Herpes zoster infection

Cost burden and temporal trends of herpes zoster in China: Evidence from Beijing's health records

Objective

Herpes zoster poses a significant health threat to the aging population in China. This study aimed to analyze the cost burden and temporal trends of herpes zoster in China.

Methods

This study encompassed herpes zoster outpatients from 15 hospitals between 2016 and 2023 and herpes zoster inpatients from 175 hospitals between 2013 and 2023. We used descriptive analysis and log-linear model to investigate herpes zoster related cost burden and their temporal trends during the selected period.

Results

Over the past eight years, outpatient visits increased by about 23.8 % across the selected hospitals, while inpatient discharges increased by approximately 124.8 %. About 23.6 % of the outpatient cases were under 45 years of age. The cost per outpatient visit fluctuated at approximately 57 USD, while the cost per hospitalization increased by over 20 %, reaching around 1931 USD in 2023. Older patients and those with post-herpetic neuralgia experienced higher herpes zoster related healthcare costs and utilization.

Conclusions

Our findings suggest that although the average cost per visit or discharge changed little in China, the growing demand for herpes zoster healthcare highlights the necessity of more preventive efforts to reduce the burden on both individuals and the healthcare system.

Fulminant hepatitis and multi-organ failure following varicella zoster virus infection in an adult with G6PD deficiency: a case report

BACKGROUND

Varicella zoster virus (VZV) infection in adults can lead to severe complications, particularly in those with underlying comorbidities. This case report presents a rare instance of VZV-associated fulminant hepatitis progressing to multi-organ failure in a 27-year-old female with glucose-6-phosphate dehydrogenase (G6PD) deficiency.

CASE PRESENTATION

The patient presented with a generalized rash and rapidly developed acute liver failure, coagulopathy, and renal dysfunction. Despite aggressive management, including intravenous immunoglobulin therapy and supportive care, the patient's condition deteriorated, ultimately resulting in mortality.

CONCLUSIONS

This case highlights the potential for severe hepatic complications in adult VZV infections, especially in patients with G6PD deficiency, and underscores the importance of early recognition and aggressive management. It also raises awareness about the risks associated with concomitant medication use, including over-the-counter drugs and herbal supplements, in the context of acute viral infections.

CLINICAL TRIAL NUMBER

Not applicable.

Global and regional estimates of vaccine-associated herpes zoster and their related vaccines from 1969 to 2023

Vaccine-induced immunosuppression can reactivate the varicella-zoster virus, potentially leading to the development of herpes zoster. However, the literature on this topic is inconsistent, resulting in limited clarity. Therefore, we aimed to enhance our understanding of vaccine-associated herpes zoster and establish guidelines for future research, utilizing a global database to improve global public health. We investigated vaccine-associated adverse events in herpes zoster using reports (~ 13 million reports) from the WHO international pharmacovigilance database. Data were analyzed for the global number of reports, reported odds ratios (ROR), and information components (IC) to determine the potential association between 18 vaccines and vaccine-associated herpes zoster reports in nearly 170 countries and territories from 1969 to 2023. Of 7,805,380 vaccine-associated adverse events, there were 51,985 herpes zoster reports. Vaccine-associated herpes zoster showed the highest strength of association with COVID-19 mRNA vaccines (ROR, 11.85 [95% CI, 11.70-12.01]; IC, 2.74 [IC0.25, 2.72]), followed by encephalitis (ROR, 4.07 [95% CI, 3.37-4.92]; IC, 2.00 [IC0.25, 1.68]), influenza (ROR, 3.44 [95% CI, 3.28-3.62]; IC, 1.77 [IC0.25, 1.69]), and ad5-vectored COVID-19 vaccines (ROR, 3.05 [95% CI, 2.97-3.14]; IC, 1.54 [IC0.25, 1.50]). The ROR and IC of vaccine-associated herpes zoster in males (ROR, 7.94 [95% CI, 7.80-8.08]; IC, 2.47 [IC0.25, 2.45]) and females (ROR, 6.71 [95% CI, 6.62-6.80]; IC, 2.30 [IC0.25, 2.28]). The ROR and IC increased with advancing age. Our findings emphasize the need to consider the immune status of vaccine recipients and to implement appropriate compensation and management manuals for vaccine-associated herpes zoster.

The association between age and acute pain sensitivity in patients with Herpes Zoster

Herpes zoster has a well-established increased incidence in older adults, but the relationship between age and acute pain severity remains less clear. This retrospective study aimed to explore the association between age and pain intensity in Herpes zoster patients. A total of 613 patients treated at the Second Affiliated Hospital of Guangxi Medical University were included. Pain intensity was measured using the Numerical Rating Scale-11, and statistical models were applied to evaluate age-related pain differences while controlling for confounders. While older age was associated with higher pain scores (β = 0.02, p < 0.001), the effect size was small. Other factors, such as pain duration and inflammatory markers (e.g., CRP levels), showed stronger associations with pain severity. These findings suggest that age may not be the dominant factor in Herpes zoster pain severity, and a more comprehensive approach is required for risk assessment and pain management in clinical practice.

Combining fire needle plus cupping with famciclovir and gabapentin in the treatment of acute herpes zoster: a revised intervention approach

This study aimed to investigate the efficacy and safety of fire needle plus cupping (FC) combined with oral famciclovir and gabapentin for the treatment of acute-phase herpes zoster (AHZ). This study was conducted as a superiority, randomized controlled trial in which 84 patients with AHZ who met the diagnostic criteria were selected and randomly assigned to three groups on a 1:1 basis. Group A: received oral famciclovir with gabapentin treatment (FG); Group B: received fire needle plus cupping (FC) with FG. The primary outcome was the difference in patients' pain levels as assessed by the VAS scale. Secondary outcomes were changes in sign-symptom scores, incidence of adverse effects, and incidence of PHN. After one week of treatment, both groups showed decreased VAS scores and symptom-sign scores compared to baseline. However, the decrease in VAS scores was significantly higher in Group B compared to Group A (p < 0.0001). Similarly, the improvement in symptom-sign scores was significantly better in Group B (p < 0.0001). Group A experienced a higher rate of adverse reactions (21.95%) compared to Group B (4.76%), with a significant difference between the groups (p = 0.021). Furthermore, the incidence of PHN was significantly lower in Group B (4.76%) compared to Group A (29.27%) (p = 0.003). Fire needle therapy combined with medication demonstrated superior analgesic effects, improved symptom relief, and reduced adverse reactions and the incidence of PHN compared to medication alone in the treatment of AHZ. Importantly, the fire needle and cupping therapy should be considered an add-on therapy to standard drug treatment, rather than a standalone treatment. Additionally, due to the lack of a sham-treated control group, the placebo effect associated with invasive therapies such as fire needling and cupping. Future studies should include a sham control group to better isolate the true effects of the treatment. Clinical trial registration: This study was registered with the Chinese Clinical Trial Registry under the code ChiCTR1800015372 ( https://www.chictr.org.cn ). Registered on 28 March 2018. All experiments on the participants were following the Declaration of Helsinki.

Analysis of Risk Factors and Development and Validation of a Dynamic Nomogram for Postherpetic Neuralgia: A Retrospective Study

Purpose

Postherpetic Neuralgia (PHN), recognized as the most common complication of Herpes Zoster, is experiencing an increasing trend in its occurrence. The goal of this study was to identify the independent risk factors for PHN and create a dynamic nomogram using routine clinical characteristics to predict PHN in patients with herpes zoster, for early identification and prevention of PHN.

Patients and Methods

A total of 2420 patients were retrospectively reviewed and divided into training (n=1696) and validation (n=724) cohort using a 7:3 random allocation. Univariable, LASSO and multivariable logistic regression analysis was performed to identified independent risk factors for PHN. A dynamic nomogram was assessed through the area under the receiver operating characteristic curve (AUC), calibration curves and Hosmer-Lemeshow test. The decision curve analysis (DCA) was used to evaluate its clinical validity.

