1
|
Pomirchy M, Bommer C, Pradella F, Michalik F, Peters R, Geldsetzer P. Herpes zoster vaccination and new diagnoses of dementia: A quasi-randomized study in Australia. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.06.27.24309563. [PMID: 38978672 PMCID: PMC11230318 DOI: 10.1101/2024.06.27.24309563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
Increasing evidence suggests that neurotropic herpesviruses could play a role in the development of dementia, possibly through a neuroinflammatory process. Herpes zoster (HZ) vaccination has been reported to lead to a reduced probability of being diagnosed with dementia in several correlational studies and in a prior analysis by our team in Wales. This present study constitutes the first investigation to use a quasi-randomized study design in an electronic health record dataset from a large and diverse nation (Australia) to aim to determine the effect of HZ vaccination on dementia. In Australia, starting on November 1 2016, live-attenuated HZ vaccination was provided for free to individuals aged 70 to 79 years of age through primary care providers. Thus, those whose 80 th birthday was just a few days prior to November 1 2016 never became eligible, whereas those whose 80 th birthday was just a few days later were eligible. The key advantage of our approach is that one would not expect that these population groups who differ in their age by only a minute degree would, on average, differ in any of their health characteristics and behaviors. We used detailed primary healthcare records with week-of-birth information from 65 general practices across Australia. We analyzed our data using a regression discontinuity approach. Our sample consisted of 101,219 patients. As expected, patients born just before versus shortly after the date-of-birth eligibility threshold (November 2 1936) for HZ vaccination were well-balanced in their past preventive health services uptake and chronic disease diagnoses. There was an abrupt increase of 15.7 (95% CI: [12.2 - 19.3], p < 0.001) percentage points in the probability of ever receiving HZ vaccination between patients born shortly before versus shortly after the eligibility threshold. The eligibility rules of the HZ vaccination program, thus, created comparison groups just on either side of the date-of-birth eligibility threshold who were similar to each other, except for a large difference in their probability of receiving the intervention (HZ vaccination) of interest. Eligibility for HZ vaccination (i.e., being born shortly before versus shortly after November 2 1936) decreased the probability of receiving a new dementia diagnosis over 7.4 years by 2.0 percentage points (95% CI: [0.3 - 3.7], p = 0.021). Being eligible for HZ vaccination did not affect the probability of taking up other preventive health services (including other vaccinations), nor the probability of being diagnosed with other common chronic conditions than dementia. This study provides important evidence on the potential benefits of HZ vaccination for dementia because its quasi-randomized design allows for conclusions that are more likely to be causal than those of the existing associational evidence.
Collapse
|
2
|
Younger DS. Headaches and Vasculitis. Neurol Clin 2024; 42:389-432. [PMID: 38575258 DOI: 10.1016/j.ncl.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Vasculitis refers to heterogeneous clinicopathologic disorders that share the histopathology of inflammation of blood vessels. Unrecognized and therefore untreated, vasculitis of the nervous system leads to pervasive injury and disability making this a disorder of paramount importance to all clinicians. Headache may be an important clue to vasculitic involvement of central nervous system (CNS) vessels. CNS vasculitis may be primary, in which only intracranial vessels are involved in the inflammatory process, or secondary to another known disorder with overlapping systemic involvement. Primary neurologic vasculitides can be diagnosed with assurance after intensive evaluation that incudes tissue confirmation whenever possible.
Collapse
Affiliation(s)
- David S Younger
- Department of Medicine, Section of Neuroscience, City University of New York School of Medicine, New York, NY, USA; Department of Neurology, White Plains Hospital, White Plains, NY, USA.
| |
Collapse
|
3
|
Philip AM, George LJ, N A, Nayar J. Varicella Zoster Virus Vasculopathy: An Under-Recognized Entity. Cureus 2024; 16:e61419. [PMID: 38947631 PMCID: PMC11214726 DOI: 10.7759/cureus.61419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2024] [Indexed: 07/02/2024] Open
Abstract
Varicella zoster virus (VZV) vasculopathy is a rare yet potentially severe neurological manifestation resulting from VZV reactivation, primarily affecting immunocompromised individuals. We present a case report of a 61-year-old male with VZV vasculopathy who initially presented with herpes zoster ophthalmicus, subsequently complicated by meningoencephalitis and an acute infarct in the territory of the left middle cerebral artery (MCA). Imaging revealed acute and chronic infarcts in the capsuloganglionic regions, accompanied by thickening and enhancement of the left MCA wall. Treatment involved a 14-day course of intravenous acyclovir, supplemented with oral prednisolone, resulting in modest clinical improvement. VZV vasculopathy represents an infrequently acknowledged neurological syndrome, particularly prevalent among immunocompromised individuals. Early recognition and appropriate intervention offer promise in ameliorating outcomes for affected patients. This case emphasizes the importance of including VZV vasculopathy in the differential diagnosis of neurological deficits, especially within high-risk populations.
Collapse
Affiliation(s)
- Anil M Philip
- Internal Medicine, Kuriakose Chavara Memorial Hospital, Nooranad, IND
| | - Lina J George
- Pulmonology, Kuriakose Chavara Memorial Hospital, Nooranad, IND
| | - Anas N
- Radiology, Metro Scans and Diagnostic Centre, Karunagappalli, IND
| | - Jemimah Nayar
- Nuclear Medicine, St. Gregorios International Cancer Care Centre, Parumala, IND
| |
Collapse
|
4
|
Jung JM, Gruber A, Heseltine P, Rajamani K, Ameriso SF, Fisher MJ. New Directions in Infection-Associated Ischemic Stroke. J Clin Neurol 2024; 20:140-152. [PMID: 38330416 PMCID: PMC10921058 DOI: 10.3988/jcn.2023.0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 09/06/2023] [Accepted: 11/12/2023] [Indexed: 02/10/2024] Open
Abstract
The relationship between infections and stroke has not been fully characterized, probably delaying the development of specific treatments. This narrative review addresses mechanisms of stroke linked to infections, including hypercoagulability, endothelial dysfunction, vasculitis, and impaired thrombolysis. SARS-CoV-2, the virus that causes COVID-19, may promote the development of stroke, which may represent its most severe neurological complication. The development of specific therapies for infection-associated stroke remains a profound challenge. Perhaps the most important remaining issue is the distinction between infections that trigger a stroke versus infections that are truly incidental. This distinction likely requires the establishment of appropriate biomarkers, candidates of which are elevated levels of fibrin D-dimer and anticardiolipin/antiphospholipid antibodies. These candidate biomarkers might have potential use in identifying pathogenic infections preceding stroke, which is a precursor to establishing specific therapies for this syndrome.
Collapse
Affiliation(s)
- Jin-Man Jung
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea; Korea University Zebrafish, Translational Medical Research Center, Ansan, Korea
| | | | - Peter Heseltine
- Division of Infectious Diseases, Department of Medicine, University of California, Irvine, Irvine, CA, USA
| | - Kumar Rajamani
- Department of Neurology, Wayne State University-Detroit Medical Center, Detroit, MI, USA
| | - Sebastián F Ameriso
- Division of Vascular Neurology, Department of Neurology, Fleni, Autonomous City of Buenos Aires, Argentina
| | - Mark J Fisher
- Department of Neurology, University of California Irvine Medical Center, Orange, CA, USA.
| |
Collapse
|
5
|
Ku HC, Wu YL, Yip HT, Hsieh CY, Li CY, Ou HT, Chen YC, Ko NY. Herpes zoster associated with stroke incidence in people living with human immunodeficiency virus: a nested case-control study. BMC Infect Dis 2023; 23:636. [PMID: 37770849 PMCID: PMC10536781 DOI: 10.1186/s12879-023-08628-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 09/19/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND The incidence of stroke is increasing among younger people with human immunodeficiency virus (HIV). The burden of stroke has shifted toward the young people living with HIV, particularly in low- and middle-income countries. People infected with herpes zoster (HZ) were more likely to suffer stroke than the general population. However, the association of HZ infection with the incidence of stroke among patients with HIV remains unclear. METHODS A nested case-control study was conducted with patients with HIV registered in the Taiwan National Health Insurance Research Database in 2000-2017. A total of 509 stroke cases were 1:10 matched to 5090 non-stroke controls on age, sex, and date of first stroke diagnosis. Logistic regression models were used to estimate the odds ratio and 95% confidence intervals (CI) of stroke incidence. RESULTS The odds ratio of stroke was significantly higher in the HIV-infected population with HZ (adjusted odds ratio [AOR]: 1.85, 95% CI: 1.42-2.41). A significantly increased AOR of stroke was associated with hypertension (AOR: 3.53, 95% CI: 2.86-4.34), heart disease (AOR: 2.32, 95% CI: 1.54-3.48), chronic kidney disease (AOR: 1.82, 95% CI: 1.16-2.85), hepatitis C virus infection (AOR: 1.49, 95% CI: 1.22-1.83), hyperlipidemia (OR: 1.41, 95% CI: 1.12-1.78), and treatment with protease inhibitors (AOR: 1.33, 95% CI: 1.05-1.69). CONCLUSIONS Our findings suggest that HZ concurrent with HIV may increase the risk of stroke. The incidence rates of stroke were independent of common risk factors, suggesting strategies for early prevention of HZ infection among people living with HIV.
Collapse
Affiliation(s)
- Han-Chang Ku
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi Branch, Chiayi, Taiwan
| | - Yi-Lin Wu
- Department of Nursing, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Hei-Tung Yip
- Clinical Trial Research Center (CTC), China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Yang Hsieh
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Huang-Tz Ou
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Pharmacy, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yen-Chin Chen
- Department of Nursing, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
- Department of Nursing, College of Medicine, National Cheng Kung University, 1 University Road, Tainan, 7010, Taiwan
| | - Nai-Ying Ko
- Department of Nursing, College of Medicine, National Cheng Kung University, 1 University Road, Tainan, 7010, Taiwan.
| |
Collapse
|
6
|
Mezzetti E, Costantino A, Leoni M, Pieretti R, Di Paolo M, Frati P, Maiese A, Fineschi V. Autoimmune Heart Disease: A Comprehensive Summary for Forensic Practice. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1364. [PMID: 37629654 PMCID: PMC10456745 DOI: 10.3390/medicina59081364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/05/2023] [Accepted: 07/20/2023] [Indexed: 08/27/2023]
Abstract
Autoimmune heart disease is a non-random condition characterised by immune system-mediated aggression against cardiac tissue. Cardiac changes often exhibit nonspecific features and, if unrecognised, can result in fatal outcomes even among seemingly healthy young individuals. In the absence of reliable medical history, the primary challenge lies in differentiating between the various cardiopathies. Numerous immunohistochemical and genetic studies have endeavoured to characterise distinct types of cardiopathies, facilitating their differentiation during autopsy examinations. However, the presence of a standardised protocol that forensic pathologists can employ to guide their investigations would be beneficial. Hence, this summary aims to present the spectrum of autoimmune cardiopathies, including emerging insights such as SARS-CoV-2-induced cardiopathies, and proposes the utilisation of practical tools, such as blood markers, to aid forensic pathologists in their routine practice.
Collapse
Affiliation(s)
- Eleonora Mezzetti
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (E.M.); (A.C.); (M.L.); (R.P.); (M.D.P.)
| | - Andrea Costantino
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (E.M.); (A.C.); (M.L.); (R.P.); (M.D.P.)
| | - Matteo Leoni
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (E.M.); (A.C.); (M.L.); (R.P.); (M.D.P.)
| | - Rebecca Pieretti
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (E.M.); (A.C.); (M.L.); (R.P.); (M.D.P.)
| | - Marco Di Paolo
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (E.M.); (A.C.); (M.L.); (R.P.); (M.D.P.)
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopedical Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy; (P.F.); (V.F.)
| | - Aniello Maiese
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (E.M.); (A.C.); (M.L.); (R.P.); (M.D.P.)
