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Hartley C, Thomas T, Smith SK, Karnsakul W. Live-Attenuated Vaccines in Pediatric Solid Organ Transplant. Vaccines (Basel) 2024; 12:376. [PMID: 38675758 PMCID: PMC11053538 DOI: 10.3390/vaccines12040376] [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: 01/26/2024] [Revised: 03/26/2024] [Accepted: 03/30/2024] [Indexed: 04/28/2024] Open
Abstract
Measles, mumps, rubella (MMR), and varicella incidence rates have increased due to the delayed vaccination schedules of children secondary to the COVID-19 pandemic. Decreased herd immunity creates a risk for immunocompetent children and immunocompromised individuals in the community. Historically, live-attenuated vaccines (MMR and varicella) were recommended before solid organ transplants. The amount of time before transplant when this is appropriate is often debated, as is the utility of vaccine titers. MMR and varicella vaccines previously were not recommended in immunocompromised patients post-solid organ transplant due to the undue risk of transmission and posed infection risk. The new literature on live-attenuated vaccines in post-transplant pediatric patients provides more insight into the vaccines' safety and efficacy. The present article aims to provide guidance on live-attenuated vaccines (MMR and varicella) in the pre-transplant and post-operative solid organ transplant phases of care in pediatric patients.
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Affiliation(s)
- Christopher Hartley
- The Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Tina Thomas
- Pediatric Liver Center, The Department of Pediatrics, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Sara Kathryn Smith
- Pediatric Liver Center, The Department of Pediatrics, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Wikrom Karnsakul
- Pediatric Liver Center, The Department of Pediatrics, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
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Kamei K. Live attenuated vaccines in patients receiving immunosuppressive agents. Pediatr Nephrol 2023; 38:3889-3900. [PMID: 37076756 PMCID: PMC10115603 DOI: 10.1007/s00467-023-05969-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 03/22/2023] [Accepted: 03/27/2023] [Indexed: 04/21/2023]
Abstract
The use of live attenuated vaccines in patients with immunosuppressive agents is contraindicated in package inserts and guidelines in Japan and other countries. However, patients receiving immunosuppressants have a high risk of infectious disease becoming severe, and the necessity to prevent infectious disease is high. To date, 2,091 vaccinations have been reported in 25 reports of live attenuated vaccines in people receiving immunosuppressants. Twenty-three patients (1.1%) became infected with the virus strain used in the vaccine, which was varicella virus in 21 patients. No reports have described life-threatening complications. A prospective study at the National Center for Child Health and Development conducted under certain immunological conditions (CD4 cell count ≥ 500/mm3, stimulation index of lymphocyte blast transformation by phytohemagglutinin (PHA) ≥ 101.6, serum immunoglobulin G ≥ 300 mg/dL) confirmed the serological effectiveness and safety. The evidence suggests that live attenuated vaccines can be used even in combination with immunosuppressants. Further evidence must be gathered and immunological criteria investigated to determine the conditions for safe use. Depending on the results of these investigations, the wording in package inserts and guidelines may need to be revised.
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Affiliation(s)
- Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan.
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Gelman D, Zektser M, Nesher L. Preventing varicella zoster infection in immunocompromised adults with varicella zoster-specific immunoglobulins. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e94. [PMID: 37256153 PMCID: PMC10226185 DOI: 10.1017/ash.2023.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 06/01/2023]
Abstract
Background Varicella zoster virus (VZV) exposure seriously threatens immunocompromised hosts. Postexposure prophylaxis (PEP) using immune globulins is considered the standard of care; however, the available literature is mainly based on its use in pediatric patients. Here, we describe a widespread VZV exposure among immunocompromised adults treated with VZV-specific immunoglobulins (VZVSIG), and we discuss management and outcomes. Methods We conducted a retrospective study to describe the exposure of immunocompromised patients to a single healthcare worker with primary VZV in 2019. Patients were grouped by their overall risk for infection, and those at risk received a single intramuscular dose of 625 IU of VZVSIG and were followed for 1 year. Results In total, 83 patients received PEP at <96 hours of exposure: 14 were hospitalized, 68 were outpatients, and 1 was an immunocompromised staff member. The median age was 69 years (range, 21-92), and 49.4% were male. In addition, 30% of the patients were deemed high risk, 42% were intermediate risk, and 28% were considered low risk, although they were given PEP. Varicella infection was not diagnosed in any patient in the first weeks of follow-up. However, during the year of follow-up, 4 patients developed symptoms suspicious of VZV, all >3 months after exposure, thus were probably unrelated to the event. Adverse events related to VZVSIG (pyrexia) were reported in 2 patients (2.4%). Conclusions Our findings demonstrate the utility of VZVSIG as PEP in one of the largest cohorts of immunocompromised adults to date. No early varicella infection was found following exposure, supporting the current recommendations of the VZVSIG administration.