Results

Multivariable logistic regression identified several independent risk factors for PHN, including age, female, diabetes mellitus, malignant tumors, and connective tissue diseases. The area under the curve was 0.698 (95% CI, 0.666-0.730) for training cohort and 0.713 (95% CI, 0.663-0.763) for the validation cohort. Calibration curve revealed a moderate consistency between actual observation and prediction. Decision curve analysis showed a risk threshold of 16% and demonstrated a clinically effective predictive model.

Conclusion

We have developed a user-friendly dynamic nomogram to predict PHN in patients with herpes zoster, which can assist in early identification and prevention of PHN.

Causal effect of gut microbiota on occurrence of herpes zoster and postherpetic neuralgia, and role of Tyzzerella 3

BACKGROUND

Previous research has established connections between gut microbiota, immune modulation, and several virus-related diseases. However, no study has explored the relationships between gut microbiota and herpes zoster and postherpetic neuralgia (PHN).

METHODS

A total of 205 taxa of gut microbiota were regarded as exposures. The occurrences of herpes zoster and PHN were selected as outcomes. The causal effects of gut microbiota on herpes zoster and PHN were estimated with multiple methods for two-sample Mendelian randomization, such as inverse variance weighted (IVW), MR-Egger, and weighted median. All results were subjected to FDR correction to prevent from possibility of multiple comparison.

RESULTS

Among the significant findings, four taxa and one genus were identified as facilitators of herpes zoster and PHN, respectively. Conversely, six genera and eleven taxa were found to inhibit herpes zoster and PHN, respectively. The causal effect of the Tyzzerella 3 was confirmed through FDR correction, making it a key focus in this study. Specifically, it was found to causally facilitate herpes zoster primarily with IVW (OR 1.420, 95% CI 1.174-1.718, p < 0.001, q = 0.039), as there is no heterogeneity or horizontal pleiotropy found.

CONCLUSIONS

With investigation of the causal association between gut microbiota, and herpes zoster/PHN, significant findings were identified in 22 different taxa. Among them, Tyzzerella 3 keeps significant after multiple comparison correction, and displays potential to facilitate the occurrence of herpes zoster.

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.

Herpes Zoster Ophthalmicus: Presentation, Complications, Treatment, and Prevention

Herpes zoster (HZ) is caused by reactivation of latent infection of varicella zoster virus (VZV) in sensory (cranial, dorsal root) ganglia. Major risk factors for HZ are increasing age and immunosuppression. HZ ophthalmicus (HZO) is a subset of HZ with involvement of the ophthalmic division of the fifth cranial trigeminal nerve. Approximately 4-20% of patients with HZ develop HZO. Approximately 50% of patients with HZO develop ocular disease, among whom up to 25% develop chronic or recurrent disease. Common manifestations of ocular disease include conjunctivitis, keratitis, and uveitis, whereas optic neuropathy and retinitis are uncommon. Due to the potential for vision impairment, ocular involvement requires urgent ophthalmic consultation. Early recognition and timely treatment with antivirals may prevent ocular complications. HZO is preventable by vaccination against HZ. Vaccine efficacy/effectiveness studies have been largely conducted for HZ with few studies assessing HZO. Both the recombinant adjuvanted vaccine (RZV) and live-attenuated vaccine (ZVL) significantly reduce the incidence of HZ and HZO in older adults. RZV is more effective than ZVL. Data on the effectiveness of vaccines for prevention of recurrent disease in patients with HZO are limited; however, vaccination is recommended. Despite recommendations to vaccinate individuals likely to benefit from an HZ vaccine, coverage for adults remains suboptimal. Barriers to vaccination include patient beliefs about HZ or HZ vaccines, and factors related to healthcare providers. In particular, the lack of a recommendation from their primary care physician is often cited by patients as a reason for remaining unvaccinated. By encouraging vaccination against HZ, physicians not only prevent HZ and HZO but also potential vision loss due to HZO.Graphical abstract available for this article.

Efficacy and safety of Pien Tze Huang capsules in patients with herpes zoster: A multicenter, randomized, double-blinded, and placebo-controlled trial

BACKGROUND

Herpes zoster (HZ) is a common medical condition accompanied by several distressing symptoms, including acute pain. Pien Tze Huang (PZH) is a well-known traditional Chinese medicine (TCM) with numerous pharmacological effects, including antiviral properties, neuroprotection, and immunity regulation.

PURPOSE

To investigate the efficacy and safety of PZH capsules in patients with HZ.

STUDY DESIGN

A multicenter, double-blinded, randomized, and placebo-controlled trial from 8 hospitals in 5 cities of China.

METHODS

Eligible participants were randomly assigned to the PZH capsule and placebo group at a 1:1 ratio. Treatment was conducted for 14 days with a window period of no more than 2 days. For the first 7 days, participants received antiviral drugs combined with PZH capsules (0.6 g/time, 3 times a day) or placebos. For the remaining 7 days, they were only treated with PZH capsules (0.6 g/time, 3 times a day) or placebos.

RESULTS

We included 222 patients in the full analysis set (FAS), and 187 patients in the per protocol set (PPS). The change of numeric rating scale pain scores from baseline to the seventh day (±1 day) after treatment in the PZH capsule group was statistically superior to the placebo group (FAS: 2.33 vs. 1.71, 97.5%CI: 0.03 ∼ 1.19; PPS: 2.29 vs. 1.51, 97.5%CI: 0.18 ∼ 1.38). In the PPS, there was a significant difference in the time (days) of pain relief between the placebo group and the PZH capsule group (Mean (SD): 5.71 (3.76) vs. 4.69 (3.57), p = 0.046). On the seventh day (±1 day) after treatment, the level of CD8+ cells in the PZH capsule group were higher than those of the placebo group (FAS: Mean (SD): 24.08 (6.81) vs. 21.93 (8.19), p = 0.007; PPS: Mean (SD): 24.26 (6.93) vs. 22.15 (8.51), p = 0.012). The level of cytotoxic lymphocyte cells found similar results on the seventh day (±1 day) (FAS: Mean (SD): 12.17 (4.65) vs. 10.55 (4.15), p = 0.018; PPS: Mean (SD): 12.25 (4.65) vs. 10.11 (3.93), p = 0.002). No serious adverse events were noted and PZH capsules were well tolerated.

CONCLUSION

PZH capsules confer therapeutic effects on HZ with the TCM symptom of stagnated heat of liver channel by substantially reducing the pain intensity, shortening the time of pain relief as well as regulating the immune function. On the basis of the efficacy and safety profiles, PZH capsules may be a promising complementary therapy for the treatment of HZ.

Humoral Cytokine Levels in Patients with Herpes Zoster: A Meta-Analysis

Background

The neurocutaneous disease caused by the reactivation of varicella-zoster virus (VZV) is called herpes zoster (HZ). The virus remains in the spinal cord back root after the chickenpox disappears. Diminished immune function can reactivate VZV, causing severe neuropathic pain that can last for months or even years, leading to postherpetic neuralgia (PHN), which severely affects the patient's quality of life. Much literature compares various cytokine levels in the body fluids HZ and PHN patients; however, no studies comprehensively evaluate them.

Methods

The Cochrane Library, PubMed, Web of Science, and Medline were screened for studies on cytokine levels in body fluids of HZ and PHN patients in the English language. Healthy individuals were selected as the control group, and the standardized mean difference (SMD) between the case and control groups was imputed using a fixed-effects or random-effects model and expressed as a 95% confidence interval (CI). The Newcastle-Ottawa Scale (NOS) was used to assess article quality.

Results

This meta-analysis included 13 articles with 1373 participants. Compared with the control group, the HZ group had significantly higher levels of interleukin (IL)-4, IL-6, IL-10, Hcy, and C-reactive protein (CRP), whereas the levels of CD3+ T and CD4+ T lymphocytes were reduced. Additionally, PHN patients had significantly higher levels of IL-6 and IL-1β compared with the control group.

