patients between 1998 and 2005 (n = 4667), and a ratio of 1∶5 randomly sampled age- and gender-matched control patients (n = 23,335). All subjects were followed up for 5 years from the date of cohort entry to identify whether or not they had developed herpes zoster. Cox proportional-hazard regressions were performed to evaluate 5-year herpes zoster-free survival rates.

Results

Of all patients, 523 patients developed herpes zoster during the 5-year follow-up period, among whom 82 were LC patients and 441 were in the comparison cohort. The adjusted hazard ratio (AHR) of herpes zoster in patients with LC was not higher (AHR: 0.77, 95% confidence interval: 0.59–1.01, p = 0.06) than that of the controls during the 5-year follow-up. No increased risk of herpes zoster was found in LC patients after stratification by age, gender, urbanization level, income, geographic region, and all comorbidities.

Conclusions

This large nationwide population-based cohort study suggests that there is no increased risk for herpes zoster among people who have LC compared to a matching population.

Cost-effectiveness of vaccination against herpes zoster

Herpes zoster (HZ) is a common disease among elderly, which may develop into a severe pain syndrome labeled postherpetic neuralgia (PHN). A live-attenuated varicella zoster virus vaccine has been shown to be effective in reducing the incidence and burden of illness of HZ and PHN, providing the opportunity to prevent significant health-related and financial consequences of HZ. In this review, we summarize the available literature on cost-effectiveness of HZ vaccination and discuss critical parameters for cost-effectiveness results. A search in PubMed and EMBASE was performed to identify full cost-effectiveness studies published before April 2013. Fourteen cost-effectiveness studies were included, all performed in western countries. All studies evaluated cost-effectiveness among elderly above 50 years and used costs per quality-adjusted life year (QALY) gained as primary outcome. The vast majority of studies showed vaccination of 60- to 75-year-old individuals to be cost-effective, when duration of vaccine efficacy was longer than 10 years. Duration of vaccine efficacy, vaccine price, HZ incidence, HZ incidence and discount rates were influential to the incremental cost-effectiveness ratio (ICER). HZ vaccination may be a worthwhile intervention from a cost-effectiveness point of view. More extensive reporting on methodology and more detailed results of sensitivity analyses would be desirable to address uncertainty and to guarantee optimal comparability between studies, for example regarding model structure, discounting, vaccine characteristics and loss of quality of life due to HZ and PHN.

Gabapentin enacarbil extended release for the treatment of postherpetic neuralgia in adults

The development of biomedical technology is allowing refinement of drug therapies in order to improve medication profiles and benefit patients. Gabapentin (Gp) is a medication licensed globally for various indications, including postherpetic neuralgia. It has a pharmacokinetic profile which has been suggested may limit its clinical effects and reduce medication compliance. In 2012, the US Food and Drug Administration licensed a novel preparation which aims to circumvent these limitations. Gp enacarbil is a prodrug of Gp, which is additionally prepared in an extended release preparation. The resulting compound has an improved absorption profile and a reduced dosing frequency in comparison to immediate release Gp. An absence of comparative data, however, limits the direct evaluation of the medication to both immediate release and other extended release preparations available on the market. Additionally, no data are currently available addressing efficacy, tolerability, or side effects with other first line treatments of postherpetic neuralgia. Additional experimental data should be sought to clarify the position of Gp enacarbil, both within postherpetic neuralgia treatment protocols and in relation to the increasing numbers of gabapentinoids available.

Statins and the risk of herpes zoster: a population-based cohort study

Statins have immunomodulating properties that may increase the risk of varicella-zoster virus reactivation. We found that older patients treated with statins were at an increased risk of developing herpes zoster relative to individuals who were not prescribed to these drugs.

Background. Statins are widely used lipid-lowering drugs with immunomodulatory properties that may favor reactivation of latent varicella-zoster virus infection. However, whether statins increase the risk of herpes zoster is unknown.

Methods. We conducted a population-based retrospective cohort study of Ontario residents aged ≥66 years between 1 April 1997 and 31 March 2010 to examine the association between statin use and incidence of herpes zoster. We used propensity score matching to ensure similarity between users and nonusers of statins, and Cox proportional hazard models to assess differences in outcomes between study groups. To test the specificity of our findings, we examined the association between statin exposure and knee arthroplasty.