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Affiliation(s)
- Daniel Gelman
- Infectious Disease Institute, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Military Medicine, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Miri Zektser
- Department of Hematology, Soroka University Medical Center, Beer Sheva, Israel
| | - Lior Nesher
- Infectious Disease Institute, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
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Herpes Simplex Virus and Varicella Zoster Virus Infections in Cancer Patients. Viruses 2023; 15:v15020439. [PMID: 36851652 PMCID: PMC9961783 DOI: 10.3390/v15020439] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/28/2023] [Accepted: 02/03/2023] [Indexed: 02/08/2023] Open
Abstract
Herpes simplex virus (HSV) and varicella zoster virus (VZV) are alpha herpesviruses that establish life-long latent infection in neuronal ganglia after primary infection. Periodic reactivation of these viruses results in recurrent infections that can have significant impact on patients' quality of life. HSV commonly causes oral and genital mucocutaneous infections whereas VZV is responsible for varicella/chickenpox and herpes zoster/shingles, but cancer patients are at particularly higher risk of complications including disseminated and visceral infections due to impaired cell-mediated immunity. While diagnosis of more common HSV and/or VZV infections is frequently clinically based, immunocompromised hosts may have atypical skin presentation or visceral involvement. Thus, diagnostic confirmation using virus-specific tests such as polymerase chain reaction or immunohistochemical staining is crucial in some cases. Oral acyclovir, valacyclovir and famciclovir are usually used for mild to moderate infections and intravenous acyclovir is the drug of choice for severe or disseminated infections. Foscarnet can be used when acyclovir-resistance is confirmed or suspected. Pharmaceutical prophylaxis against HSV and/or VZV should be considered in high-risk cancers patients. Currently, there is no commercially available vaccine against HSV, but VZV vaccines are available to prevent varicella and zoster.
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Dooling K, Marin M, Gershon AA. Clinical Manifestations of Varicella: Disease Is Largely Forgotten, but It's Not Gone. J Infect Dis 2022; 226:S380-S384. [PMID: 36265857 DOI: 10.1093/infdis/jiac390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
After 25 years of varicella vaccination in the United States, classic varicella and its complications have become an uncommon occurrence. The clinical manifestation of varicella among vaccinated persons is usually modified, with fewer skin lesions, mostly maculopapular, and milder presentation. However, the potential for severe manifestations from varicella still exists among both vaccinated and unvaccinated persons, and thus healthcare providers should keep varicella in the differential diagnosis of a maculopapular or vesicular rash. The prompt recognition and diagnosis of varicella is important because when confirmed, clinical and public health measures need to be taken swiftly.
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Affiliation(s)
- Kathleen Dooling
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mona Marin
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Anne A Gershon
- Columbia University College of Physicians and Surgeons, New York, New York, USA
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Cuerden C, Gower C, Brown K, Heath PT, Andrews N, Amirthalingam G, Bate J. PEPtalk 3: oral aciclovir is equivalent to varicella zoster immunoglobulin as postexposure prophylaxis against chickenpox in children with cancer - results of a multicentre UK evaluation. Arch Dis Child 2022; 107:1029-1033. [PMID: 35803693 DOI: 10.1136/archdischild-2022-324396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 06/28/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare the occurrence of chickenpox in children with cancer who received varicella immunoglobulin (VZIG) or aciclovir as postexposure prophylaxis (PEP). DESIGN Prospective multicentre service evaluation of children with cancer who received either VZIG or aciclovir as PEP following significant exposure to varicella zoster virus (VZV) over a 24-month period from May 2018. SETTING Data were collected from 9 UK Paediatric Oncology Primary Treatment Centres. PATIENTS Children under 16 years old with a diagnosis of cancer and/or previous haematopoietic stem cell transplant who were VZV seronegative at exposure and/or diagnosis and received PEP following significant VZV exposure. MAIN OUTCOME MEASURES The primary outcome was the incidence of breakthrough varicella within 6 weeks of VZV exposure and treatment with PEP. RESULTS A total of 105 eligible patients were registered with a median age of 4.9 years (range 1.1-10.5 years). Underlying diagnoses were acute leukaemia (64), solid tumours (22), Langerhans cell histiocytosis (9), central nervous system (CNS) tumours (8) and other (2). Aciclovir was received by 86 patients (81.9%), 18 received VZIG (17.1%) and 1 valaciclovir (0.9%). There were seven reported break-through VZV infections in 103 patients at follow-up (7/103, 6.8%). Clinical VZV developed in 5/84 of the aciclovir group (6.0%, 95% CI 2.0 to 13.3) and 2/18 of VZIG group (11.1%, 95% CI 1.4 to 34.7). All breakthrough infections were either mild (5/7) or moderate (2/7) in severity. CONCLUSION Aciclovir is a safe and effective alternative to VZIG as VZV PEP in children with cancer and should be considered as standard of care.