Conclusion

This meta-analysis provides compelling evidence that CRP, Hcy, IL-1β, IL-4, IL-6, IL-8, and IL-10 are associated with the genesis and development of HZ and PHN. These markers can be used to improve the diagnosis and treatment of these diseases.Furthermore, for making the results more convincing, it is necessary to harmonize sample acquisition techniques and analytical methods and also require larger, more rigorously designed studies with broader subgroups and sex/age-matched controls.

Practice Patterns in the Initial Management of Herpes Zoster Ophthalmicus in the United States

PURPOSE

The aims of this study were to examine the trends in the initial management of herpes zoster ophthalmicus (HZO) in the United States from 2010 to 2018 and compare them with the treatment preferences of corneal specialists.

METHODS

A retrospective, observational deidentified cohort study was conducted on individuals enrolled in the OptumLabs Data Warehouse who had a new diagnosis of HZO from 1/1/2010 to 12/31/2018. An online survey ascertaining HZO management perspectives was distributed to The Cornea Society listserv. The main outcome assessed was proportion of cases with systemic antiviral prescriptions, eye care provider involvement, and follow-up visits after the initial HZO diagnosis.

RESULTS

Approximately 50% of patients received systemic antivirals the day of initial HZO diagnosis or within 7 days (45.6% and 53.7%, respectively). Most initial diagnoses were made by ophthalmologists (45.0%), followed by optometrists (19.2%). Referral rate to ophthalmology within a year of initial diagnosis was 38.6%. 48.7% cases had at least 1 follow-up visit with any type of provider within 30 days. Our survey of corneal specialists found 97% would prescribe systemic antivirals to those with ocular involvement, but 66% would prescribe antivirals to those without ocular or eyelid involvement. Seventy percent supported all patients having follow-up with an eye care provider within a month.

CONCLUSIONS

HZO antiviral therapies seem to be underprescribed in the United States, referral rates to ophthalmology are low, and follow-up is suboptimal, which are not aligned with recommendations from corneal specialists. More research is needed to establish standardized guidelines for treatment, referral, and follow-up with ophthalmology for HZO.

Characteristics and economic burden of hospitalized patients with herpes zoster in China, before vaccination

Herpes zoster (HZ) brings a significant economic burden. The HZ vaccine was introduced in China for the first time in 2020, and there is a lack of up-to-date information on the hospitalization costs and characteristics prior to vaccination. This study aimed to describe the characteristics and economic burden of HZ inpatients in Hunan Province, China, and analyze the factors influencing the length of stay (LOS) and costs. This was a retrospective study and we extracted information from the Chinese National Health Statistics Network Reporting System on HZ inpatients in Hunan Province, China from 2017 to 2019. Spatial join tools and Global or Local Moran's Index were used for the geographic analysis of hospitalized HZ incidence. Multivariate linear regression models were used to analyze the factors influencing LOS and costs. There were 44,311 HZ inpatients included in this study, incurring a total of $31,857,734 medical costs. These patients had a median LOS of 8 days and a median expenditure of $573.47. Older age, more comorbidities, and the presence of complications with nervous system involved were all significantly associated with longer LOS and higher costs. HZ infection resulted in a large direct medical cost and heavy disease burden, especially in patients with advanced age or underlying medical conditions. The HZ vaccine has the potential to effectively reduce the disease burden and should be widely popularized especially among high-risk groups.

Corticosteroids for preventing postherpetic neuralgia

BACKGROUND

Postherpetic neuralgia (PHN) is a common, serious, painful complication of herpes zoster. Corticosteroids have anti-inflammatory properties, and might be beneficial. This is an update of a review first published in 2008, and previously updated in 2013.

OBJECTIVES

To assess the effects (benefits and harms) of corticosteroids in preventing postherpetic neuralgia.

SEARCH METHODS

We updated the searches for randomised controlled trials (RCTs) of corticosteroids for preventing postherpetic neuralgia in the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, two other databases, and two trials registers (June 2022). We also reviewed the bibliographies of identified trials, contacted authors, and approached pharmaceutical companies to identify additional published or unpublished data.

SELECTION CRITERIA

We included all RCTs involving corticosteroids given by oral, intramuscular, or intravenous routes for people of all ages, with herpes zoster of all degrees of severity within seven days after onset, compared with no treatment or placebo, but not with other treatments.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified potential articles, extracted data, assessed the risk of bias of each trial, and the certainty of the evidence. Disagreement was resolved by discussion among the co-authors. We followed standard Cochrane methodology.

MAIN RESULTS

We identified five trials with a total of 787 participants that met our inclusion criteria. No new studies were identified for this update. All were randomised, double-blind, placebo-controlled parallel-group studies. The evidence is very uncertain about the effects of corticosteroids given orally during an acute herpes zoster infection in preventing postherpetic neuralgia six months after the onset of herpes (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.45 to 1.99; 2 trials, 114 participants; very low-certainty evidence (downgraded for serious risk of bias and very serious imprecision)). The three other trials that fulfilled our inclusion criteria were not included in the meta-analysis because they did not provide separate information on the number of participants with PHN at six months. Adverse events during or within two weeks after stopping treatment were reported in all five included trials. There were no observed differences in serious (RR 1.65, 95% CI 0.51 to 5.29; 5 trials, 755 participants; very low-certainty evidence (downgraded for serious risk of bias and very serious imprecision)), or non-serious adverse events (RR 1.30, 95% CI 0.90 to 1.87; 5 trials, 755 participants; low-certainty evidence (downgraded for serious risk of bias and serious imprecision)) between the corticosteroid and placebo groups. One of these trials was at high risk of bias because of incomplete outcome data, two were at unclear risk of bias, and the other was at low risk of bias. The review was first published in 2008; no new RCTs were identified for inclusion in subsequent updates in 2010, 2013, and 2023.

AUTHORS' CONCLUSIONS

Based on the current available evidence, we are uncertain about the effects of corticosteroids given orally during an acute herpes zoster infection on preventing postherpetic neuralgia. Corticosteroids given orally or intramuscularly may result in little to no difference in the risk of adverse events in people with acute herpes zoster. Some researchers have recommended using corticosteroids to relieve the zoster-associated pain in the acute phase of the disease. If further research is designed to evaluate the efficacy of corticosteroids for herpes zoster, long-term follow-up should be included to observe their effect on the transition from acute pain to postherpetic neuralgia. Future trials should include measurements of function and quality of life, as well as updated measures of pain.

Infectious Neuropathies

OBJECTIVE

This article discusses the clinical manifestations and management of infectious peripheral neuropathies.

LATEST DEVELOPMENTS

Several infectious etiologies of peripheral neuropathy are well-recognized and their treatments are firmly established. The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is associated with several central and peripheral nervous system manifestations, including peripheral neuropathies. Additionally, some COVID-19 vaccines have been associated with Guillain-Barré syndrome. These disorders are an active area of surveillance and research. Recent evidence-based guidelines have provided updated recommendations for the diagnosis and treatment of Lyme disease.

ESSENTIAL POINTS

Infectious agents of many types (primarily bacteria and viruses) can affect the peripheral nerves, resulting in various clinical syndromes such as mononeuropathy or mononeuropathy multiplex, distal symmetric polyneuropathy, radiculopathy, inflammatory demyelinating polyradiculoneuropathy, and motor neuronopathy. Knowledge of these infections and the spectrum of peripheral nervous system disorders associated with them is essential because many have curative treatments. Furthermore, understanding the neuropathic presentations of these disorders may assist in diagnosing the underlying infection.

Immunogenicity and Efficacy of Vaccination in People Living with Human Immunodeficiency Virus

People living with HIV (PLWH) remain at high risk of mortality and morbidity from vaccine-preventable diseases, even though antiretroviral therapy (ART) has restored life expectancy and general well-being. When, which, and how many doses of vaccine should be administered over the lifetime of PLWH are questions that have become clinically relevant. Immune responses to most vaccines are known to be impaired in PLWH. Effective control of viremia with ART and restored CD4+ T-cell count are correlated with an improvement in responsiveness to routine vaccines. However, the presence of immune alterations, comorbidities and co-infections may alter it. In this article, we provide a comprehensive review of the literature on immune responses to different vaccines in the setting of HIV infection, emphasizing the potential effect of HIV-related factors and presence of comorbidities in modulating such responses. A better understanding of these issues will help guide vaccination and prevention strategies for PLWH.