Results. During the 13-year study period, we matched 494 651 individuals treated with a statin to an equal number of untreated individuals. In the main analysis, the rate of herpes zoster was higher among users of statins relative to nonusers of these drugs (13.25 vs 11.71 per 1000 person-years, respectively; hazard ratio [HR], 1.13; 95% confidence interval [CI], 1.10–1.17). The attributable fraction of exposed individuals was 11.6%. In a prespecified analysis, we found a similar risk of herpes zoster among statin users in the subgroup of patients with diabetes (HR, 1.18; 95% CI, 1.09–1.27). As expected, we found no association between statin use and knee arthroplasty (HR, 1.04; 95% CI, .99–1.09).

Conclusions. Among older patients, treatment with statins is associated with a small but significantly increased risk of herpes zoster.

The short- and long-term risk of stroke after herpes zoster - a nationwide population-based cohort study

BACKGROUND AND OBJECTIVE

Varicella zoster virus (VZV) is known to cause VZV vasculopathy, which may be associated with stroke. A recent study found an increased risk of stroke within one year of herpes zoster. We aimed to investigate the short and long-term effects of herpes zoster on the risk of stroke.

METHODS

Using Danish national registers, we constructed a cohort consisting of all Danish adults ≥18 years old between 1995 and 2008 (n = 4.6 million; person-years of follow-up = 52.9 million). Individual-level information on prescriptions for herpes zoster antiviral treatment and diagnoses of stroke was obtained from national registers. We compared the risk of stroke in persons who had received the specific dosage of acyclovir for herpes zoster with persons who had never received antiviral treatment by Poisson regression.

RESULTS

During follow-up, 2.5% received treatment for herpes zoster and 5.0% were diagnosed with stroke. Individuals who had received medication had a 127% (95% CI 83-182%) increased risk the first two weeks, 17% (CI 9-24%) between two weeks and one year, and 5% (2-9%) after the first year. The increased risk was greatest in the youngest age group (<40). To control for healthcare-seeking behaviour, we conducted parallel analyses investigating the risk of selected fractures after herpes zoster and found no similar increased risks.

CONCLUSIONS

This large nationwide cohort study found an increased risk of stroke after treatment for herpes zoster. Although the short-term risk was particularly high, we cannot rule out the possibility of a small but important long-term risk.

Herpes zoster

Herpes zoster is a common condition that significantly affects health-related quality of life. Most cases occur in immunocompetent individuals older than 60 years; however, immunosuppressed patients are at particularly high risk. Post-herpetic neuralgia is the most common serious complication of herpes zoster, and is much more common in the very elderly. Vaccination with the zoster vaccine is recommended for most people older than 60, and reduces the incidence of herpes zoster and the occurrence of post-herpetic neuralgia.

Herpes zoster as a marker of underlying malignancy

BACKGROUND

Both herpes zoster and malignancy are associated with immunosuppression. However, the association between herpes zoster and the subsequent diagnosis of malignancy is unclear. We undertook this study to assess whether a diagnosis of herpes zoster is a risk factor for subsequent malignancy.

METHODS

For this matched retrospective cohort study, a physician billing database was used to identify individuals 18 years of age or older with a diagnosis of herpes zoster and no prior diagnosis of cancer or HIV infection. Individuals with a herpes zoster diagnosis were matched one-to-one to individuals without a herpes zoster diagnosis, and both groups were examined for up to 5 years for diagnosis of cancer.

RESULTS

A total of 542,575 individuals with a diagnosis of herpes zoster were identified. Compared with matched controls, these patients were more likely (p < 0.001) to have a history of myocardial infarction, asthma, congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus, and hypertension. The incidence of cancer was significantly greater among individuals with herpes zoster than among those without herpes zoster, for both men and women and across all time intervals studied (up to 5 years). The greatest adjusted hazard ratio was seen 180 days after a herpes zoster diagnosis (1.19, 95% confidence interval 1.12-1.25); the hazard ratio decreased as the time from herpes zoster diagnosis increased. Lymphoma was the type of cancer with the greatest relative increase in incidence following diagnosis of herpes zoster.

INTERPRETATION

There is a risk of malignancy following an episode of herpes zoster in both men and women and in all age groups 18 years and over. The risk is greatest during the first 180 days following the diagnosis of herpes zoster.