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopedical Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy; (P.F.); (V.F.)
| |
Collapse
|
7
|
Baiardi G, Cafaro A, Stella M, Caviglia MC, Poeta MG, Cangemi G, Mattioli F. Altered plasma levels of apixaban in major gastrointestinal tract surgery: a case report and review of the literature. Clin Biochem 2023; 118:110613. [PMID: 37451498 DOI: 10.1016/j.clinbiochem.2023.110613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 07/06/2023] [Accepted: 07/08/2023] [Indexed: 07/18/2023]
Abstract
Altered direct oral anticoagulant (DOAC) plasma levels can lead either to spontaneous hemorrhagic or thrombotic complications. We describe a case of suspected altered apixaban disposition in a patient with an upper gastrointestinal cancer resection treated with apixaban for non-valvular atrial fibrillation. Diagnosis of ischemic stroke for left hemiparesis was confirmed due to recent emergence of a hypodense area in the posterior capsular nucleus of ischemic reference in a context of binuclear capsular lacunar lesions. Thus, apixaban underexposure was suspected from anamnestic data and oral anticoagulation was switched to parenteral at the next scheduled dose for stroke recurrence. Before switching apixaban pharmacokinetic analysis was performed and unexpectedly showed apixaban plasma overexposure. After 3 days from the switch, the patient experienced spontaneous bleeding complications, for which the risk-benefit profile of continuing anticoagulant treatment for stroke recurrences warranted treatment discontinuation. Unexpected DOAC plasma exposure may present in special patient populations with thrombotic and bleeding complications. Though universally recognized therapeutic ranges have yet to be established for DOACs, periodic drug monitoring may aid in guiding optimization of DOAC therapy and reduce the risk of adverse events in special patient populations.
Collapse
Affiliation(s)
- Giammarco Baiardi
- Clinical Pharmacology Unit, Ente Ospedaliero Ospedali Galliera, Genoa, Italy; Pharmacology & Toxicology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy.
| | - Alessia Cafaro
- Pharmacology & Toxicology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy; Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Manuela Stella
- Clinical Pharmacology Unit, Ente Ospedaliero Ospedali Galliera, Genoa, Italy; Pharmacology & Toxicology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Michela Cameran Caviglia
- Clinical Pharmacology Unit, Ente Ospedaliero Ospedali Galliera, Genoa, Italy; Pharmacology & Toxicology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | | | - Giuliana Cangemi
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Francesca Mattioli
- Clinical Pharmacology Unit, Ente Ospedaliero Ospedali Galliera, Genoa, Italy; Pharmacology & Toxicology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| |
Collapse
|
8
|
Novel discovery of exosomes biomarker from herpes zoster viral infection: linking to cerebrovascular coincidence. Ann Med Surg (Lond) 2023; 85:343-344. [PMID: 36845815 PMCID: PMC9949861 DOI: 10.1097/ms9.0000000000000220] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 01/01/2023] [Indexed: 02/28/2023] Open
|
9
|
Risk of, and risk factors for, vasculopathy associated with acute herpes zoster. J Stroke Cerebrovasc Dis 2023; 32:106891. [PMID: 36473399 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 10/31/2022] [Accepted: 11/09/2022] [Indexed: 12/10/2022] Open
Abstract
OBJECTIVES We aimed to summarize the known risk of vasculopathy (stroke, myocardial infarction [MI], and transient ischemic attack [TIA]) after herpes zoster (HZ) and the impact of antiviral treatment and vaccination against HZ on the risk of vasculopathy. MATERIALS AND METHODS A narrative literature review was conducted in PubMed to identify evidence published in the past 15 years that was relevant to the scope of this article. RESULTS Ten studies reported that HZ was associated with an increased risk of stroke and one UK study reported no association. Four studies reported that HZ was associated with an increased risk of MI, and four reported that HZ was associated with an increased risk of TIA. Two studies reported that antiviral treatment was associated with a reduced risk of stroke and an additional two studies reported no association between antiviral treatment and the risk of stroke. In addition, two studies reported that vaccination against HZ using the live zoster vaccine (ZVL) was associated with a reduced risk of stroke, and an additional two studies reported that the risk of stroke or MI after HZ was similar between ZVL vaccinated and unvaccinated individuals. CONCLUSIONS HZ is associated with an increased risk of stroke, MI, or TIA (strongest association is between HZ and stroke). Further studies are needed to determine whether antiviral treatment or ZVL vaccination influence the risk of HZ-associated vasculopathy. In addition, the effect of the recombinant zoster vaccine on the risk of HZ-associated vasculopathy should be studied.
Collapse
|
10
|
Xie L, Lu A, Wang X, Cheng B, Zhu X, Hu H. Herpes simplex virus type 2 encephalitis in a child with chronic progressive white matter lesions: A case report. Medicine (Baltimore) 2022; 101:e32289. [PMID: 36550828 PMCID: PMC9771169 DOI: 10.1097/md.0000000000032289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
RATIONALE This case is a rare manifestation of central nervous system infection of Herpes simplex virus (HSV)-2. Due to few studies in China, it provides a pathological basis for further diagnosis and treatment of HSV-2. PATIENT CONCERNS We describe a patient with HSV-2 virus infection who was diagnosed with HSV-2 encephalitis in a Chinese patient. DIAGNOSIS Based on brain biopsy and pathological findings, the patient was diagnosed with HSV-2 encephalitis. INTERVENTIONS Hormone and antiviral therapy were given. OUTCOME The patient eventually died. LESSONS The diagnosis and differential diagnosis of the disease is very difficult. Its differential diagnosis include cerebrovascular disease, bacteria or fungi and other viral infection of the brain.
Collapse
Affiliation(s)
- Lei Xie
- School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Aijun Lu
- School of Clinical Medicine, Weifang Medical University, Weifang, China
| | | | - Bihong Cheng
- School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Xuemin Zhu
- School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Huaiqiang Hu
- The 960th Hospital of PLA, Jinan, China
- * Correspondence: Hu, Huaiqiang, The 960th Hospital of PLA, Jinan, China (e-mail: )
| |
Collapse
|
11
|
Curhan SG, Kawai K, Yawn B, Rexrode KM, Rimm EB, Curhan GC. Herpes Zoster and Long-Term Risk of Cardiovascular Disease. J Am Heart Assoc 2022; 11:e027451. [PMID: 36382961 PMCID: PMC9851464 DOI: 10.1161/jaha.122.027451] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background We investigated the longitudinal association of herpes zoster (HZ), commonly known as "shingles," and long-term risk of stroke or coronary heart disease (CHD) among participants in 3 large US cohorts, the NHS (Nurses' Health Study), NHS II (Nurses' Health Study II), and HPFS (Health Professionals Follow-Up Study). Methods and Results Participants were 79 658 women in the NHS (2000-2016), 93 932 women in the NHS II (2001-2017), and 31 440 men in the HPFS (2004-2016), without prior stroke or CHD. Information on HZ, stroke, and CHD was collected on biennial questionnaires and confirmed by medical record review. Cox proportional hazards regression models were used to estimate multivariable-adjusted hazard ratios for stroke and for CHD according to years since HZ compared with never HZ. During >2 million person-years of follow-up, 3603 incident stroke and 8620 incident CHD cases were documented. History of HZ was significantly and independently associated with higher long-term risk of stroke and CHD. In pooled analyses, compared with individuals with no history of HZ, the multivariable-adjusted hazard ratios (95% CIs) for stroke were 1.05 (0.88-1.25) among those with 1 to 4 years since HZ, 1.38 (1.10-1.74) for among those with 5 to 8 years since HZ, 1.28 (1.03-1.59) among those with for 9 to 12 years since HZ, and 1.19 (0.90-1.56) among those with ≥13 years since HZ. For CHD, the corresponding multivariable-adjusted hazard ratios (95% CIs) were 1.13 (1.01-1.27) for 1 to 4 years, 1.16 (1.02-1.32) for 5 to 8 years, 1.25 (1.07-1.46) for 9 to 12 years, and 1.00 (0.83-1.21) for ≥13 years. Conclusions HZ is associated with higher long-term risk of a major cardiovascular event. These findings suggest there are long-term implications of HZ and underscore the importance of prevention.
Collapse
Affiliation(s)
- Sharon G. Curhan
- Channing Division of Network Medicine, Department of MedicineBrigham and Women’s HospitalBostonMA,Harvard Medical SchoolBostonMA
| | - Kosuke Kawai
- Harvard Medical SchoolBostonMA,Institutional Centers for Clinical and Translational ResearchBoston Children’s HospitalBostonMA
| | - Barbara Yawn
- Department of ResearchOlmsted Medical CenterRochesterMA
| | - Kathryn M. Rexrode
- Harvard Medical SchoolBostonMA,Division of Women’s HealthBrigham and Women’s HospitalBostonMA
| | - Eric B. Rimm
- Channing Division of Network Medicine, Department of MedicineBrigham and Women’s HospitalBostonMA,Harvard Medical SchoolBostonMA,Department of NutritionHarvard T.H. Chan School of Public HealthBostonMA,Department of EpidemiologyHarvard T.H. Chan School of Public HealthBostonMA
| | - Gary C. Curhan
- Channing Division of Network Medicine, Department of MedicineBrigham and Women’s HospitalBostonMA,Harvard Medical SchoolBostonMA,Department of EpidemiologyHarvard T.H. Chan School of Public HealthBostonMA,Renal Division, Department of MedicineBrigham and Women’s HospitalBostonMA
| |
Collapse
|
12
|
Kraemer M, Strunk D, Becker J, Veltkamp R, Berlit P. Recovery of intracranial stenoses in varicella zoster virus vasculitis after long-term treatment with valacyclovir and prednisolone. Neurol Res Pract 2022; 4:18. [PMID: 35570315 PMCID: PMC9109369 DOI: 10.1186/s42466-022-00180-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/11/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND AND PURPOSE Optimal treatment of intracranial stenoses in varicella zoster virus (VZV)-associated vasculitis is unknown. This study aims to evaluate the merits and potential pitfalls of a specific therapeutic strategy, initially proposed by Don Gilden in 2015. METHODS We describe three patients with intracranial stenoses caused by VZV vasculitis successfully treated by a long-term combination of valacyclovir and prednisolone. RESULTS All three patients were young men suffering from stroke. Only one reported a first contact to VZV in adulthood. All three presented stenoses in the intracranial part of the internal carotid artery or the proximal segments of the middle cerebral artery as well as an elevated cell count and positive VZV antibody index in cerebrospinal fluid. They received a combination therapy regimen with prednisone and valacyclovir about a minimum of one year. Intracranial stenoses improved markedly in one and almost resolved completely in the other two patients. Side effects of corticosteroid treatment occurred in two patients. CONCLUSIONS Long-term combination treatment with prednisone and valacyclovir proved to be effective in three young men suffering from intracranial stenosis due to VZV vasculitis.
Collapse
Affiliation(s)
- Markus Kraemer
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany. .,Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany.
| | - Daniel Strunk
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany
| | - Jana Becker
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany
| | - Roland Veltkamp
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany.,Department of Brain Sciences, Imperial College London, London, UK
| | | |
Collapse
|
13
|
A case of ischemic stroke secondary to varicella-zoster virus meningoencephalitis. J Neurovirol 2022; 28:319-321. [PMID: 35275391 DOI: 10.1007/s13365-022-01050-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 11/14/2021] [Accepted: 01/11/2022] [Indexed: 10/18/2022]
Abstract
Varicella-zoster virus (VZV) lurks in cranial nerves and other brain ganglias after infection. Because middle cerebral artery (MCA) receives the ipsilateral trigeminal ganglia afferent innervations, the reactivated VZV infects the adventitia and intima of cerebral artery wall probably through this way and causes vascular inflammation, finally resulting in artery remodeling, vessel occlusion, and ischemia. In fact, there is a growing clinical recognition that there is an association between VZV reactivation and subsequent stroke. Here, we showed a case of ischemic stroke secondary to varicella-zoster virus meningoencephalitis and reviewed the literature to emphasize the importance of VZV-associated vasculopathy.