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Affiliation(s)
- Claire Cuerden
- Department of Paediatric Oncology, Southampton Children's Hospital, Southampton, UK
| | - Charlotte Gower
- Department of Immunisation and Counter Measures, Public Health England Colindale, London, UK
| | - Kevin Brown
- Immunisation and Vaccine Preventable Diseases Division, UK Health Security Agency, London, UK
| | - Paul T Heath
- Vaccine Institute, St George's, University of London, London, UK
| | - Nick Andrews
- Statistics, Modelling and Economics Unit, UK Health Security Agency, London, UK
| | - Gayatri Amirthalingam
- Immunisation and Vaccine Preventable Diseases Division, UK Health Security Agency, London, UK
| | - Jessica Bate
- Department of Paediatric Oncology, Southampton Children's Hospital, Southampton, UK
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Levin MJ, Weinberg A. Immune Responses to Varicella-Zoster Virus Vaccines. Curr Top Microbiol Immunol 2022; 438:223-246. [PMID: 35102438 DOI: 10.1007/82_2021_245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The live attenuated varicella vaccine is intended to mimic the tempo and nature of the humoral and cell-mediated immune responses to varicella infection. To date, two doses of varicella vaccine administered in childhood have been very effective in generating varicella-zoster virus (VZV) immune responses that prevent natural infection for at least several decades. After primary infection, the infecting VZV establishes latency in sensory and cranial nerve ganglia with the potential to reactivate and cause herpes zoster. Although, the immune responses developed during varicella are important for preventing herpes zoster they wane with increasing age (immune senescence) or with the advent of immune suppression. Protection can be restored by increasing cell-mediated immune responses with two doses of an adjuvanted recombinant VZV glycoprotein E vaccine that stimulates both VZV-and gE-specific immunity. This vaccine provides ~85-90% protection against herpes zoster for 7-8 years (to date).
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Affiliation(s)
- Myron J Levin
- Departments of Pediatrics and Medicine, University of Colorado Denver School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Adriana Weinberg
- Departments of Pediatrics, Medicine, and Pathology, University of Colorado Denver School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
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Costa G, Orbach D, Saulpic J, Sarda-Thibault H, Hanslik T, Brethon B, Tabone MD, Raimbault S, Papillard S, Guillaumat C, Nathanson S, Pellegrino B, Belloy M, Mesples B, Trioche P, Jaber H, Raimondo G, Gilet C, Cohen-Gogo S. Varicella post-exposure management for pediatric oncology patients. Bull Cancer 2022; 109:287-295. [PMID: 35093244 DOI: 10.1016/j.bulcan.2021.11.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/05/2021] [Accepted: 11/21/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The objective was to evaluate health care providers' (HCP) adherence to and efficacy of varicella post-exposure prophylaxis (PEP) recommendations. It was an observational, prospective, multicenter study set in Ile-de-France, France. METHODS All children under 18 with a cancer diagnosis, currently or within 3months of receiving cancer treatment, regardless of varicella zoster virus (VZV) serostatus or previous personal history of varicella, were eligible. Study participants with significant exposure were reviewed prospectively for PEP indications. Main outcome measures were the percentage of exposure situations for which HCP were guideline-compliant, the proportion of available VZV serostatuses and the incidence of breakthrough varicella after different PEP approaches. RESULTS A total of 51 patients from 15 centers were enrolled after 52 exposure episodes. Median age at exposure was 5 years (range, 1-15). Exposure within the household led to 38% of episodes. Prophylactic treatment consisted in specific anti-VZV immunoglobulins (V-ZIG) (n=19) or in oral aciclovir (n=15). No prophylactic treatment was given for 18 patients (in compliance, n=16). In compliance with guidelines, 17 patients received V-ZIG, 11 did not develop varicella (65%, [95% CI, 39-90%]); 15 received aciclovir, 13 did not develop varicella (87%, [95% CI, 67-100%]). Breakthrough varicella occurred in 11 patients, with simple clinical course in all cases; in 8/47 (17%) episodes when PEP was guideline-compliant versus 3/5 (60%) when not. DISCUSSION Recommendations have been respected and are efficient. PEP needs to be standardized and a study carried out to define the optimal approach. Anti-VZV immunization of seronegative family members should be encouraged.