Clinical efficacy of LED golden light combined with acyclovir in the treatment of herpes zoster: a single-center prospective study

This study aimed to explore the safety and clinical efficacy of light emitting diode (LED) golden light combined with acyclovir in treating herpes zoster (HZ). According to the random number table, 54 inpatients with HZ were divided into control group, golden-light group, and red-light group, with 18 cases in each group. The control group received acyclovir intravenous drip, while the patients in the red-light group received acyclovir intravenous drip and red-light LED phototherapy, and the golden-light group received acyclovir intravenous drip and golden-light LED phototherapy. Primary assessments included herpes stopping time, incrustation time, decrustation time, pain visual analog scale scores (VAS), and incidence of postherpetic neuralgia (PHN) on the 30th and 90th days. Golden-light group and red-light group showed a shorter herpes stopping time, incrustation time, and decrustation time (P < 0.05) compared to the control group (P < 0.05), while the golden-light group showed a shorter incrustation time and decrustation time than the red light group (all P < 0.05). After treatment VAS scores, the golden-light group showed a significant improvement compared to the control group. The golden-light group showed a better PHN incidence than the control group at 30 days follow-up. Compared with the comprehensive curative effect, the total effective rates of the golden-light group, red-light group, and control group were 88.89%, 77.78%, and 72.22%, respectively, and the efficacy of the golden-light group was better than that of the control group and red-light group. Golden light combined with acyclovir can shorten the course of HZ, relieve pain, and reduce the occurrence of PHN, and the effect is better than that of the red-light group and the control group.

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.

Bidirectional two-sample Mendelian randomization analysis reveals a causal effect of interleukin-18 levels on postherpetic neuralgia risk

Background

Postherpetic neuralgia (PHN) is a debilitating complication of herpes zoster, characterized by persistent neuropathic pain that significantly impairs patients' quality of life. Identifying factors that determine PHN susceptibility is crucial for its management. Interleukin-18 (IL-18), a pro-inflammatory cytokine implicated in chronic pain, may play a critical role in PHN development.

Methods

In this study, we conducted bidirectional two-sample Mendelian randomization (MR) analyses to assess genetic relationships and potential causal associations between IL-18 protein levels increasing and PHN risk, utilizing genome-wide association study (GWAS) datasets on these traits. Two IL-18 datasets obtained from the EMBL's European Bioinformatics Institute database which contained 21,758 individuals with 13,102,515 SNPs and Complete GWAS summary data on IL-18 protein levels which contained 3,394 individuals with 5,270,646 SNPs. The PHN dataset obtained from FinnGen biobank had 195,191 individuals with 16,380,406 SNPs.

Results

Our findings from two different datasets of IL-18 protein levels suggest a correlation between genetically predicted elevations in IL-18 protein levels and an increased susceptibility to PHN.(IVW, OR and 95% CI: 2.26, 1.07 to 4.78; p = 0.03 and 2.15, 1.10 to 4.19; p =0.03, respectively), potentially indicating a causal effect of IL-18 protein levels increasing on PHN risk. However, we did not detect any causal effect of genetic liability to PHN risk on IL-18 protein levels.

Conclusion

These findings suggest new insights into identifying IL-18 protein levels increasing at risk of developing PHN and may aid in the development of novel prevention and treatment approaches for PHN.

Prevalence and risk factors of herpes zoster infection in patients with rheumatic diseases not receiving biologic or targeted therapies

OBJECTIVES

The objective was to study the prevalence and risk factors of herpes zoster (HZ) infection in patients with rheumatic diseases.

METHODS

Consecutive patients with rheumatic diseases not receiving biologic/targeted DMARDs who attended our rheumatology clinics between March and August 2019 were retrospectively reviewed. Episodes of HZ infection since their first clinic attendance were identified. Laboratory results (total white cell count, neutrophil-to-lymphocyte ratio (NLR), serum albumin, globulin, and creatinine) and use of immunosuppressive medications were compared between those with (preceding infection) and without (preceding last visit) HZ infection. Cox regression analysis was performed to identify factors associated with the first HZ infection in all patients.

RESULTS

1,479 patients were studied (88.3% women, age 45.0 ± 15.8 years). Systemic lupus erythematosus (SLE) (38.7%) and rheumatoid arthritis (28.3%) were the commonest rheumatic diseases. After a follow-up of 14,715 patient-years (9.9 ± 7.0 years), 219 (14.8%) patients developed 258 episodes of HZ infection, giving an overall prevalence of 1.75/100-patient years. The prevalence rates of HZ were highest in SLE and inflammatory myopathies (2.54 and 2.58 per 100 patient-years, respectively). Patients who experienced HZ reactivation were younger, more likely to have SLE, and had significantly lower serum albumin/globulin levels but higher NLR. Significantly more patients with HZ reactivation were using prednisolone and other immunosuppressive drugs in the visits preceding HZ infection. The cumulative risk of having HZ reactivation at 24 and 48 months was 4.9% and 7.6%, respectively. Cox regression analysis revealed that a diagnosis of SLE, increasing age, higher NLR, use of cyclophosphamide, and increasing doses of prednisolone, azathioprine, hydroxychloroquine and leflunomide were independently associated with HZ infection.

CONCLUSIONS

Reactivation of HZ is fairly common in patients with rheumatic diseases. Underlying SLE, age, neutrophil/lymphocyte ratio, and immunosuppressive therapies are independent risk factors. Key Points • Herpes zoster (HZ) infection is fairly common in patients with rheumatic diseases undergoing conventional DMARD or immunosuppressive therapies. • Underlying SLE, increasing age, higher neutrophil/lymphocyte ratio and increasing dosages of immunosuppressive drugs are independent risk factors. • Patients with rheumatic diseases, particularly SLE, should be encouraged to receive HZ vaccination.

Patterns and Trends in Pharmacological Treatment for Outpatients with Postherpetic Neuralgia in Six Major Areas of China, 2015-2019

The aim of this study was to assess the patterns and trends of pharmacological treatment for outpatients with postherpetic neuralgia (PHN) in China in the period 2015-2019. Prescription data for outpatients with PHN were extracted from the database of the Hospital Prescription Analysis Program of China according to the inclusion criteria. The trends in yearly prescriptions and corresponding costs were analyzed and stratified by drug class and specific drugs. A total of 19,196 prescriptions from 49 hospitals in 6 major regions of China were included for analysis. The yearly prescriptions increased from 2534 in 2015 to 5676 in 2019 (p = 0.027), and the corresponding expenditures increased from CNY 898,618 in 2015 to CNY 2,466,238 in 2019 (p = 0.027). Gabapentin and pregabalin are the most commonly used drugs for PHN, and more than 30% of these two drugs were combined with mecobalamin. Opioids were the second most frequently prescribed drug class, and oxycodone accounted for the largest share of the cost. Topical drugs and TCAs are rarely used. The frequent use of pregabalin and gabapentin was in accordance with current guidelines; however, the use of oxycodone raised concerns about rationality and economic burden. The results of this study may benefit the allocation of medical resources and management for PHN in China and other countries.

Systematic review with network meta-analysis: Risk of Herpes zoster with biological therapies and small molecules in inflammatory bowel disease

BACKGROUND

Biologics and small molecules for inflammatory bowel disease (IBD) may increase infection risk. Herpes zoster causes acute and long-term symptoms, but vaccination is not recommended in patients with IBD, unless >50 years of age.

AIMS

To examine risk of Herpes zoster infection with all licensed biologics and small molecules for IBD using network meta-analysis.

METHODS

We searched the literature to 4th October 2022, for randomised controlled trials of these drugs in luminal Crohn's disease or ulcerative colitis reporting data on occurrence of Herpes zoster infection during follow-up. We used a frequentist approach and a random effects model, pooling data as relative risks (RRs) with 95% confidence intervals (CIs).