Collapse
|
14
|
Marais G, Naidoo M, McMullen K, Stanley A, Bryer A, van der Westhuizen D, Bateman K, Hardie DR. Varicella-zoster virus reactivation is frequently detected in HIV-infected individuals presenting with stroke. J Med Virol 2022; 94:2675-2683. [PMID: 35133008 DOI: 10.1002/jmv.27651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 11/07/2022]
Abstract
Infections are an underappreciated cause of stroke, particularly in young and immunocompromised individuals. Varicella-zoster virus (VZV) reactivation, particularly ophthalmic zoster, has been linked to increased risk of stroke but diagnosing VZV-associated cerebral vasculopathy is challenging as neither a recent Zoster rash, nor detectable levels of VZV DNA are universally present at stroke presentation. Detection of VZV IgG in cerebrospinal fluid (CSF-VZVG) presents a promising alternative, but requires evaluation of individual blood-CSF dynamics, particularly in the setting of chronic inflammatory states such as HIV infection. Consequently, its use has not been broadly adopted as simple diagnostic algorithms are not available. In this study looking at young adults presenting with acute stroke, we used an algorithm that includes testing for both VZV nucleic acids and CSF-VZVG which was corrected for blood-CSF barrier dynamics and poly-specific immune activation. We found that 13 of 35 (37%), including 7 with a positive CSF VZV PCR, young HIV-infected adults presenting with stroke, 3 of 34 (9%) young HIV-uninfected adults presenting with stroke and 1 of 18 (6%) HIV-infected non-stroke controls demonstrated evidence of central nervous system reactivation of VZV. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Gert Marais
- Division of Medical Virology, University of Cape Town, Cape Town, Western Cape, South Africa
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, Western Cape, South Africa
| | - Michelle Naidoo
- Division of Medical Virology, University of Cape Town, Cape Town, Western Cape, South Africa
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, Western Cape, South Africa
| | - Kate McMullen
- Department of Medicine, Division of Neurology, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Alan Stanley
- Department of Neurology, Hawke's Bay Fallen Soldiers Memorial Hospital, Hastings, New Zealand
| | - Alan Bryer
- Department of Medicine, Division of Neurology, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Diederick van der Westhuizen
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, Western Cape, South Africa
- Division of Chemical Pathology, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Kathleen Bateman
- Department of Medicine, Division of Neurology, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Diana Ruth Hardie
- Division of Medical Virology, University of Cape Town, Cape Town, Western Cape, South Africa
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, Western Cape, South Africa
| |
Collapse
|
15
|
Desai R, Welsh CT, Schumann SO. Elsberg Syndrome, Lumbosacral Radiculopathy, and Myelitis Due to Herpes Zoster in a Patient With Smoldering Myeloma. J Investig Med High Impact Case Rep 2022; 10:23247096211063348. [PMID: 35073764 PMCID: PMC8793366 DOI: 10.1177/23247096211063348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Herpes zoster (HZ) is a common illness caused by the reactivation of latent varicella zoster virus (VZV) due to waning immunity, often secondary to old age or an underlying immunocompromised state. Its complications can manifest in variety of ways, including persistent neuralgias, vasculopathies, and stroke. Here, we describe a case of a 45-year-old man with a history of cryptogenic stroke and smoldering myeloma who was admitted with sacral HZ complicated by right lumbosacral radiculopathy and myelitis, otherwise known as Elsberg syndrome (ES). He was found to have an enhancing lesion in the peripheral conus medullaris on magnetic resonance imaging (MRI) with nonspecific inflammation and necrosis on biopsy pathology and cerebrospinal fluid (CSF) polymerase chain reaction (PCR) positive for VZV. The patient was initially treated with intravenous acyclovir and dexamethasone and discharged with a steroid taper and indefinite valacyclovir therapy. Twelve months postdischarge, the patient’s right lumbosacral radiculopathy and myelitis had almost completely resolved; however, he continued to require bladder self-catheterization. We believe that the patient’s underlying smoldering myeloma lead to an immunocompromised state, allowing for reactivation of latent VZV, resulting in both the patient’s cryptogenic stroke years earlier and recent ES.
Collapse
Affiliation(s)
- Rohan Desai
- Medical University of South Carolina, Charleston, USA
| | | | | |
Collapse
|
16
|
Yan Y, Yuan Y, Wang J, Zhang Y, Liu H, Zhang Z. Meningitis/meningoencephalitis caused by varicella zoster virus reactivation: a retrospective single-center case series study. Am J Transl Res 2022; 14:491-500. [PMID: 35173869 PMCID: PMC8829630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 12/07/2021] [Indexed: 06/14/2023]
Abstract
Recent clinical studies showed that central nervous system (CNS) infection caused by varicella zoster virus (VZV) reactivation was more than previously reported. The clinical manifestations were often diverse and complex, and the outcome often varied among different patients. A systematic study is needed to provide clinical characteristics of the CNS VZV infection to help clinicians with clinical diagnosis and management. Toward that end, we retrospectively analyzed the clinical presentations, laboratory results, imaging findings, treatment and outcomes in74 patients with meningitis or meningoencephalitis caused by VZV reactivation in our center from August 2018 to December 2020. Fever, headache, cranial nerve involvement, cognitive changes, meningeal irritation, nausea, vomiting, and Ramsay-Hunt syndrome (RHS) were the most common clinical manifestations of VZV meningitis or meningoencephalitis. Brain MRI analysis showed no obvious abnormal manifestation. Compared to VZV meningoencephalitis, patients with VZV meningitis were younger (56.9±13.8 vs 66.1±8.5 years; P=0.01), and more likely to develope in winter (P=0.04), had lower cerebrospinal fluid (CSF) glucose content (3.68±0.79 vs 4.21±0.94 mmol/L, P=0.02), and a better outcome at discharge (P=0.00). The outcome at discharge was worse in male patients and when longer than 1.5 days passed between onset of the neurological symptoms to initiation of the antiviral treatment.Early intravenous antiviral treatment for VZV meningitis and meningoencephalitis is important and is expected for a good outcome.
Collapse
Affiliation(s)
- Yongxing Yan
- Department of Neurology, The Third People's Hospital of Hangzhou Zhejiang, China
| | - Yanrong Yuan
- Department of Neurology, The Third People's Hospital of Hangzhou Zhejiang, China
| | - Jun Wang
- Department of Neurology, The Third People's Hospital of Hangzhou Zhejiang, China
| | - Yan Zhang
- Department of Neurology, The Third People's Hospital of Hangzhou Zhejiang, China
| | - Huili Liu
- Department of Neurology, The Third People's Hospital of Hangzhou Zhejiang, China
| | - Zuyong Zhang
- Department of Neurology, The Third People's Hospital of Hangzhou Zhejiang, China
| |
Collapse
|
17
|
Abstract
Inflammation and its myriad pathways are now recognized to play both causal and consequential roles in vascular brain health. From acting as a trigger for vascular brain injury, as evidenced by the coronavirus disease 2019 (COVID-19) pandemic, to steadily increasing the risk for chronic cerebrovascular disease, distinct inflammatory cascades play differential roles in varying states of cerebrovascular injury. New evidence is regularly emerging that characterizes the role of specific inflammatory pathways in these varying states including those at risk for stroke and chronic cerebrovascular injury as well as during the acute, subacute, and repair phases of stroke. Here, we aim to highlight recent basic science and clinical evidence for many distinct inflammatory cascades active in these varying states of cerebrovascular injury. The role of cerebrovascular infections, spotlighted by the severe acute respiratory syndrome coronavirus 2 pandemic, and its association with increased stroke risk is also reviewed. Rather than converging on a shared mechanism, these emerging studies implicate varied and distinct inflammatory processes in vascular brain injury and repair. Recognition of the phasic nature of inflammatory cascades on varying states of cerebrovascular disease is likely essential to the development and implementation of an anti-inflammatory strategy in the prevention, treatment, and repair of vascular brain injury. Although advances in revascularization have taught us that time is brain, targeting inflammation for the treatment of cerebrovascular disease will undoubtedly show us that timing is brain.
Collapse
Affiliation(s)
- Katherine T Mun
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles
| | - Jason D Hinman
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles
| |
Collapse
|
18
|
Bubak AN, Como CN, Hassell JE, Mescher T, Frietze SE, Niemeyer CS, Cohrs RJ, Nagel MA. Targeted RNA Sequencing of VZV-Infected Brain Vascular Adventitial Fibroblasts Indicates That Amyloid May Be Involved in VZV Vasculopathy. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 9:9/1/e1103. [PMID: 34759019 PMCID: PMC8587729 DOI: 10.1212/nxi.0000000000001103] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/09/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Compared with stroke controls, patients with varicella zoster virus (VZV) vasculopathy have increased amyloid in CSF, along with increased amylin (islet amyloid polypeptide [IAPP]) and anti-VZV antibodies. Thus, we examined the gene expression profiles of VZV-infected primary human brain vascular adventitial fibroblasts (HBVAFs), one of the initial arterial cells infected in VZV vasculopathy, to determine whether they are a potential source of amyloid that can disrupt vasculature and potentiate inflammation. METHODS Mock- and VZV-infected quiescent HBVAFs were harvested at 3 days postinfection. Targeted RNA sequencing of the whole-human transcriptome (BioSpyder Technologies, TempO-Seq) was conducted followed by gene set enrichment and pathway analysis. Selected pathways unique to VZV-infected cells were confirmed by enzyme-linked immunoassays, migration assays, and immunofluorescence analysis (IFA) that included antibodies against amylin and amyloid-beta, as well as amyloid staining by Thioflavin-T. RESULTS Compared with mock, VZV-infected HBVAFs had significantly enriched gene expression pathways involved in vascular remodeling and vascular diseases; confirmatory studies showed secretion of matrix metalloproteinase-3 and -10, as well increased migration of infected cells and uninfected cells when exposed to conditioned media from VZV-infected cells. In addition, significantly enriched pathways involved in amyloid-associated diseases (diabetes mellitus, amyloidosis, and Alzheimer disease), tauopathy, and progressive neurologic disorder were identified; predicted upstream regulators included amyloid precursor protein, apolipoprotein E, microtubule-associated protein tau, presenilin 1, and IAPP. Confirmatory IFA showed that VZV-infected HBVAFs contained amyloidogenic peptides (amyloid-beta and amylin) and intracellular amyloid. DISCUSSION Gene expression profiles and pathway enrichment analysis of VZV-infected HBVAFs, as well as phenotypic studies, reveal features of pathologic vascular remodeling (e.g., increased cell migration and changes in the extracellular matrix) that can contribute to cerebrovascular disease. Furthermore, the discovery of amyloid-associated transcriptional pathways and intracellular amyloid deposition in HBVAFs raise the possibility that VZV vasculopathy is an amyloid disease. Amyloid deposition may contribute to cell death and loss of vascular wall integrity, as well as potentiate chronic inflammation in VZV vasculopathy, with disease severity and recurrence determined by the host's ability to clear virus infection and amyloid deposition and by the coexistence of other amyloid-associated diseases (i.e., Alzheimer disease and diabetes mellitus).
Collapse
Affiliation(s)
- Andrew N Bubak
- From the Department of Neurology (A.N.B., C.N.C., J.E.H., T.M., C.S.N., R.J.C., M.A.N.), University of Colorado; Department of Medical Laboratory Sciences (S.E.F.), University of Vermont, Burlington, VT; Department of Immununology & Microbiology (R.J.C.), University of Colorado; and Department of Ophthalmology (M.A.N.), University of Colorado, Aurora, CO
| | - Christina N Como
- From the Department of Neurology (A.N.B., C.N.C., J.E.H., T.M., C.S.N., R.J.C., M.A.N.), University of Colorado; Department of Medical Laboratory Sciences (S.E.F.), University of Vermont, Burlington, VT; Department of Immununology & Microbiology (R.J.C.), University of Colorado; and Department of Ophthalmology (M.A.N.), University of Colorado, Aurora, CO
| | - James E Hassell
- From the Department of Neurology (A.N.B., C.N.C., J.E.H., T.M., C.S.N., R.J.C., M.A.N.), University of Colorado; Department of Medical Laboratory Sciences (S.E.F.), University of Vermont, Burlington, VT; Department of Immununology & Microbiology (R.J.C.), University of Colorado; and Department of Ophthalmology (M.A.N.), University of Colorado, Aurora, CO
| | - Teresa Mescher
- From the Department of Neurology (A.N.B., C.N.C., J.E.H., T.M., C.S.N., R.J.C., M.A.N.), University of Colorado; Department of Medical Laboratory Sciences (S.E.F.), University of Vermont, Burlington, VT; Department of Immununology & Microbiology (R.J.C.), University of Colorado; and Department of Ophthalmology (M.A.N.), University of Colorado, Aurora, CO
| | - Seth E Frietze
- From the Department of Neurology (A.N.B., C.N.C., J.E.H., T.M., C.S.N., R.J.C., M.A.N.), University of Colorado; Department of Medical Laboratory Sciences (S.E.F.), University of Vermont, Burlington, VT; Department of Immununology & Microbiology (R.J.C.), University of Colorado; and Department of Ophthalmology (M.A.N.), University of Colorado, Aurora, CO
| | - Christy S Niemeyer
- From the Department of Neurology (A.N.B., C.N.C., J.E.H., T.M., C.S.N., R.J.C., M.A.N.), University of Colorado; Department of Medical Laboratory Sciences (S.E.F.), University of Vermont, Burlington, VT; Department of Immununology & Microbiology (R.J.C.), University of Colorado; and Department of Ophthalmology (M.A.N.), University of Colorado, Aurora, CO
| | - Randall J Cohrs
- From the Department of Neurology (A.N.B., C.N.C., J.E.H., T.M., C.S.N., R.J.C., M.A.N.), University of Colorado; Department of Medical Laboratory Sciences (S.E.F.), University of Vermont, Burlington, VT; Department of Immununology & Microbiology (R.J.C.), University of Colorado; and Department of Ophthalmology (M.A.N.), University of Colorado, Aurora, CO
| | - Maria A Nagel
- From the Department of Neurology (A.N.B., C.N.C., J.E.H., T.M., C.S.N., R.J.C., M.A.N.), University of Colorado; Department of Medical Laboratory Sciences (S.E.F.), University of Vermont, Burlington, VT; Department of Immununology & Microbiology (R.J.C.), University of Colorado; and Department of Ophthalmology (M.A.N.), University of Colorado, Aurora, CO.
| |
Collapse
|
19
|
Kilic B. Cerebral Venous Sinus Thrombosis: Its Association with Primary Varicella-Zoster Virus Infection. Neurol India 2021; 69:1898. [PMID: 34979730 DOI: 10.4103/0028-3886.333447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Betul Kilic
- Derince Education and Research Hospital, Pediatric Neurology, Kocaeli, Turkey
| |
Collapse
|
20
|
Williams L, Delaney F, Kenny G, Marnane M, Kavanagh E, Sheehan G, Murphy S. Varicella-Zoster Vasculopathy Causing Carotid Artery Dissection. Neurol Clin Pract 2021; 11:e373-e375. [PMID: 34484920 DOI: 10.1212/cpj.0000000000000802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/04/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Laura Williams
- Department of Neurology (LW, MM), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Radiology (FD, EK), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Stroke Medicine (GK, SM), Mater Misericordiae University Hospital, Dublin, Ireland; and Department of Infectious Diseases (GS), Mater Misericordiaae University Hospital, Dublin, Ireland
| | - Francis Delaney
- Department of Neurology (LW, MM), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Radiology (FD, EK), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Stroke Medicine (GK, SM), Mater Misericordiae University Hospital, Dublin, Ireland; and Department of Infectious Diseases (GS), Mater Misericordiaae University Hospital, Dublin, Ireland
| | - Grace Kenny
- Department of Neurology (LW, MM), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Radiology (FD, EK), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Stroke Medicine (GK, SM), Mater Misericordiae University Hospital, Dublin, Ireland; and Department of Infectious Diseases (GS), Mater Misericordiaae University Hospital, Dublin, Ireland
| | - Michael Marnane
- Department of Neurology (LW, MM), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Radiology (FD, EK), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Stroke Medicine (GK, SM), Mater Misericordiae University Hospital, Dublin, Ireland; and Department of Infectious Diseases (GS), Mater Misericordiaae University Hospital, Dublin, Ireland
| | - Eoin Kavanagh
- Department of Neurology (LW, MM), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Radiology (FD, EK), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Stroke Medicine (GK, SM), Mater Misericordiae University Hospital, Dublin, Ireland; and Department of Infectious Diseases (GS), Mater Misericordiaae University Hospital, Dublin, Ireland
| | - Gerald Sheehan
- Department of Neurology (LW, MM), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Radiology (FD, EK), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Stroke Medicine (GK, SM), Mater Misericordiae University Hospital, Dublin, Ireland; and Department of Infectious Diseases (GS), Mater Misericordiaae University Hospital, Dublin, Ireland
| | - Séan Murphy
- Department of Neurology (LW, MM), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Radiology (FD, EK), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Stroke Medicine (GK, SM), Mater Misericordiae University Hospital, Dublin, Ireland; and Department of Infectious Diseases (GS), Mater Misericordiaae University Hospital, Dublin, Ireland
| |
Collapse
|
21
|
Fouladseresht H, Safa A, Khosropanah S, Doroudchi M. Increased frequency of HLA-A*02 in patients with atherosclerosis is associated with VZV seropositivity. Arch Physiol Biochem 2021; 127:351-358. [PMID: 31306045 DOI: 10.1080/13813455.2019.1640253] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND HLA molecules are inherited key molecules in the immune inflammation and specific responses to environmental pathogens. We investigated the association of HLA-A alleles with Varicella zoster virus (VZV) seropositivity in patients with atherosclerosis (AS). MATERIALS AND METHODS Plasma Anti-VZV IgG and molecular HLA type were detected in 203 (100 AS+ and 103 AS-) individuals. RESULTS Of 100 AS+ individuals, 66 were anti-VZV+ and 34 were anti-VZV-. Of 103 age/sex-matched AS- individuals, 59 were anti-VZV+ and 44 were anti-VZV-. Anti-VZV-IgG in AS+ cases was higher than AS- controls (p = .034). The mean anti-VZV IgG in HLA-A*02+AS+ individuals was higher than HLA-A*02+AS- controls (p < .001). HLA-A*02 was associated with VZV-seropositivity (p = .01) in AS+ patients. A higher frequency of HLA-A*02-allele in AS+ patients compared to AS- controls (p = .015) and an accumulation of HLA-A*02-allele in AS+ anti-VZV+ group (33.3%, p = .004) was observed. CONCLUSIONS HLA-A alleles and immune responses to VZV are associated with clinical atherosclerosis.
Collapse
Affiliation(s)
- Hamed Fouladseresht
- Department of Immunology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amin Safa
- Department of Immunology, Ophthalmology and ENT, School of Medicine, Complutense University, Madrid, Spain
| | - Shahdad Khosropanah
- Department of Cardiology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehrnoosh Doroudchi
- Department of Immunology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| |
Collapse
|
22
|
Saito M, Kawano H, Amano T, Hirano T. Acute Stroke Caused by Progressive Intracranial Artery Stenosis Due to Varicella Zoster Virus Vasculopathy after Chemotherapy for Malignant Lymphoma. Intern Med 2021; 60:1769-1773. [PMID: 33390495 PMCID: PMC8222136 DOI: 10.2169/internalmedicine.6365-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Decreased cell-mediated immunity can reactivate Varicella zoster virus (VZV), which can lead to various neurological complications, including vasculopathy. We herein report the case of a patient with acute stroke with progressive internal carotid artery stenosis due to VZV vasculopathy after chemotherapy for malignant lymphoma. Treatment for VZV vasculopathy improved the stenosis and prevented recurrent stroke. VZV vasculopathy is an important treatable cause of stroke in immunosuppressed patients.
Collapse
Affiliation(s)
- Mikito Saito
- Department of Stroke and Cerebrovascular Medicine, Kyorin University Faculty of Medicine, Japan
| | - Hiroyuki Kawano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University Faculty of Medicine, Japan
| | - Tatsuo Amano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University Faculty of Medicine, Japan
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University Faculty of Medicine, Japan
| |
Collapse
|
23
|
Bahouth MN, Venkatesan A. Acute Viral Illnesses and Ischemic Stroke: Pathophysiological Considerations in the Era of the COVID-19 Pandemic. Stroke 2021; 52:1885-1894. [PMID: 33794653 PMCID: PMC8078120 DOI: 10.1161/strokeaha.120.030630] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The severe acute respiratory syndrome coronavirus 2 or coronavirus disease 2019 (COVID-19) pandemic has raised concerns about the correlation with this viral illness and increased risk of stroke. Although it is too early in the pandemic to know the strength of the association between COVID-19 and stroke, it is an opportune time to review the relationship between acute viral illnesses and stroke. Here, we summarize pathophysiological principles and available literature to guide understanding of how viruses may contribute to ischemic stroke. After a review of inflammatory mechanisms, we summarize relevant pathophysiological principles of vasculopathy, hypercoagulability, and hemodynamic instability. We will end by discussing mechanisms by which several well-known viruses may cause stroke in an effort to inform our understanding of the relationship between COVID-19 and stroke.
Collapse
Affiliation(s)
- Mona N. Bahouth
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Arun Venkatesan
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| |
Collapse
|
24
|
Anthony CL, Costarides AP, Yeh S, Shantha JG. Varicella zoster virus anterior uveitis complicated by thalamic stroke. J Ophthalmic Inflamm Infect 2021; 11:13. [PMID: 33931827 PMCID: PMC8087730 DOI: 10.1186/s12348-021-00243-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 03/15/2021] [Indexed: 11/10/2022] Open
Abstract
We report a case of varicella zoster virus (VZV)-associated anterior uveitis in a patient with weight loss, arthritis and signs of inflammatory bowel disease. Her clinical course included the development of a thalamic stroke secondary to VZV cerebral vasculopathy. Following antiviral therapy, the patient's neurologic symptoms recovered and her ophthalmic findings improved.
Collapse
Affiliation(s)
- Casey L Anthony
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | | | - Steven Yeh
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, 30322, USA.,Truhlsen Eye Institute, University of Nebraska Medical Center College of Medicine, Omaha, NE, 68105, USA
| | - Jessica G Shantha
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, 30322, USA.
| |
Collapse
|
25
|
Abstract
PURPOSE OF REVIEW Varicella zoster virus (VZV) causes varicella, establishes latency, then reactivates to produce herpes zoster. VZV reactivation can also cause central nervous system (CNS) disease with or without rash. Herein, we review these CNS diseases, pathogenesis, diagnosis, and treatment. RECENT FINDINGS The most common CNS manifestation of VZV infection is vasculopathy that presents as headache, cognitive decline, and/or focal neurological deficits. VZV vasculopathy has also been associated with cerebral amyloid angiopathy and moyamoya syndrome. Rarely, VZV will produce a meningitis, encephalitis, cerebellitis, and myelopathy. Pathogenic mechanisms include direct VZV infection of affected tissue, persistent inflammation, and/or virus-induced hypercoagulability. Diagnosis is confirmed by the temporal association of rash to disease onset, intrathecal synthesis of anti-VZV antibodies, and/or the presence of VZV DNA in CSF. Most cases respond to intravenous acyclovir with corticosteroids. SUMMARY VZV produces a wide spectrum of CNS disorders that may be missed as some cases do not have an associated rash or a CSF pleocytosis. Clinicians must be vigilant in including VZV in their differential diagnosis of CNS infections as VZV is a ubiquitous pathogen; importantly, VZV CNS infections are treatable with intravenous acyclovir therapy and corticosteroids.
Collapse
|
26
|
Raadsen M, Du Toit J, Langerak T, van Bussel B, van Gorp E, Goeijenbier M. Thrombocytopenia in Virus Infections. J Clin Med 2021; 10:jcm10040877. [PMID: 33672766 PMCID: PMC7924611 DOI: 10.3390/jcm10040877] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/10/2021] [Accepted: 02/17/2021] [Indexed: 02/07/2023] Open
Abstract
Thrombocytopenia, which signifies a low platelet count usually below 150 × 109/L, is a common finding following or during many viral infections. In clinical medicine, mild thrombocytopenia, combined with lymphopenia in a patient with signs and symptoms of an infectious disease, raises the suspicion of a viral infection. This phenomenon is classically attributed to platelet consumption due to inflammation-induced coagulation, sequestration from the circulation by phagocytosis and hypersplenism, and impaired platelet production due to defective megakaryopoiesis or cytokine-induced myelosuppression. All these mechanisms, while plausible and supported by substantial evidence, regard platelets as passive bystanders during viral infection. However, platelets are increasingly recognized as active players in the (antiviral) immune response and have been shown to interact with cells of the innate and adaptive immune system as well as directly with viruses. These findings can be of interest both for understanding the pathogenesis of viral infectious diseases and predicting outcome. In this review, we will summarize and discuss the literature currently available on various mechanisms within the relationship between thrombocytopenia and virus infections.
Collapse
Affiliation(s)
- Matthijs Raadsen
- Department of Viroscience, Erasmus MC Rotterdam, Doctor molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (M.R.); (T.L.); (E.v.G.)
| | - Justin Du Toit
- Department of Haematology, Wits University Donald Gordon Medical Centre Johannesburg, Johannesburg 2041, South Africa;
| | - Thomas Langerak
- Department of Viroscience, Erasmus MC Rotterdam, Doctor molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (M.R.); (T.L.); (E.v.G.)
| | - Bas van Bussel
- Department of Intensive Care Medicine, Maastricht University Medical Center Plus, 6229 HX Maastricht, The Netherlands;
- Care and Public Health Research Institute (CAPHRI), Maastricht University, 6229 GT Maastricht, The Netherlands
| | - Eric van Gorp
- Department of Viroscience, Erasmus MC Rotterdam, Doctor molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (M.R.); (T.L.); (E.v.G.)