RESULTS

We identified 25 trials (9935 patients). Only tofacitinib 10 mg b.d. (RR = 6.90; 95% CI 1.56-30.63, number needed to harm (NNH) = 97; 95% CI 19-1022) and upadacitinib 45 mg o.d. (RR = 7.89; 95% CI 1.04-59.59, NNH = 83; 95% CI 10-14,305) were significantly more likely to increase risk of Herpes zoster infection. Janus kinase inhibitors were the most likely drug class to increase risk of infection, and risk increased with higher doses (RR with lowest dose = 3.16; 95% CI 1.02-9.84, NNH = 265; 95% CI 65-28,610, RR with higher dose = 5.91; 95% CI 2.21-15.82, NNH = 117; 95% CI 39-473).

CONCLUSIONS

In a network meta-analysis, the janus kinase inhibitor tofacitinib, and all janus kinase inhibitors considered as a class, were most likely to increase risk of Herpes zoster infection. Risk increased with higher doses.

Varicella zoster virus reactivation following COVID-19 vaccination in patients with autoimmune inflammatory rheumatic diseases: A cross-sectional Chinese study of 318 cases

Recently, varicella-zoster virus (VZV) reactivation has been observed after the administration of coronavirus disease 2019 (COVID-19) vaccines. Autoimmune inflammatory rheumatic diseases (AIIRDs) patients are at a higher risk for VZV reactivation for immunocompromised status. The study aimed to investigate the adverse events (AEs), especially VZV reactivation, following vaccination against  severe acute respiratory syndrome coronavirus-2 in a Chinese cohort of AIIRD patients. A cross-sectional survey using an online questionnaire was conducted among AIIRD patients and healthy controls (HCs). Multivariate logistic regression was used to identify potential factors associated with VZV reactivation. 318 AIIRD patients and 318 age and sex-matched HCs who got COVID-19 inactivated vaccines were recruited. The main AIIRDs are rheumatoid arthritis (31.8%) and systemic lupus erythematous (23.9%). Most of patients (85.5%) had stable disease and 13.2% of them had aggravation after vaccination. Compared to HCs, patients had higher rates of rash (p = 0.001), arthralgia (p < 0.001) and insomnia (p = 0.007). In addition, there were 6 (1.9%) AIIRD patients and 5 (1.6%) HCs reported VZV reactivation after the COVID-19 vaccination (p = 0.761). Multivariate logistic regression analysis illustrated that diabetes mellitus (odd ratio [OR], 20.69; 95% confidence interval [CI], 1.08-396.79; p = 0.044), chronic hepatitis B virus infection (OR, 24.34; 95% CI, 1.27-466.74; p = 0.034), and mycophenolate mofetil (OR, 40.61; 95% CI, 3.33-496.15; p = 0.004) independently identified patients with VZV reactivation. Our findings showed that the inactivated COVID-19 vaccination was safe for AIIRD patients though some patients could suffer from VZV reactivation.

Association between a History of herpes zoster and the risk of Sjögren's syndrome: a nationwide, population-based, case-control study

OBJECTIVE

Viral infection is an exogenous factor for Sjögren's syndrome (SS). The relationship between herpes zoster infection and the ensuring risk of SS has remained unclear. This study investigated the association between a history of herpes zoster infection and the risk of SS through a nationwide population-based case-control study.

DESIGN

Retrospective case-control study.

SETTING

General population of Taiwan.

DATA SOURCE

2003-2013 National Health Insurance Research Database of Taiwan.

PARTICIPANTS

We identified all patients with newly diagnosed SS between 1 January 2007 and 31 December 2012 without a history of rheumatoid arthritis or systemic lupus erythematosus as the SS group.

CONTROLS

We randomly selected patients without SS between 1 January 2003 and 31 December 2012 and matched 1:5 with controls based on index year, age and sex.

MAIN OUTCOME MEASURE

Conditional logistic regression analysis to examine the association between a history of herpes zoster and the risk of SS.

RESULTS

The study included 5751 patients with SS and 28 755 matched controls. The risk of SS was significantly associated with a history of herpes zoster (model A (adjusted for Charlson Comorbidity Index (CCI) (excluding connective tissue disease, CTD)): OR 1.89; 95% CI 1.71 to 2.08; model B (adjusted for comorbidities used to calculate CCI (excluding CTD)): OR 1.90; 95% CI 1.72 to 2.10), in particular if the interval from the last visit for herpes zoster infection to the index date was <3 months (model A: OR 3.09; 95% CI 2.20 to 4.34; model B: OR 3.13; 95% CI 2.20 to 4.45). Such associations remained robust using various definitions of herpes zoster.

CONCLUSION

This nationwide, population-based, case-control study revealed a significant association between a history of herpes zoster and the risk of SS.

Efficacy, effectiveness, and safety of herpes zoster vaccine in the immunocompetent and immunocompromised subjects: A systematic review and network meta-analysis

Objective

To investigate the efficacy, effectiveness and safety of recombinant zoster vaccine (RZV) and zoster vaccine live (ZVL) in immunocompetent and immunocompromised subjects.

Methods

Data sources: PubMed, EMBASE, Cochrane Library, and Web of Science databases (up to Jan 2022) were searched to identify English articles. Search terms included randomized controlled trials (RCTs), observational studies, herpes zoster, RZV, ZVL. Study Selection: Only randomized controlled trials (RCTs) evaluating vaccine efficacy and safety and observational studies assessing vaccine effectiveness (after a vaccine was approved for marketing) were included. Data Extraction: Two researchers independently screened the literature, extracted the data, and checked the each other results.

Results

Seventeen RCTs and 19 cohort studies were included. Among immunocompetent subjects, RZV was superior to ZVL at wide intervals (relative vaccine efficacy: 84%, 95% CI: 53%–95%; relative vaccine effectiveness: 49%, 95% CI: 21%–67%), across genders and subjects aged ≥ 60 years. Among immunocompromised subjects, RZV was superior to placebo in terms of vaccine efficacy (60%, 95% CI: 49%–69%). There was no difference between ZVL and placebo in those with selected immunosuppressive conditions. RZV was 45% (95% CI: 30%–59%) superior to ZVL in real-world practice. Compared with placebo, adverse events related to RZV were primarily related to injection-site and systemic, and RZV did not increase the risk of serious adverse events (SAEs) or death. There was no difference in the incidence of adverse events between groups with and without immunosuppression.

Conclusions

Both RZV and ZVL can reduce the risk of herpes zoster in both immunocompetent and immunocompromised subjects. RZV was well-tolerated in the study population and demonstrated stronger protection than ZVL.

Systematic review registration

Prospero CRD42022310495.

Effect and safety of extracorporeal shockwave therapy for postherpetic neuralgia: A randomized single-blind clinical study

Objective

To evaluate the efficacy and safety of extracorporeal shockwave therapy (ESWT) for postherpetic neuralgia.

Design

Randomized single-blind clinical study.

Patients

Patients with postherpetic neuralgia.

Methods

Patients were randomly divided into the control group and the ESWT group. The control group received conventional treatment while the ESWT group received conventional treatment and ESWT. The primary outcome is pain degree as assessed by the numeric rating scale (NRS), and secondary outcomes include brief pain inventory (BPI), Self-rating Anxiety Scale (SAS), Self-rating Depression Scale (SDS), and Pittsburgh Sleep Quality Index (PSQI). Data were collected at baseline and at weeks 1, 4, and 12. Linear mixed-effects models were applied to repeated measurement data.

Results

The scores on the NRS, BPI, SAS, SDS, and PSQI decreased over time in both groups. The NRS and SDS scores of the ESWT group were statistically lower than the control group. There was no time × group interaction in the mixed model analysis. Baseline age was correlated with NRS scores and BPI scores, and invasive treatment was related to PSQI scores, with no interaction effect for baseline confounders observed. No adverse events were observed during the process of this trial.

Conclusion

Extracorporeal shockwave therapy combined with conventional treatment could relieve pain and improve the psychological state in patients with postherpetic neuralgia without serious adverse effects.