- Department of Internal Medicine, Erasmus MC Rotterdam, 3000 CA Rotterdam, The Netherlands
| | - Marco Goeijenbier
- Department of Viroscience, Erasmus MC Rotterdam, Doctor molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (M.R.); (T.L.); (E.v.G.)
- Department of Internal Medicine, Erasmus MC Rotterdam, 3000 CA Rotterdam, The Netherlands
- Correspondence:
| |
Collapse
|
27
|
Mescher T, Boyer PJ, Bubak AN, Hassell JE, Nagel MA. Detection of varicella zoster virus antigen and DNA in two cases of cerebral amyloid angiopathy. J Neurol Sci 2021; 422:117315. [PMID: 33503519 DOI: 10.1016/j.jns.2021.117315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 12/16/2020] [Accepted: 01/06/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Varicella zoster virus (VZV) vasculopathy and cerebral amyloid angiopathy (CAA) have similar clinical presentations: both affect cerebrovasculature in the elderly, produce hemorrhage, and can have a protracted course of cognitive decline and other neurological deficits. The cause of CAA is unknown, but amyloid-beta (Aβ) is found within arterial walls. Recent studies show that VZV induces Aβ and amylin expression and an amyloid-promoting environment. Thus, we determined if VZV was present in CAA-affected arteries. METHODS Two subjects with pathologically-verified CAA were identified postmortem and frontal lobes analyzed by immunohistochemistry for arteries containing VZV, Aβ, and amylin and H&E for pathological changes. VZV antigen detection was confirmed by PCR for VZV DNA in the same region. RESULTS In both CAA cases, sections with cerebral arteries containing VZV antigen with corresponding VZV DNA were identified; VZV antigen co-localized with Aβ in media of arteries with histological changes characteristic of CAA. Amylin was also seen in the intima of a VZV-positive artery in the diabetic subject. Not all Aβ-containing arteries had VZV, but all VZV-positive arteries contained Aβ. CONCLUSIONS VZV antigen co-localized with Aβ in some affected arteries from two CAA cases, suggesting a possible association between VZV infection and CAA.
Collapse
Affiliation(s)
- Teresa Mescher
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO 80045, United States.
| | - Philip J Boyer
- Department of Pathology, East Carolina University Brody School of Medicine, Greenville, NC 27934, United States.
| | - Andrew N Bubak
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO 80045, United States.
| | - James E Hassell
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO 80045, United States.
| | - Maria A Nagel
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO 80045, United States; Department of Ophthalmology, University of Colorado School of Medicine, Aurora, CO 80045, United States.
| |
Collapse
|
28
|
Kesserwani H. Severe Post-Herpetic Lumbar Plexopathy Responds to Pulse Intravenous Methylprednisolone: A Case Report With a Side Note on its Parallel Semiology to Diabetic Radiculoplexopathy and the Vascular Invasiveness of the Varicella-Zoster Virus. Cureus 2020; 12:e12171. [PMID: 33489582 PMCID: PMC7813428 DOI: 10.7759/cureus.12171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Post-herpetic lumbar plexopathy (post-herpetic segmental paresis), immune-mediated lumbar plexopathy and diabetic radiculoplexopathy (diabetic amyotrophy) have similar and seemingly parallel semiologies. The latter two conditions have an underlying microvasculitic pathological substrate that has shown potential (yet unproven) amelioration with immunodulatory therapy. These observations gave us the motivation to treat our patient with intravenous methylprednisolone for a profound proximal left leg weakness due to post-herpetic segmental paresis. In this case report, we outline in detail the clinical and electophysiolgical phenotype of this disease and we demonstrate the spectacular improvement of left leg power that had previously remained static for three months. In the discussion section, we review the vascular invasiveness of the varicella-zoster virus.
Collapse
|
29
|
Muñoz-Ortiz J, Rubio-Romero OL, Cedeño MC, Arteaga-Rivera K, de-la-Torre A. A white circular-spot pattern of iridian atrophy associated with Varicella-zoster virus and Toxoplasma gondii coinfection: a case report. BMC Ophthalmol 2020; 20:479. [PMID: 33287739 PMCID: PMC7720502 DOI: 10.1186/s12886-020-01748-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 11/30/2020] [Indexed: 11/17/2022] Open
Abstract
Background We report a case of white circular spots of iridian atrophy, which we will call “polka dots” pattern, as a rare ophthalmological finding associated with uveitis secondary to varicella-zoster virus and Toxoplasma gondii coinfection in a male patient in Bogotá, Colombia. Case presentation We present de case of a 53-year-old Colombian male patient with a diagnosis of anterior uveitis in his left eye due to varicella-zoster virus and Toxoplasma gondii coinfection documented by polymerase chain reaction analysis. He presented with multiple areas of superficial white circular spots of iridian atrophy in 360º, some with deeper atrophy where the stroma fibers were visualized and only a small punctate defect of transillumination was evident. This rare pattern of iridian atrophy has not been previously described in cases of uveitis in the literature. Conclusions This is the first case reporting the findings of superficial “polka dots” pattern iridian atrophy in 360° secondary to anterior uveitis due to the coinfection of a virus and a parasite. The identification of similar clinical cases may lead to early initiation of systemic treatment in these patients.
Collapse
Affiliation(s)
- Juliana Muñoz-Ortiz
- Escuela Barraquer. Research Group, Escuela Superior de Oftalmología - Instituto Barraquer de América, Avenida Calle 100 # 18A - 51, Bogotá, Colombia.,NeURos Research Group, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Carrera 24 # 63 C 69, Bogotá, Colombia
| | - Olga Lorena Rubio-Romero
- NeURos Research Group, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Carrera 24 # 63 C 69, Bogotá, Colombia
| | | | - Karla Arteaga-Rivera
- Escuela Barraquer. Research Group, Escuela Superior de Oftalmología - Instituto Barraquer de América, Avenida Calle 100 # 18A - 51, Bogotá, Colombia
| | - Alejandra de-la-Torre
- NeURos Research Group, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Carrera 24 # 63 C 69, Bogotá, Colombia.
| |
Collapse
|
30
|
Panwar C, Singh S, Sharma N. Acute Cerebral Venous Sinus Thrombosis: A Rare Complication of Primary Varicella Zoster Virus Infection. J Pediatr Neurosci 2020; 15:116-119. [PMID: 33042243 PMCID: PMC7519734 DOI: 10.4103/jpn.jpn_167_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 11/18/2019] [Accepted: 11/27/2019] [Indexed: 11/25/2022] Open
Abstract
Varicella-Zoster is a benign self limiting exanthematous illness in pediatric population which can rarely present with severe neurological manifestations such as cerebral venous thrombosis(CVT).We report the case of a 17-years old adolescent male with left hemiparesis, cranial nerve palsies associated with primary Varicella infection. MRI revealed cerebral venous thrombosis involving right transverse sinus, sigmoid sinus, internal jugular vein and infarct involving right cerebral hemisphere, Midbrain and Pons. The patient responded well to Acyclovir, cerebral decongestants and oral anticoagulant therapy.CVT is a rare but the most life threatening complication following primary Varicella infection and early diagnosis is essential for proper management of the patient.
Collapse
Affiliation(s)
- Champa Panwar
- Department of Paediatrics, Indira Gandhi Medical College (IGMC), Shimla, Himachal Pradesh, India
| | - Surinder Singh
- Department of Paediatrics, Indira Gandhi Medical College (IGMC), Shimla, Himachal Pradesh, India
| | - Neeraj Sharma
- Department of Paediatrics, Indira Gandhi Medical College (IGMC), Shimla, Himachal Pradesh, India
| |
Collapse
|
31
|
Cornelius LP, Raju V, Paulraj AJ. Cerebral Venous Sinus Thrombosis Following Primary Varicella Infection in a Child. J Pediatr Neurosci 2020; 15:150-152. [PMID: 33042251 PMCID: PMC7519745 DOI: 10.4103/jpn.jpn_136_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 01/15/2020] [Accepted: 02/06/2020] [Indexed: 12/02/2022] Open
Abstract
Varicella infection commonly called chicken pox is a benign self-limiting infection in children. Neurological complications following varicella infection are rare. Cerebral venous sinus thrombosis following varicella infection is very rare. Herewith we report a child who developed transverse and sigmoid sinus thrombosis following chicken pox.
Collapse
Affiliation(s)
- Leema P Cornelius
- Department of Paediatric Neurology, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India
| | - Vivekasaravanan Raju
- Department of Paediatric Neurology, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India
| | - Asir J Paulraj
- Department of Paediatric Neurology, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India
| |
Collapse
|
32
|
Elevated serum substance P during simian varicella virus infection in rhesus macaques: implications for chronic inflammation and adverse cerebrovascular events. J Neurovirol 2020; 26:945-951. [PMID: 32964407 DOI: 10.1007/s13365-020-00907-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/24/2020] [Accepted: 08/28/2020] [Indexed: 01/16/2023]
Abstract
Varicella and zoster, produced by varicella-zoster virus (VZV), are associated with an increased risk of stroke that may be due to persistent inflammation and hypercoagulability. Because substance P is associated with inflammation, hypercoagulability, and atherosclerotic plaque rupture that may contribute to increased stroke risk after VZV infection, we measured serum substance P in simian varicella virus-infected rhesus macaques. We found significantly increased and persistent serum substance P concentrations during varicella and zoster compared with pre-inoculation, supporting the hypothesis that VZV-induced increases in serum substance P may contribute to increased stroke risk associated with VZV infection.
Collapse
|
33
|
Cervantes-Arslanian AM, Anand P. Infectious Vasculitides of the Central Nervous System. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00815-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
34
|
Maeda Y, Watanabe M, Maeda N, Ogata H, Shinoda K, Iwaki T, Kira JI. [An autopsied case of severe varicella zoster virus-associated encephalomyelitis under immunosuppressant therapy]. Rinsho Shinkeigaku 2020; 60:351-357. [PMID: 32307398 DOI: 10.5692/clinicalneurol.cn-001413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The patient was a 40-year-old woman who was previously diagnosed with systemic lupus erythematosus and myasthenia gravis and had received prednisolone and tacrolimus for more than 7 years. In February 2017, she noticed pain in her lower back and weakness of the lower limbs, and was referred to our hospital on day 5. She had shingles in the right lower thoracic dermatomes and Brown-Séquard syndrome with right-sided dominant weakness in her lower limbs and left-sided superficial sensory disturbance below the L1 level. Varicella zoster virus (VZV)-associated myelopathy was suspected because of her symptoms and clinical findings. Despite the immediate administration of intravenous acyclovir after hospitalization, she lost consciousness and experienced a seizure related to cerebral hemorrhage in the left temporal lobe on the night of day 5. MRI showed enhanced lesions along the spinal cord and leptomeninges of the brainstem and temporal lobe. VZV-IgG and VZV-DNA were positive in the cerebrospinal fluid. Based on these clinical features and laboratory findings, she was diagnosed as VZV-associated vasculopathy and myelopathy. She subsequently had multiple cerebral infractions and hemorrhage, and developed sudden cardiopulmonary arrest on day 6, culminating in death on day 17. Autopsy showed that inflammatory mononuclear cells had infiltrated the vascular walls of the spinal cord. Immunohistochemistry revealed that some neurons and macrophages in the white matter of the spinal cord were positive for VZV. In addition, atrophic neurons, satellite cells surrounding these neurons, and infiltrating macrophages were immune-positive for VZV at the L2 dorsal root ganglia. These findings were consistent with VZV-associated vasculopathy and myelitis. Under immunosuppressive conditions, VZV can cause shingles and neuronal complications such as vasculopathy and myelitis, which are sometimes fatal despite the immediate administration of intravenous acyclovir. New treatment drugs or drugs to prevent VZV activation are desired.