The potential role of ischaemia-reperfusion injury in chronic, relapsing diseases such as rheumatoid arthritis, Long COVID, and ME/CFS: evidence, mechanisms, and therapeutic implications

Ischaemia-reperfusion (I-R) injury, initiated via bursts of reactive oxygen species produced during the reoxygenation phase following hypoxia, is well known in a variety of acute circumstances. We argue here that I-R injury also underpins elements of the pathology of a variety of chronic, inflammatory diseases, including rheumatoid arthritis, ME/CFS and, our chief focus and most proximally, Long COVID. Ischaemia may be initiated via fibrin amyloid microclot blockage of capillaries, for instance as exercise is started; reperfusion is a necessary corollary when it finishes. We rehearse the mechanistic evidence for these occurrences here, in terms of their manifestation as oxidative stress, hyperinflammation, mast cell activation, the production of marker metabolites and related activities. Such microclot-based phenomena can explain both the breathlessness/fatigue and the post-exertional malaise that may be observed in these conditions, as well as many other observables. The recognition of these processes implies, mechanistically, that therapeutic benefit is potentially to be had from antioxidants, from anti-inflammatories, from iron chelators, and via suitable, safe fibrinolytics, and/or anti-clotting agents. We review the considerable existing evidence that is consistent with this, and with the biochemical mechanisms involved.

Antiviral treatment in outpatients with herps zoster in six major areas of China, 2010–2019

Objective

The objective of this study was to assess the status and trends of antiviral treatment in outpatients with herpes zoster in China.

Methods

Prescription data on antiviral drugs were extracted from the database of the Hospital Prescription Analysis Program of China according to the inclusion criteria. Yearly prescriptions and costs were calculated, and trends were analyzed. The trends were further stratified by age, sex, and specific drug use. The distribution of defined daily costs (DDCs) of valaciclovir and famciclovir were analyzed, and trends in the median DDCs were identified.

Results

A total of 132,911 prescriptions from 49 hospitals located in six major areas of China were included in the analysis. The yearly prescriptions containing antivirals increased from 8,819 in 2010 to 16,361 in 2019. The percentage of prescriptions for patients aged 65 years and above also increased (27.7% in 2010 to 31.0% in 2019), and the number of prescriptions for females was higher than those for males (P < 0.001). The average cost of antivirals per prescription decreased; thus, the yearly cost showed no increasing trend. The main prescribed antivirals were valaciclovir and famciclovir, which progressively increased in prescriptions. The use of acyclovir decreased during the study period. Prescriptions containing topical formulations, acyclovir and penciclovir, both increased. The DDCs of valaciclovir and famciclovir decreased dramatically.

Conclusion

The use of antivirals has increased over the decade, while the cost has not. Antiviral treatments adhere well to recent recommendations, except for the use of topical antivirals. The findings of this study may benefit the healthcare source allocation and management of herpes zoster in China.

Dermatological Conditions Inducing Acute and Chronic Pain

Pain is a common condition in dermatology. The aim of this review is to analyse the characteristics of pain in dermatology. Some skin diseases are conventionally known to cause pain; e.g. ulcers, pyoderma gangrenosum and herpes zoster. Common dermatoses, such as psoriasis or atopic dermatitis, can also cause significant pain. Some conditions are characterized by neuropathic pain and/or pruritus, without visible primary lesions: e.g. the neurocutaneous diseases, including small fibre neuropathies. Patients often fear pain in skin surgery; however, surgical procedures are rather well tolerated and any pain is mainly due to administration of local anaesthetic. Some therapies may also be uncomfortable for the patient, such as photodynamic therapy or aesthetic procedures. Thus, pain in dermatology is common, and its aetiology and characteristics are very varied. Knowledge of the different situations that cause pain will enable dermatologists to propose suitable analgesic solutions.

Herpes Zoster Duplex Bilateralis After Trauma Induced Emotional Dysregulation: A Case Report and Literature Review

Herpes zoster (HZ) is usually distributed on one side of the body; HZ duplex bilateralis is very rare with only 0.1% of all HZ cases. The occurrence of HZ duplex bilateralis is associated with abnormal immune function. In this report, we present a case of a 47-year-old woman who had no major health issues developed HZ duplex bilateralis after an adverse life event and extreme depression one month ago. HZ related symptoms were controlled after patient received antiviral, analgesic, and nerve-nourishing treatment in our hospital.

Safety of JAK inhibitor use in patients with rheumatoid arthritis who developed herpes zoster after receiving JAK inhibitors

INTRODUCTION

To determine the safety of Janus kinase inhibitor (JAKi) use following herpes zoster (HZ) reactivation in patients with rheumatoid arthritis (RA).

METHODS

Medical records of all patients who received JAKi at a tertiary referral center between August 2015 and June 2021 were retrospectively reviewed. Data from patients who developed HZ reactivation were collected, and the HZ-related safety of those who continued JAKis after reactivation was evaluated.

RESULTS

Of the 416 patients who received JAKis, 33 (7.9%) developed HZ reactivation during treatment (tofacitinib, n = 22; baricitinib, n = 11). The mean age of the patients was 60.2 ± 11.8 years. Fourteen patients (42.4%) received glucocorticoids with a median dose of 3.75 mg of prednisone (IQR, 2.5-5.0). The median duration of JAKi administration before HZ reactivation was 11 months (IQR, 4-29). JAKi was continued in 24 (72.7%) patients during the HZ episode, while it was temporarily discontinued and then resumed after the HZ episode in 5 (15.2%) patients. Three (9.1%) patients had acute complications, such as encephalitis with HZ ophthalmicus. Four (12.1%) patients, including the 3 with complications, permanently discontinued JAKis. Of the 29 patients who were observed for a median of 12 months (IQR, 6-21) after the initial HZ reactivation episode, reactivation recurred in one (3.4%); this patient maintained JAKi treatment for a further 18 months without additional HZ recurrence.

CONCLUSION

JAKis were commonly continued or re-administered in patients with HZ reactivation, and the majority of these patients did not experience significant complications or recurrence of HZ reactivation. Thus, the use of JAKi after HZ reactivation episode seems to be tolerated.

Herpes Zoster in Four HIV Seropositive Patients and One Patient With Recurrent Carcinoma After Radiotherapy

Herpes zoster is a ubiquitous ultramicroscopic neurotropic virus that causes pruritic acute grouped vesicular eruptions and rashes, these vesicles rupture spontaneously resulting in pustules, crustations, which are pruritic in nature on the affected skin along the course of the dermatome resulting in scab. The scab withers off later leaving a permanent scar and pigmentation. The characteristic clinical finding was that vesicles or ulcers resulting from herpes zoster lesions never cross the midline. Two such reported cases of herpes zoster in seropositive HIV patients that resulted in extensive crustations and periorbital edema, left unilateral facial pain of burning quality in 25-year-old female patient and spontaneous exfoliation of a tooth in another 35-year-old patient, treated with drug therapy comprising acyclovir, gabapentin, amitriptyline are discussed here.

Association between cirrhosis and herpes zoster in a cohort study in Taiwan

OBJECTIVES

The aim of the study was to assess if an association exists between cirrhosis and herpes zoster in Taiwan.

METHODS

A retrospective cohort study was designed to analyse the 2000-2013 claim dataset of 1 million insured residents who were randomly sampled from the Taiwan National Health Insurance Program. In total, 16 190 subjects aged 20-84 years old with newly diagnosed cirrhosis since 2000 to 2012 were identified as the cirrhosis group and 16 190 sex- and age-matched subjects without cirrhosis were selected as the non-cirrhosis group. Both cirrhosis and non-cirrhosis groups were followed until a new diagnosis of herpes zoster was made or until the end of 2013. The multivariable Cox proportional hazard regression model was applied to calculate the hazard ratio (HR) and 95% confidence interval (CI) for herpes zoster associated with cirrhosis.

RESULTS

The incidence rate of herpes zoster was 1.08-fold greater in the cirrhosis group than the non-cirrhosis group (8.33 vs 7.69 per 1000 person-years, 95%CI 1.02-1.15). After adjusting for confounders, the adjusted HR of herpes zoster was 1.11 (95% CI 1.004-1.24) for the cirrhosis group compared with the non-cirrhosis group. The adjusted HR increased to 1.33 (95% CI 1.02-1.74) for the decompensated cirrhosis group compared with the non-cirrhosis group.

CONCLUSIONS

Cirrhosis is associated with a small but significant increase in the risk of herpes zoster. Given that the risk of herpes zoster is small and the expense of herpes zoster vaccination is high, whether cirrhotic persons need to be vaccinated should assess the balance of cost and benefit.

The incidence rate of herpes zoster in inflammatory bowel disease: A meta-analysis of cohort studies

ABSTRACT

Inflammatory bowel disease is associated with an increased risk of opportunistic infections. This study aimed to investigate the incidence rate of herpes zoster in patients with inflammatory bowel disease.A meta-analysis was conducted by searching PubMed literature published from January 2000 to July 2019. The main outcome was the incidence rate of a new diagnosis of herpes zoster in patients previously diagnosed with inflammatory bowel disease. The incidence rate ratio (IRR) and 95% confidence interval (95% CI) for herpes zoster associated with inflammatory bowel disease was measured.A total of 6 eligible cohort studies matching the entry criteria were included in the meta-analysis, providing 216,552 participants with inflammatory bowel disease and 790 events of herpes zoster among these participants with inflammatory bowel disease. The pooled incidence rate of developing herpes zoster was 10.41 per 1000 person-years in the inflammatory bowel disease group and 6.10 per 1000 person-years in the non-inflammatory bowel disease group, respectively. The meta-analysis demonstrated that patients with inflammatory bowel disease were associated with 1.68-fold increased risk of developing herpes zoster when compared to those without inflammatory bowel disease (IRR = 1.68, 95% CI = 1.53-1.84). Crohn disease and ulcerative colitis were associated with an increased risk of developing herpes zoster (IRR = 1.67, 95% CI = 1.40-1.98 for Crohn disease and IRR = 1.49, 95% CI = 1.34-1.65 for ulcerative colitis, respectively).Patients with inflammatory bowel disease are at increased risk of developing herpes zoster. We suggest that the vaccination should be considered at the time of inflammatory bowel disease being diagnosed.

Ultrasound-Guided Continuous Thoracic Paravertebral Infusion of Methylene Blue in the Treatment of Postherpetic Neuralgia: A Prospective, Randomized, Controlled Study

INTRODUCTION

Postherpetic neuralgia (PHN) is the most common complication of herpes zoster. Methylene blue (MB) is an inhibitor of nitric oxide synthesis with potentially analgesic and anti-inflammatory properties. Studies have demonstrated that thoracic paravertebral single MB injection is effective in treating chronic pain. However, there are rare reports of the efficacy of continuous thoracic paravertebral infusion of MB for pain management in PHN patients. The purpose of this study was to evaluate the therapeutic effects of continuous thoracic paravertebral infusion of MB on PHN.

METHODS

A total of 104 PHN patients were randomly divided into two groups: the control group (continuous thoracic paravertebral infusion of 5% lidocaine in a total volume of 300 ml) and the MB group (continuous thoracic paravertebral infusion of 5% lidocaine plus 0.2% MB in a total volume of 300 ml). All patients were evaluated using the Numerical Rating Scale (NRS), Insomnia Severity Index (ISI), Patient Health Questionnaire-9 (PHQ-9), 36-Item Short-Form Health Survey (SF-36), and medication doses before and after the procedure. The effective treatment rate and adverse complications were recorded 6 months after the procedure.

RESULTS

In both groups, the NRS scores, ISI scores, PHQ-9 scores, and rescue medication dosages were significantly decreased at different time points after treatment compared to baseline, while the SF-36 scores were evidently improved at different time points after treatment compared to baseline. Compared with the control group, the MB group had significantly reduced NRS scores, ISI scores, PHQ-9 scores, and rescue medication dosages at each observation time point. Furthermore, the SF-36 scores in the MB group were significantly higher than those in the control group at each observation time point. The total effective treatment rate of the MB group was higher than that of the control group 6 months after the procedure. No severe adverse complications were observed in either group.

CONCLUSIONS

Ultrasound-guided continuous thoracic paravertebral infusion with MB is a safe and effective therapy for PHN. Continuous infusion with MB can significantly reduce pain intensity, improve pain-related depression, increase quality of life, and decrease the amount of rescue medicine with no serious adverse complications.

Impact of a Publicly Funded Herpes Zoster Immunization Program on the Burden of Disease in Ontario, Canada: A Population-based Study

Background

In September 2009, a live attenuated herpes zoster vaccine (ZVL) became available in Canada. Beginning in September 2016, ZVL was made available to all Ontario residents aged 65–70 through a publicly funded immunization program. We assessed the impact of ZVL availability and its subsequent public funding on herpes zoster burden in this population.

Methods

A population-based study of Ontario residents aged 65–70 between January 2005 and September 2018. We used interventional autoregressive integrated moving average models to examine the impact of ZVL market availability and the publicly funded ZVL program on monthly incidence rate of medically attended herpes zoster, defined as an outpatient visit for herpes zoster with a prescription for a herpes zoster antiviral dispensed ≤5 days before or after the visit, or a herpes zoster–related emergency department (ED) visit or hospitalization. In secondary analyses, we examined impacts on any herpes zoster–related ED visits and hospitalizations.

Results

We found no association between ZVL market availability and monthly incidence of herpes zoster (P = .32) or monthly rates of ED visits and hospitalizations (P = .88). Conversely, the introduction of publicly funded ZVL reduced the monthly rate of medically attended herpes zoster by 19.1% (from 4.8 to 3.8 per 10 000 population; P < .01) and herpes zoster–related ED visits and hospitalizations by 38.2% (from 1.7 to 1.0 per 10 000 population; P < .05).

Conclusions

The introduction of a publicly funded immunization program for herpes zoster was associated with reduced disease burden and related acute healthcare service use.

Herpes Zoster and Postherpetic Neuralgia in an Elderly Patient with Critical COVID-19: A Case Report

Critical patients with COVID-19 are thought to be at high risk of developing chronic pain. However, the exact nature and mechanisms of COVID-19-related chronic pain remain largely unknown. Here, we describe clinical features, treatments and outcome of herpes zoster as well as postherpetic neuralgia in a 70-year-old woman with critical COVID-19. The patient had a history of type 2 diabetes and myasthenia gravis. She developed herpes zoster in the right 10 to 12 lumbar dermatomes in the recovery period of COVID-19. Intravenous (250 mg 3 times a day) and then oral (400 mg 5 times a day) acyclovir was used for antiviral therapy. Pregabalin (75 mg orally twice a day) and ibuprofen was used for analgesia. Her skin lesions resolved 21 days after the onset of rash. However, she continued to have persistent pain in the same dermatomal distribution. After the dosage of pregabalin was increased to 150 mg orally twice a day, her pain was partially relieved. During the telephone follow-up 4 months after herpes zoster eruption, the patient still complained intermittent pain in the right 10 to 12 lumbar dermatomes. Our case draws attention to postherpetic neuralgia in COVID-19 patients and provides a targeted suggestion for this kind of patients.

Fire needle plus cupping for acute herpes zoster: study protocol for a randomized controlled trial

BACKGROUND

Acute herpes zoster (AHZ) is a common skin disease caused by invasion of the varicella zoster virus into the ganglia and skin, and the severe pain is the most complaint, which can seriously disturb the normal life of patients. Fire needle plus cupping is a special acupuncture treatment, which is widely used to treat AHZ for its better analgesic effect in China although it has not been fully verified by rigorous randomized controlled trial (RCT).