Collapse
Affiliation(s)
- Yasuhiro Maeda
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University
| | - Mitsuru Watanabe
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University
| | - Norihisa Maeda
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University.,Department of Neuropathology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University
| | - Hidenori Ogata
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University
| | - Koji Shinoda
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University
| | - Toru Iwaki
- Department of Neuropathology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University
| | - Jun-Ichi Kira
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University
| |
Collapse
|
35
|
Eleftheriou D, Moraitis E, Hong Y, Turmaine M, Venturini C, Ganesan V, Breuer J, Klein N, Brogan P. Microparticle-mediated VZV propagation and endothelial activation: Mechanism of VZV vasculopathy. Neurology 2019; 94:e474-e480. [PMID: 31892634 PMCID: PMC7080289 DOI: 10.1212/wnl.0000000000008885] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 08/20/2019] [Indexed: 11/29/2022] Open
Abstract
Objective Varicella zoster virus (VZV) can spread anterogradely and infect cerebral arteries causing VZV vasculopathy and arterial ischemic stroke. In this study, we tested the hypothesis that virus-infected cerebrovascular fibroblasts undergo phenotypic changes that promote vascular remodeling and facilitate virus transmission in an in vitro model of VZV vasculopathy. The aims of this project were therefore to examine the changes that virus-infected human brain adventitial vascular fibroblasts (HBVAFs) undergo in an in vitro model of VZV vasculopathy and to identify disease biomarkers relating to VZV-related vasculopathy. Methods HBVAFs were infected with VZV, and their ability to migrate, proliferate, transdifferentiate, and interact with endothelial cells was studied with flow cytometry. Microparticles (MPs) released from these cells were isolated and imaged with transmission electron microscopy, and their protein content was analyzed with mass spectrometry. Circulating MP profiles were also studied in children with VZV and non-VZV vasculopathy and compared with controls. Results VZV-infected HBVAFs transdifferentiated into myofibroblasts with enhanced proliferative and migratory capacity. Interaction of VZV-infected HBVAFs with endothelial cells resulted in endothelial dysfunction. These effects were, in part, mediated by the release of MPs from VZV-infected HBVAFs. These MPs contained VZV virions that could transmit VZV to neighboring cells, highlighting a novel model of VZV cell-to-cell viral dissemination. MPs positive for VZV were significantly higher in children with VZV-related vasculopathy compared to children with non-VZV vasculopathy (p = 0.01) and controls (p = 0.007). Conclusions VZV-infected HBVAFs promote vascular remodeling and facilitate virus transmission. These effects were mediated by the release of apoptotic MPs that could transmit VZV infection to neighboring cells through a Trojan horse means of productive viral infection. VZV+ MPs may represent a disease biomarker worthy of further study.
Collapse
Affiliation(s)
- Despina Eleftheriou
- From the Infection, Immunology and Rheumatology Section (D.E., E.M., Y.H., C.V., J.B., N.K., P.B.) and Clinical Neurosciences (V.G.), University College London GOS Institute of Child Health; Arthritis Research UK Centre for Adolescent Rheumatology (D.E.); and Department of Cell and Developmental Biology (M.T.), University College London, UK.
| | - Elena Moraitis
- From the Infection, Immunology and Rheumatology Section (D.E., E.M., Y.H., C.V., J.B., N.K., P.B.) and Clinical Neurosciences (V.G.), University College London GOS Institute of Child Health; Arthritis Research UK Centre for Adolescent Rheumatology (D.E.); and Department of Cell and Developmental Biology (M.T.), University College London, UK
| | - Ying Hong
- From the Infection, Immunology and Rheumatology Section (D.E., E.M., Y.H., C.V., J.B., N.K., P.B.) and Clinical Neurosciences (V.G.), University College London GOS Institute of Child Health; Arthritis Research UK Centre for Adolescent Rheumatology (D.E.); and Department of Cell and Developmental Biology (M.T.), University College London, UK
| | - Mark Turmaine
- From the Infection, Immunology and Rheumatology Section (D.E., E.M., Y.H., C.V., J.B., N.K., P.B.) and Clinical Neurosciences (V.G.), University College London GOS Institute of Child Health; Arthritis Research UK Centre for Adolescent Rheumatology (D.E.); and Department of Cell and Developmental Biology (M.T.), University College London, UK
| | - Cristina Venturini
- From the Infection, Immunology and Rheumatology Section (D.E., E.M., Y.H., C.V., J.B., N.K., P.B.) and Clinical Neurosciences (V.G.), University College London GOS Institute of Child Health; Arthritis Research UK Centre for Adolescent Rheumatology (D.E.); and Department of Cell and Developmental Biology (M.T.), University College London, UK
| | - Vijeya Ganesan
- From the Infection, Immunology and Rheumatology Section (D.E., E.M., Y.H., C.V., J.B., N.K., P.B.) and Clinical Neurosciences (V.G.), University College London GOS Institute of Child Health; Arthritis Research UK Centre for Adolescent Rheumatology (D.E.); and Department of Cell and Developmental Biology (M.T.), University College London, UK
| | - Judith Breuer
- From the Infection, Immunology and Rheumatology Section (D.E., E.M., Y.H., C.V., J.B., N.K., P.B.) and Clinical Neurosciences (V.G.), University College London GOS Institute of Child Health; Arthritis Research UK Centre for Adolescent Rheumatology (D.E.); and Department of Cell and Developmental Biology (M.T.), University College London, UK
| | - Nigel Klein
- From the Infection, Immunology and Rheumatology Section (D.E., E.M., Y.H., C.V., J.B., N.K., P.B.) and Clinical Neurosciences (V.G.), University College London GOS Institute of Child Health; Arthritis Research UK Centre for Adolescent Rheumatology (D.E.); and Department of Cell and Developmental Biology (M.T.), University College London, UK
| | - Paul Brogan
- From the Infection, Immunology and Rheumatology Section (D.E., E.M., Y.H., C.V., J.B., N.K., P.B.) and Clinical Neurosciences (V.G.), University College London GOS Institute of Child Health; Arthritis Research UK Centre for Adolescent Rheumatology (D.E.); and Department of Cell and Developmental Biology (M.T.), University College London, UK
| |
Collapse
|
36
|
Spiekerkoetter E, Goncharova EA, Guignabert C, Stenmark K, Kwapiszewska G, Rabinovitch M, Voelkel N, Bogaard HJ, Graham B, Pullamsetti SS, Kuebler WM. Hot topics in the mechanisms of pulmonary arterial hypertension disease: cancer-like pathobiology, the role of the adventitia, systemic involvement, and right ventricular failure. Pulm Circ 2019; 9:2045894019889775. [PMID: 31798835 PMCID: PMC6868582 DOI: 10.1177/2045894019889775] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 10/29/2019] [Indexed: 02/06/2023] Open
Abstract
In order to intervene appropriately and develop disease-modifying therapeutics for pulmonary arterial hypertension, it is crucial to understand the mechanisms of disease pathogenesis and progression. We herein discuss four topics of disease mechanisms that are currently highly debated, yet still unsolved, in the field of pulmonary arterial hypertension. Is pulmonary arterial hypertension a cancer-like disease? Does the adventitia play an important role in the initiation of pulmonary vascular remodeling? Is pulmonary arterial hypertension a systemic disease? Does capillary loss drive right ventricular failure? While pulmonary arterial hypertension does not replicate all features of cancer, anti-proliferative cancer therapeutics might still be beneficial in pulmonary arterial hypertension if monitored for safety and tolerability. It was recognized that the adventitia as a cell-rich compartment is important in the disease pathogenesis of pulmonary arterial hypertension and should be a therapeutic target, albeit the data are inconclusive as to whether the adventitia is involved in the initiation of neointima formation. There was agreement that systemic diseases can lead to pulmonary arterial hypertension and that pulmonary arterial hypertension can have systemic effects related to the advanced lung pathology, yet there was less agreement on whether idiopathic pulmonary arterial hypertension is a systemic disease per se. Despite acknowledging the limitations of exactly assessing vascular density in the right ventricle, it was recognized that the failing right ventricle may show inadequate vascular adaptation resulting in inadequate delivery of oxygen and other metabolites. Although the debate was not meant to result in a definite resolution of the specific arguments, it sparked ideas about how we might resolve the discrepancies by improving our disease modeling (rodent models, large-animal studies, studies of human cells, tissues, and organs) as well as standardization of the models. Novel experimental approaches, such as lineage tracing and better three-dimensional imaging of experimental as well as human lung and heart tissues, might unravel how different cells contribute to the disease pathology.
Collapse
Affiliation(s)
- Edda Spiekerkoetter
- Division of Pulmonary and Critical Care Medicine, Wall Center for Pulmonary Vascular Disease, Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Elena A. Goncharova
- Pittsburgh Heart, Blood and Vascular Medicine Institute, Pulmonary, Allergy & Critical Care Division, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Christophe Guignabert
- INSERM UMR_S 999, Université Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Kurt Stenmark
- Department of Pediatrics, School of Medicine, University of Colorado, Denver, CO, USA
- Cardio Vascular Pulmonary Research Lab, University of Colorado, Denver, CO, USA
| | - Grazyna Kwapiszewska
- Ludwig Boltzmann Institute, Lung Vascular Research, Medical University of Graz, Graz, Austria
| | - Marlene Rabinovitch
- Division of Pediatric Cardiology, Wall Center for Pulmonary Vascular Disease, Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Norbert Voelkel
- Department of Pulmonary Medicine, Vrije Universiteit MC, Amsterdam, The Netherlands
| | - Harm J. Bogaard
- Department of Pulmonary Medicine, Vrije Universiteit MC, Amsterdam, The Netherlands
| | - Brian Graham
- Pulmonary Sciences and Critical Care, School of Medicine, University of Colorado, Denver, CO, USA
| | - Soni S. Pullamsetti
- Max Planck Institute for Heart and Lung Research, Bad Nauheim, Germany
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Wolfgang M. Kuebler
- Institute of Physiology, Charité – Universitaetsmedizin Berlin, Berlin, Germany
- The Keenan Research Centre for Biomedical Science at St. Michael's, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Department of Physiology, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
37
|
Bakradze E, Kirchoff KF, Antoniello D, Springer MV, Mabie PC, Esenwa CC, Labovitz DL, Liberman AL. Varicella Zoster Virus Vasculitis and Adult Cerebrovascular Disease. Neurohospitalist 2019; 9:203-208. [PMID: 31534609 PMCID: PMC6739663 DOI: 10.1177/1941874419845732] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The role of Varicella zoster virus (VZV) in neurological illness, particularly cerebrovascular disease, has been increasingly recognized. Primary infection by VZV causes varicella (chickenpox), after which the virus remains latent in neuronal ganglia. Later, during aging or immunosuppression, the virus can reactivate causing zoster (shingles). Virus reactivation can also spread to cerebral arteries causing vasculitis and stroke. Zoster is a recognized risk factor for stroke, but stroke can occur without preceding zoster rash. The diagnosis of VZV cerebral vasculitis is established by abnormal brain imaging and confirmed by presence of viral DNA or anti-VZV antibodies in cerebrospinal fluid. Treatment with acyclovir with or without prednisone is usually recommended. VZV vasculitis is a unique and uncommon stroke mechanism that has been under recognized. Careful diagnostic investigation may be warranted in a subgroup of patients with ischemic stroke to detect VZV vasculitis and initiate appropriate therapy. In the following review, we detail the clinical presentation of VZV vasculitis, diagnostic challenges in VZV detection, and suggest the ways to enhance recognition and treatment of this uncommon disease.
Collapse
Affiliation(s)
- Ekaterina Bakradze
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kathryn F. Kirchoff
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Daniel Antoniello
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Peter C. Mabie
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Neurology, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Charles C. Esenwa
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Daniel L. Labovitz
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ava L. Liberman
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| |
Collapse
|
38
|
Abstract
Varicella zoster virus (VZV) is a ubiquitous, exclusively human alphaherpesvirus that produces varicella then becomes latent in ganglionic neurons. In elderly and immunocompromised individuals, VZV reactivates and typically produces herpes zoster. Studies of patients with VZV vasculopathy have identified key clinical, imaging, and laboratory features to assist in diagnosis and treatment. Complementary studies have further expanded the spectrum of VZV vasculopathy to include the extracranial circulation and identified mechanisms contributing to its pathogenesis. Given our increasing aging population and recognition that VZV reactivation manifesting as zoster is a risk factor for stroke and myocardial infarction, recognition of VZV as a potential cause of vascular disease with or without associated zoster rash is essential to decrease associated morbidity and mortality because VZV vasculopathy can be treated with antiviral therapy.
Collapse
Affiliation(s)
- Maria A Nagel
- Department of Neurology, University of Colorado School of Medicine, Aurora.,Department of Ophthalmology, University of Colorado School of Medicine, Aurora
| | - Andrew N Bubak
- Department of Neurology, University of Colorado School of Medicine, Aurora
| |
Collapse
|
39
|
Zuin M, Rigatelli G, Adami A. Cerebrovascular events after herpes zoster infection: a risk that should be not underestimated. J Neurovirol 2019; 25:439-447. [PMID: 31069708 DOI: 10.1007/s13365-019-00748-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 03/21/2019] [Accepted: 04/03/2019] [Indexed: 02/07/2023]
Abstract
The occurrence of a cerebrovascular event after a herpes zoster (HZ) infection represents a nightmare in clinical practice, especially in those patients with concomitant cardiovascular comorbidities/risk factors and disease related per se to a higher risk of zoster infection. Moreover, the absence of a consensus opinion regarding a specific and adequate prevention of cerebrovascular events in these patients further complicates the treatment. Accumulating evidences demonstrated that HZ and HZ ophtalmicus (HZO) increase the risk of cerebrovascular events in the short-and long-term periods. Moreover, patient's ages < 40 years old, despite having fewer traditional cardiovascular comorbidities, demonstrated a higher risk of cerebrovascular events after both HZ and HZO infection. Further prospective studies are needed to analyse the role of antiviral treatments and vaccination in these subjects to clarify if they could be able to reduce the risk of stroke after a zoster infection. In the meanwhile, physicians must be aware of a higher risk of cerebrovascular events, especially in younger patients, with few cardiovascular risk factors, after an HZ infection.
Collapse
Affiliation(s)
- Marco Zuin
- Section of Internal and Cardiopulmonary Medicine, University of Ferrara, Ferrara, Italy
| | - Gianluca Rigatelli
- Section of Adult Congenital and Adult Heart Disease, Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, Via WA Mozart, 9, 37040 Legnago, Verona, Italy.
| | - Alessandro Adami
- Division of Neurology, Stroke Center, SacroCuore-Don Calabria Hospital, Negrar, Italy
| |
Collapse
|
40
|
Wu PH, Chuang YS, Lin YT. Does Herpes Zoster Increase the Risk of Stroke and Myocardial Infarction? A Comprehensive Review. J Clin Med 2019; 8:jcm8040547. [PMID: 31013629 PMCID: PMC6518274 DOI: 10.3390/jcm8040547] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 04/11/2019] [Accepted: 04/18/2019] [Indexed: 12/16/2022] Open
Abstract
Herpes zoster (HZ) caused by varicella zoster virus (VZV) reactivation is characterized as a vesicular rash of unilateral distribution that can also cause multiple complications; such as post-herpetic neuralgia; ophthalmic zoster; and other neurological issues. VZV can also increase incident hemorrhagic or ischemic complications by causing inflammatory vasculopathy. Thus; emerging epidemiological and clinical data recognizes an association between HZ and subsequent acute strokes or myocardial infarction (MI). This study reviewed published articles to elucidate the association between HZ and cerebrovascular and cardiac events. Individuals exposed to HZ or herpes zoster ophthalmicus had 1.3 to 4-fold increased risks of cerebrovascular events. Higher risks were noted among younger patients (age < 40 years) within one year after an HZ episode. The elevated risk of CV events diminished gradually according to age and length of time after an HZ episode. The putative mechanisms of VZV vasculopathy were also discussed. Several studies showed that the development of herpes zoster and herpes zoster ophthalmicus increased the risks of stroke; transient ischemic attack; and acute cardiac events. The association between VZV infection and cardiovascular events requires further studies to establish the optimal antiviral treatment and zoster vaccination to reduce zoster-associated vascular risk
Collapse
Affiliation(s)
- Ping-Hsun Wu
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan.
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan.
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan.
| | - Yun-Shiuan Chuang
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan.
| | - Yi-Ting Lin
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan.
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan.
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan.
| |
Collapse
|
41
|
Lind L, Eriksson K, Grahn A. Chemokines and matrix metalloproteinases in cerebrospinal fluid of patients with central nervous system complications caused by varicella-zoster virus. J Neuroinflammation 2019; 16:42. [PMID: 30777092 PMCID: PMC6378740 DOI: 10.1186/s12974-019-1428-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 02/03/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Varicella-zoster virus (VZV) is a common viral agent causing central nervous system (CNS) infections including encephalitis, meningitis, and Ramsay Hunt syndrome. Neurological complications occur frequently despite antiviral treatment. Matrix metalloproteinases (MMPs) and cytokines are involved in the neuroinflammatory response during CNS infection. Their role in VZV CNS infections and how they differ between different CNS entities caused by VZV are poorly investigated. METHODS We analyzed the levels of 30 chemokines and 9 MMPs in cerebrospinal fluid (CSF) and serum from 66 patients with VZV CNS infections diagnosed by detection of VZV DNA in CSF and concomitant neurological symptoms and compared with a control group (n = 24). RESULTS Levels of CCL19, CXCL8, CXCL9, and CXCL10 were significantly increased and surpassing the levels in serum when analyzing all patients with VZV CNS infections whereas CXCL11 was only increased in CSF of patients with VZV meningitis. MMP-2-levels were highly elevated in CSF of all 66 VZV patients. The patients with encephalitis had the most significantly increased levels of MMPs in CSF, and MMP-3, MMP-8, and MMP-12 were exclusively increased in this group, whereas MMP-9 in CSF was increased in the patients with VZV meningitis. CONCLUSIONS We show that both chemokines and MMPs are elevated in the CSF of patients with VZV CNS infections. Encephalitis and meningitis patients differed with respect to other chemokines (CXCL11) and MMPs (MMP-3, MMP-8, MMP-9, and MMP-12), indicating that different location of the virus gives rise to qualitative differences in the ensuing inflammatory response. In addition, the pronounced increase of MMPs in CSF of the patients with encephalitis suggests an association to the severity of this manifestation, compared to VZV meningitis and Ramsay Hunt syndrome. The role of MMPs in association to chemokines should be further investigated to evaluate their significance in the neuropathogenesis of VZV CNS infections and as a potential target for new treatment alternatives.
Collapse
Affiliation(s)
- Liza Lind
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kristina Eriksson
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anna Grahn
- Department of Infectious Diseases, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| |
Collapse
|
42
|
Guedes M, Filipe R, Costa A, Soares C, Sarmento A, Tavares M. Central nervous system varicella zoster vasculopathy in an immunocompromised patient. IDCases 2018; 15:e00483. [PMID: 30701156 PMCID: PMC6348231 DOI: 10.1016/j.idcr.2018.e00483] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 12/26/2018] [Accepted: 12/26/2018] [Indexed: 12/26/2022] Open
Abstract
Central nervous system (CNS) vasculopathy associated with Varicella Zoster Virus (VZV) infection, usually manifesting as stroke due to ischemic lesions by involvement of small arteries, is frequently misdiagnosed. Immunocompromised patients have a particularly higher risk of severe disease and also CNS involvement during or following VZV presentations. We report a case of an 84-year-old man, with myelodysplastic syndrome, who presented with herpes zoster ophthalmicus complicated with left periocular cellulitis and an abnormal neurological exam. Intravenous treatment with acyclovir and amoxicillin/clavulanic acid was began. VZV DNA was detected in the cerebrospinal fluid (CSF) and brain magnetic resonance imaging revealed three acute ischemic lesions in the left frontal and both cerebellar lobes. A VZV CNS multifocal vasculopathy was diagnosed and treatment with intravenous acyclovir continued for 21 days. Immunocompromised patients with VZV infection can have a more severe course of disease with disseminated involvement and multifocal vasculopathy. In these patients the CSF detection of anti-VZV IgG as well as VZV DNA can be helpful in the diagnosis of CNS VZV vasculopathy. The antiviral treatment can improve the outcome and should be adjusted taking in consideration the degree of immunosuppression. This clinical case and review of the literature highlights the challenges in the diagnosis and management of VZV CNS vasculopathy in immunocompromised patients.
Collapse
Affiliation(s)
- Mariana Guedes
- Infectious Diseases Department, Centro Hospitalar Universitário São João, Oporto, Portugal
| | - Rita Filipe
- Infectious Diseases Department, Centro Hospitalar Universitário São João, Oporto, Portugal
| | - Andreia Costa
- Neurology Department, Centro Hospitalar Universitário São João, Oporto, Portugal
| | - Carolina Soares
- Neurology Department, Centro Hospitalar Universitário São João, Oporto, Portugal
| | - António Sarmento
- Infectious Diseases Department, Centro Hospitalar Universitário São João, Oporto, Portugal.,Nephrology and Infectious Diseases R&D Group - Health Investigation and Innovation 17 Institutive (I3S), University of Oporto, Oporto, Portugal.,Oporto Medical School, University of Oporto, Oporto, Portugal
| | - Margarida Tavares
- Infectious Diseases Department, Centro Hospitalar Universitário São João, Oporto, Portugal.,EPI Unit - Instituto de Saúde Pública, University of Oporto, Oporto, Portugal
| |
Collapse
|
43
|
Hoshino T, Toi S, Toda K, Uchiyama Y, Yoshizawa H, Iijima M, Shimizu Y, Kitagawa K. Ischemic Stroke due to Virologically-Confirmed Varicella Zoster Virus Vasculopathy: A Case Series. J Stroke Cerebrovasc Dis 2018; 28:338-343. [PMID: 30392831 DOI: 10.1016/j.jstrokecerebrovasdis.2018.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 09/26/2018] [Accepted: 10/01/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Limited data are available regarding the characteristics and prognosis of patients with stroke due to varicella zoster virus (VZV) vasculopathy. METHODS We studied 4 patients (2 men and 2 women; age, 38-63 years) from a single center who developed acute ischemic stroke due to VZV vasculopathy. The virological diagnosis was confirmed by detecting VZV DNA and/or the IgG antibody to VZV in the cerebrospinal fluid. RESULTS Three patients were taking immunosuppressive agents, including prednisolone and/or methotrexate, at baseline. Each patient had a characteristic skin rash prior to stroke, with the interval from rash to stroke onset ranging from 13 to 122 days. Two patients experienced antecedent cranial nerve palsies; one had the third, seventh, ninth, and 10th nerve palsies and the other had the fourth nerve palsy before stroke. Cerebral infarctions were located in the anterior circulation lesion (n = 1), in the posterior circulation lesion (n = 2), and in both lesions (n = 1). Intracranial arterial stenosis was only identified in one patient on magnetic resonance angiography. A high plasma d-dimer level was detected in 1 patient, whereas high β-thromboglobulin and platelet factor 4 levels were detected in 2 patients. As a result of combined therapies with acyclovir, steroid, and antithrombotic agents, neurological symptoms markedly improved in 3 patients, whereas 1 patient was left with moderate hemiplegia. CONCLUSIONS Cranial nerve palsies may be prodromal symptoms of VZV-associated stroke. Increased levels of thrombotic markers may support the use of antithrombotic agents, although the benefit of combined treatment should be determined through larger studies.
Collapse
Affiliation(s)
- Takao Hoshino
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan.
| | - Sono Toi
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan.
| | - Kunio Toda
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan.
| | - Yumiko Uchiyama
- Department of Neurology, Tokyo Women's Medical University Yachiyo Medical Center, Chiba, Japan.
| | - Hiroshi Yoshizawa
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan.
| | - Mutsumi Iijima
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan.
| | - Yuko Shimizu
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan.
| | - Kazuo Kitagawa
- Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan.
| |
Collapse
|
44
|
Small Vessel Vasculitis in Herpes Zoster—Discussion of Current Aspects of Varicella Zoster Virus Vasculopathy. Am J Dermatopathol 2018; 40:602-604. [DOI: 10.1097/dad.0000000000001134] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
45
|
Iwasa M, Mima Y, Ito A, Abe Y, Ueda N, Otsubo R. [A case of bilateral cervical internal carotid artery dissection following herpes zoster of the trigeminal nerve]. Rinsho Shinkeigaku 2018; 58:292-296. [PMID: 29710022 DOI: 10.5692/clinicalneurol.cn-001108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
A 62 year-old man, who was taking prednisolone for nephrotic syndrome, was diagnosed with herpes zoster of the trigeminal nerve and treated with oral valacyclovir. One month later, he reported pain from the right side of the head and vomiting. MRI revealed an acute infarction in the right frontal lobe and dissection of the internal carotid artery of the right cervix. Trauma or other potential triggers were not observed. In consideration of the preceding condition of varicella zoster virus infection, acyclovir was administered in addition to unfractionated heparin, but an intramural hematoma emerged in the left internal carotid artery. Furthermore, evidence showing progression of these lesions was found. On the fifth day, prednisolone was increased to 1 mg/kg/day, and progression of vascular lesions was not observed. This case may prove valuable because it suggests a relationship between cervical artery dissection and herpes zoster.