METHODS/DESIGN

To test the effect, a three-arm randomized parallel controlled trial protocol has been designed. A total of 105 AHZ patients suffering pain will be randomly divided into three groups in an equal proportion. The interventions are fire needle plus cupping (FC) in group A, famciclovir plus gabapentin (FG) in group B, and fire needle plus cupping plus famciclovir (FCF) in group C. The length for the trial is set for a week time frame. Precisely speaking, the A group (FC) is to carry out 1 treatment per day for the total of 7 treatment sessions within 1 week period. On the other hand, the B group (FG) will take drugs orally three times a day within the trial 1 week. Meanwhile, with its combination element, the C group (FCF) is due to undertake both treatments and drugs as prescribed for A and B groups within the trial week. As an intra-trial arrangement, analgesic medication will be carefully administered for temporary pain release if the sudden intolerable pain appeared. For the primary outcome, this study is due to apply visual analogue scale to identify pain intensity relief. As the secondary outcomes are concerned, this study is aiming to focus on the issues related to changes in substance P and beta-endorphin concentrations in peripheral plasma, as well as those issues of analgesic needs, side effects, symptoms, and physical signs including pain classification, local itching, burning sensation, fever, local lymphadenopathy, skin lesion area, blisters, herpes clusters, vesicular traits, ulcers, and pimples; all these are taken into account for evaluation. For the final stage, the participants are to be followed up for postherpetic neuralgia.

DISCUSSION

The results of this trial aim to provide sufficient evidence on FC treatment over both FG and FCF treatments. It will then give a credible alternative treatment to cut down acute pain and to cure AHZ infection.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1800015372 . Registered on 28 March 2018.

A Randomized, Open-Label, Bioequivalence Study of Lidocaine Topical System 1.8% and Lidocaine Patch 5% in Healthy Subjects

Purpose

This study was designed to characterize drug delivery with lidocaine topical system 1.8% vs lidocaine patch 5% through 2 PK studies.

Patients and Methods

Two Phase 1, single-center, open-label, randomized PK studies were performed in healthy adults. In Study 1, 56 subjects received a single intravenous bolus of 0.7 mg/kg of lidocaine as a lead-in to allow for the accurate determination of apparent dose of both products. After a 7-day washout period, subjects were randomized to receive either lidocaine topical system 1.8% or lidocaine patch 5% for 12 hours followed by another 7-day washout period, after which subjects crossed over to receive the other treatment for 12 hours. In Study 2, 54 subjects were randomized to receive either lidocaine topical system 1.8% or lidocaine patch 5% for 12 hours. After a 7-day washout period, subjects crossed over to receive the other treatment. Adhesion and skin irritation assessments were performed after application of the products in Study 2. In both studies, serial blood samples were collected to measure the plasma concentration of lidocaine after product application. Safety assessments and adverse events were monitored in both studies.

Results

The comparative PK analysis demonstrated that the two products, despite their difference in drug load and strength, are bioequivalent. Both products were well tolerated. In Study 2, dermal response scores (skin tolerability after removal) were similar between lidocaine topical system 1.8% and lidocaine patch 5%, with a mean irritation score per patch <1 (barely perceptible erythema), which is not considered to be clinically significant.

Conclusion

Bioequivalence was demonstrated between lidocaine topical system 1.8% and lidocaine patch 5%. A comparison of the single-time adhesion scores at 12 hours in Study 2 favored lidocaine topical system 1.8% over lidocaine patch 5%. Both products were well tolerated as a single application in healthy adult human subjects.

ClinicalTrialsgov

NCT04144192, NCT04149938.

A Randomized, Open-Label, Bioequivalence Study of Lidocaine Topical System 1.8% and Lidocaine Patch 5% in Healthy Subjects

Purpose

This study was designed to characterize drug delivery with lidocaine topical system 1.8% vs lidocaine patch 5% through 2 PK studies.

Patients and Methods

Two Phase 1, single-center, open-label, randomized PK studies were performed in healthy adults. In Study 1, 56 subjects received a single intravenous bolus of 0.7 mg/kg of lidocaine as a lead-in to allow for the accurate determination of apparent dose of both products. After a 7-day washout period, subjects were randomized to receive either lidocaine topical system 1.8% or lidocaine patch 5% for 12 hours followed by another 7-day washout period, after which subjects crossed over to receive the other treatment for 12 hours. In Study 2, 54 subjects were randomized to receive either lidocaine topical system 1.8% or lidocaine patch 5% for 12 hours. After a 7-day washout period, subjects crossed over to receive the other treatment. Adhesion and skin irritation assessments were performed after application of the products in Study 2. In both studies, serial blood samples were collected to measure the plasma concentration of lidocaine after product application. Safety assessments and adverse events were monitored in both studies.

Results

The comparative PK analysis demonstrated that the two products, despite their difference in drug load and strength, are bioequivalent. Both products were well tolerated. In Study 2, dermal response scores (skin tolerability after removal) were similar between lidocaine topical system 1.8% and lidocaine patch 5%, with a mean irritation score per patch <1 (barely perceptible erythema), which is not considered to be clinically significant.

Conclusion

Bioequivalence was demonstrated between lidocaine topical system 1.8% and lidocaine patch 5%. A comparison of the single-time adhesion scores at 12 hours in Study 2 favored lidocaine topical system 1.8% over lidocaine patch 5%. Both products were well tolerated as a single application in healthy adult human subjects.

ClinicalTrials.gov

NCT04144192, NCT04149938.

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Prevalence and risk factors of herpes zoster infection in patients with biopsy proven lupus nephritis undergoing immunosuppressive therapies

OBJECTIVES

To study the prevalence of herpes zoster infection in patients with biopsy-confirmed lupus nephritis undergoing immunosuppressive therapies.

METHODS

Patients who had histologically active lupus nephritis between 2004 and 2018 were retrospectively reviewed. Clinical and laboratory data at baseline and six months post-therapy were collected. The incidence of herpes zoster reactivation within two years of lupus nephritis treatment was calculated. Risk factors for herpes zoster reactivation were studied by logistic regression.

RESULTS

Patients (N = 251) with 311 episodes of lupus nephritis were studied (92% women; age 34.2 ± 14.2 years; histological classes III/IV ± V (69%)). Within two years of therapy, 55 (18%) episodes of lupus nephritis were complicated by herpes zoster infection (incidence 8.84/100 patient-years). Fourteen episodes (25%) of herpes zoster were treated by intravenous anti-viral drugs in hospital but disseminated disease or mortality was not reported. Significant post-herpetic neuralgia developed in 9% of the episodes. Patients with herpes zoster reactivation, compared with those without, were more likely to have first-time renal disease and a shorter systemic lupus erythematosus duration at lupus nephritis than those without. Disease activity, treatment response and other clinical/laboratory parameters were not significantly different between patients with and without herpes zoster reactivation. Herpes zoster-infected patients had been treated with a significantly higher dose of prednisolone as induction therapy. Logistic regression revealed that first-time renal disease, peak daily mycophenolate mofetil dose and cumulative cyclophosphamide dose during induction therapy were significantly associated with herpes zoster reactivation.

CONCLUSIONS

Herpes zoster reactivation is common in lupus nephritis patients but unpredictable from clinical parameters. Although adverse outcomes of herpes zoster infection are uncommon, using the minimally effective doses of mycophenolate mofetil and cyclophosphamide during induction therapy may help reduce the risk of herpes zoster infection.

Herpes zoster: vaccination status and virtuous experiences

Herpes zoster (HZ) infection is widespread in the general population - especially in the elderly - and can be associated with major sequelae such as post-herpetic neuralgia. Live attenuated zoster vaccine was licensed in Europe in May 2006 and in Italy in 2010; since March 2014, it has been commercially available in Italy. In Italy, vaccination against HZV is recommended in all subjects at risk - for example, those with diabetes, cardiovascular disease, chronic obstructive pulmonary disease or patients on immunosuppressive agents - from the age of 50 years onwards and for all persons aged >64 years. This paper summarizes the virtuous experiences on the effectiveness of the HZ vaccine in the elderly, with a focus on the Italian scenario. Considering the current barriers to this immunization registered in some areas (difficulties of vaccine distribution, lack of physician recommendations, costs), proper educational and communication efforts should be pursued to guarantee a good coverage of HZ vaccination.