Collapse
Affiliation(s)
- Mariko Iwasa
- Department of Neurology, Yodogawa Christian Hospital
| | - Yohei Mima
- Department of Neurology, Yodogawa Christian Hospital
| | - Aya Ito
- Department of Neurology, Yodogawa Christian Hospital
| | - Yuko Abe
- Department of Neurology, Yodogawa Christian Hospital
| | - Naoko Ueda
- Department of Neurology, Yodogawa Christian Hospital
| | | |
Collapse
|
46
|
Davico C, Canavese C, Tocchet A, Brusa C, Vitiello B. Acute Hemichorea Can Be the Only Clinical Manifestation of Post-Varicella Vasculopathy: Two Pediatric Clinical Cases. Front Neurol 2018; 9:164. [PMID: 29615962 PMCID: PMC5869195 DOI: 10.3389/fneur.2018.00164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/05/2018] [Indexed: 11/13/2022] Open
Abstract
Acute hemichorea can occur in the context of infectious, autoimmune, metabolic, toxic, and vascular neuropathologies. Primary infection by varicella zoster virus (VZV) can result in vasculopathy with neurological manifestations, such as hemiparesis, at times accompanied by hemichorea. Isolated hemichorea, however, had not been reported. We here describe two cases of VZV-induced vasculopathy whose sole clinical manifestation was acute hemichorea. Both cases involved young boys of 3 years of age, who presented with acute hemichorea 4–6 months after initial VZV infection. All hematological, immunological, and toxicological tests were normal, except for the presence of VZV IgG. Brain structural magnetic resonance imaging (MRI) and magnetic resonance angiography revealed specific signs of vasculitis and ischemic lesions in the basal ganglia region (lentiform nucleus, thalamus, and internal capsule). Following corticosteroid and acetylsalicylic acid treatment, full symptomatic recovery was achieved within 3 weeks. Repeated MRI documented full neurostructural recovery, which was confirmed at extended follow-up for more than 1 year. These cases indicate that VZV-induced vasculopathy should be considered in the case of pediatric isolated acute hemichorea.
Collapse
Affiliation(s)
- Chiara Davico
- Division of Child and Adolescent Neuropsychiatry, University of Turin, Turin, Italy
| | - Carlotta Canavese
- Division of Child and Adolescent Neuropsychiatry, University of Turin, Turin, Italy
| | - Aba Tocchet
- Division of Child and Adolescent Neuropsychiatry, University of Turin, Turin, Italy
| | - Chiara Brusa
- Division of Child and Adolescent Neuropsychiatry, University of Turin, Turin, Italy
| | - Benedetto Vitiello
- Division of Child and Adolescent Neuropsychiatry, University of Turin, Turin, Italy
| |
Collapse
|
47
|
Sadaoka T, Mori Y. Vaccine Development for Varicella-Zoster Virus. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1045:123-142. [PMID: 29896666 DOI: 10.1007/978-981-10-7230-7_7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Varicella-zoster virus (VZV) is the first and only human herpesvirus for which a licensed live attenuated vaccine, vOka, has been developed. vOka has highly safe and effective profiles; however, worldwide herd immunity against VZV has not yet been established and it is far from eradication. Despite the successful reduction in the burden of VZV-related illness by the introduction of the vaccine, some concerns about vOka critically prevent worldwide acceptance and establishment of herd immunity, and difficulties in addressing these criticisms often relate to its ill-defined mechanism of attenuation. Advances in scientific technologies have been applied in the VZV research field and have contributed toward uncovering the mechanism of vOka attenuation as well as VZV biology at the molecular level. A subunit vaccine targeting single VZV glycoprotein, rationally designed based on the virological and immunological research, has great potential to improve the strategy for eradication of VZV infection in combination with vOka.
Collapse
Affiliation(s)
- Tomohiko Sadaoka
- Division of Clinical Virology, Center for Infectious Diseases, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan.
| | - Yasuko Mori
- Division of Clinical Virology, Center for Infectious Diseases, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| |
Collapse
|
48
|
Liou LS, Chang CY, Chen HJ, Tseng CH, Chen CY, Sung FC. Increased risk of peripheral arterial occlusive disease in patients with Bell's palsy using population data. PLoS One 2017; 12:e0188982. [PMID: 29216223 PMCID: PMC5720702 DOI: 10.1371/journal.pone.0188982] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 11/16/2017] [Indexed: 11/19/2022] Open
Abstract
Objective This population-based cohort study investigated the risk of developing peripheral arterial occlusive disease (PAOD) in patients with Bell’s palsy. Methods We used longitudinal claims data of health insurance of Taiwan to identify 5,152 patients with Bell’s palsy newly diagnosed in 2000–2010 and a control cohort of 20,608 patients without Bell’s palsy matched by propensity score. Incidence and hazard ratio (HR) of PAOD were assessed by the end of 2013. Results The incidence of PAOD was approximately 1.5 times greater in the Bell’s palsy group than in the non-Bell’s palsy controls (7.75 vs. 4.99 per 1000 person-years). The Cox proportional hazards regression analysis measured adjusted HR was 1.54 (95% confidence interval (CI) = 1.35–1.76) for the Bell’s palsy group compared to the non-Bell’s palsy group, after adjusting for sex, age, occupation, income and comorbidities. Men were at higher risk of PAOD than women in the Bell’s palsy group, but not in the controls. The incidence of PAOD increased with age in both groups, but the Bell’s palsy group to control group HR of PAOD decreased as age increased. The systemic steroid treatment reduced 13% of PAOD hazard for Bell’s palsy patients, compared to those without the treatment, but not significant. Conclusions Bell’s palsy appears to be associated with an increased risk of developing PAOD. Further pathophysiologic, histopathology and immunologic research is required to explore the underlying biologic mechanism.
Collapse
Affiliation(s)
- Li-Syue Liou
- Department of Family Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien City, Hualien County, Taiwan, ROC
- Department of Family Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Xindian Dist., New Taipei City, Taiwan(R.O.C)
- Department of Family and Community Medicine, Tri-Service General Hospital, Neihu District, Taipei City, Taiwan(R.O.C.)
- School of Medicine, National Defense Medical Center, Neihu Dist., Taipei City, aiwan (R.O.C.)
| | - Chih-Ya Chang
- School of Medicine, National Defense Medical Center, Neihu Dist., Taipei City, aiwan (R.O.C.)
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, Neihu District, Taipei City, Taiwan(R.O.C.)
| | - Hsuan-Ju Chen
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan, Taichung, Taichung, Taiwan (R.O.C.)
| | - Chun-Hung Tseng
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan, North District, Taichung, Taiwan (R.O.C.)
- School of Medicine, China Medical University, Taichung, Taiwan, Taichung, Taichung, Taiwan (R.O.C.)
| | - Cheng-Yu Chen
- Department of Family Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Xindian Dist., New Taipei City, Taiwan(R.O.C)
| | - Fung-Chang Sung
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan, Taichung, Taichung, Taiwan (R.O.C.)
- Graduate Institute of Clinical Medicine Science, College of Medicine, China Medical University, Taichung, Taiwan; Taichung, Taichung, Taiwan (R.O.C.)
- Department of Health Services Administration, China Medical University, Taichung, Taiwan; Taichung, Taichung, Taiwan (R.O.C.)
- * E-mail:
| |
Collapse
|
49
|
Zhang Y, Luo G, Huang Y, Yu Q, Wang L, Li K. Risk of Stroke/Transient Ischemic Attack or Myocardial Infarction with Herpes Zoster: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2017; 26:1807-1816. [PMID: 28501259 DOI: 10.1016/j.jstrokecerebrovasdis.2017.04.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 04/01/2017] [Accepted: 04/09/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Accumulating evidence indicates that herpes zoster (HZ) may increase the risk of stroke/transient ischemic attack (TIA) or myocardial infarction (MI), but the results are inconsistent. We aim to explore the relationship between HZ and risk of stroke/TIA or MI and between herpes zoster ophthalmicus (HZO) and stroke. METHODS We estimated the relative risk (RR) and 95% confidence intervals (CIs) with the meta-analysis. Cochran's Q test and Higgins I2 statistic were used to check for heterogeneity. RESULTS HZ infection was significantly associated with increased risk of stroke/TIA (RR = 1.30, 95% CI: 1.17-1.46) or MI (RR = 1.18, 95% CI: 1.07-1.30). The risk of stroke after HZO was 1.91 (95% CI 1.32-2.76), higher than that after HZ. Subgroup analyses revealed increased risk of ischemic stroke after HZ infection but not hemorrhagic stroke. The risk of stroke was increased more at 1 month after HZ infection than at 1-3 months, with a gradual reduced risk with time. The risk of stroke after HZ infection was greater with age less than 40 years than 40-59 years and more than 60 years. Risk of stroke with HZ infection was greater without treatment than with treatment and was greater in Asia than Europe and America but did not differ by sex. CONCLUSIONS Our study indicated that HZ infection was associated with increased risk of stroke/TIA or MI, and HZO infection was the most marked risk factor for stroke. Further studies are needed to explore whether zoster vaccination could reduce the risk of stoke/TIA or MI.
Collapse
Affiliation(s)
- Yanting Zhang
- Department of Public Health, Shantou University Medical College, Shantou, Guangdong, China
| | - Ganfeng Luo
- Department of Public Health, Shantou University Medical College, Shantou, Guangdong, China
| | - Yuanwei Huang
- Department of Public Health, Shantou University Medical College, Shantou, Guangdong, China
| | - Qiuyan Yu
- National Center of STD/AIDS Control and Prevention, China CDC, Changping District, Beijing, China
| | - Li Wang
- Department of Public Health, Shantou University Medical College, Shantou, Guangdong, China
| | - Ke Li
- Department of Public Health, Shantou University Medical College, Shantou, Guangdong, China.
| |
Collapse
|
50
|
Erskine N, Tran H, Levin L, Ulbricht C, Fingeroth J, Kiefe C, Goldberg RJ, Singh S. A systematic review and meta-analysis on herpes zoster and the risk of cardiac and cerebrovascular events. PLoS One 2017; 12:e0181565. [PMID: 28749981 PMCID: PMC5531458 DOI: 10.1371/journal.pone.0181565] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 07/01/2017] [Indexed: 01/11/2023] Open
Abstract
Background Patients who develop herpes zoster or herpes zoster ophthalmicus may be at risk for cerebrovascular and cardiac complications. We systematically reviewed the published literature to determine the association between herpes zoster and its subtypes with the occurrence of cerebrovascular and cardiac events. Methods/Results Systematic searches of PubMed (MEDLINE), SCOPUS (Embase) and Google Scholar were performed in December 2016. Eligible studies were cohort, case-control, and self-controlled case-series examining the association between herpes zoster or subtypes of herpes zoster with the occurrence of cerebrovascular and cardiac events including stroke, transient ischemic attack, coronary heart disease, and myocardial infarction. Data on the occurrence of the examined events were abstracted. Odds ratios and their accompanying confidence intervals were estimated using random and fixed effects models with statistical heterogeneity estimated with the I2 statistic. Twelve studies examining 7.9 million patients up to 28 years after the onset of herpes zoster met our pre-defined eligibility criteria. Random and fixed effects meta-analyses showed that herpes zoster, type unspecified, and herpes zoster ophthalmicus were associated with a significantly increased risk of cerebrovascular events, without any evidence of statistical heterogeneity. Our meta-analysis also found a significantly increased risk of cardiac events associated with herpes zoster, type unspecified. Conclusions Our results are consistent with the accumulating body of evidence that herpes zoster and herpes zoster ophthalmicus are significantly associated with cerebrovascular and cardiovascular events.
Collapse
Affiliation(s)
- Nathaniel Erskine
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Hoang Tran
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Leonard Levin
- Lamar Soutter Library, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Christine Ulbricht
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Joyce Fingeroth
- Division of Infectious Diseases and Immunology, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Catarina Kiefe
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Robert J. Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
- * E-mail:
| | - Sonal Singh
- Division of General Internal Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
- Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| |
Collapse
|