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Affiliation(s)
- Guillaume Costa
- Centre Hospitalier Sud Francilien, Corbeil-Essonnes, Department of Pediatrics, 40, Avenue Serge Dassault, 91100 Corbeil-Essonnes, France
| | - Daniel Orbach
- PSL University, SIREDO oncology center (Care, Innovation and Research for Children, Adolescents and young Adults with Cancer) Institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - Juliette Saulpic
- Centre Médical et Pédagogique Edouard Rist, Department of Hemato-Oncology, 14, Rue Boileau, 75016 Paris, France
| | - Hélène Sarda-Thibault
- Centre Hospitalier Réné Dubos, Department of Pediatrics, 6, avenue de l'Île de France, 95300 Pontoise, France
| | - Thomas Hanslik
- CHU Ambroise Paré, Department of Internal Medicine, 9, Avenue Charles de Gaulle, 92100 Boulogne-Billancourt, France
| | - Benoit Brethon
- CHU Robert-Debré, Department of Pediatric Immuno-hematology, 48, Bd Sérurier, 75019 Paris, France
| | - Marie-Dominique Tabone
- Armand-Trousseau Sorbonne University Hospital, AP-HP, Department of Pediatric Hemato-Oncology, 26, Av. du Dr Arnold Netter, 75012 Paris, France
| | - Sandra Raimbault
- Institut Gustave Roussy, Department of Pediatric Oncology, 114, Rue Edouard Vaillant, 94805 Villejuif, France
| | - Solesne Papillard
- CHU Ambroise Paré, Department of Pediatrics, 9, Av. Charles de Gaulle, 92100 Boulogne-Billancourt, France
| | - Cécile Guillaumat
- Centre Hospitalier Sud Francilien, Corbeil-Essonnes, Department of Pediatrics, 40, Avenue Serge Dassault, 91100 Corbeil-Essonnes, France
| | - Sylvie Nathanson
- Centre Hospitalier André Mignot, Department of Pediatrics, 177, Rue de Versailles, 78150 Le Chesnay-Rocquencourt, France
| | - Béatrice Pellegrino
- Centre Hospitalier François Quesnay, Department of Pediatrics, 2 Bd Sully, 78200 Mantes-la-Jolie, France
| | - Marie Belloy
- Centre Hospitalier Robert Ballanger, Department of Pediatrics, Boulevard Robert Ballanger, 93602 Aulnay-sous-Bois, France
| | - Bettina Mesples
- CHU Louis Mourier, Department of Pediatrics, 178, rue des Renouillers, 92701 Colombes, France
| | - Pascale Trioche
- CHU Antoine Béclère, Department of Pediatrics, 157, Rue de la Porte de Trivaux, 92140 Clamart, France
| | - Hania Jaber
- Centre Hospitalier Simone Veil, Department of Pediatrics, 14, Rue de Saint-Prix, 95600 Eaubonne, France
| | - Graziella Raimondo
- Hospital Margency Croix-Rouge, Department of Pediatrics, 18, rue Roger Salengro, 95580 Margency, France
| | - Céline Gilet
- Regional care network for pediatric hematology-oncology-Ile-de-France (RIFHOP), 3-5, rue de Metz, 75010 Paris, France
| | - Sarah Cohen-Gogo
- The Hospital for Sick Children, Division of Hematology, Oncology, Department of Pediatrics, 555, University Avenue, Toronto, Canada.
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Marin M, Leung J, Gershon AA. Transmission of Vaccine-Strain Varicella-Zoster Virus: A Systematic Review. Pediatrics 2019; 144:peds.2019-1305. [PMID: 31471448 PMCID: PMC6957073 DOI: 10.1542/peds.2019-1305] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2019] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Live vaccines usually provide robust immunity but can transmit the vaccine virus. OBJECTIVE To assess the characteristics of secondary transmission of the vaccine-strain varicella-zoster virus (Oka strain; vOka) on the basis of the published experience with use of live varicella and zoster vaccines. DATA SOURCES Systematic review of Medline, Embase, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and Scopus databases for articles published through 2018. STUDY SELECTION Articles that reported original data on vOka transmission from persons who received vaccines containing the live attenuated varicella-zoster virus. DATA EXTRACTION We abstracted data to describe vOka transmission by index patient's immune status, type (varicella or herpes zoster) and severity of illness, and whether transmission was laboratory confirmed. RESULTS Twenty articles were included. We identified 13 patients with vOka varicella after transmission from 11 immunocompetent varicella vaccine recipients. In all instances, the vaccine recipient had a rash: 6 varicella-like and 5 herpes zoster. Transmission occurred mostly to household contacts. One additional case was not considered direct transmission from a vaccine recipient, but the mechanism was uncertain. Transmission from vaccinated immunocompromised children also occurred only if the vaccine recipient developed a rash postvaccination. Secondary cases of varicella caused by vOka were mild. LIMITATIONS It is likely that other vOka transmission cases remain unpublished. CONCLUSIONS Healthy, vaccinated persons have minimal risk for transmitting vOka to contacts and only if a rash is present. Our findings support the existing recommendations for routine varicella vaccination and the guidance that persons with vaccine-related rash avoid contact with susceptible persons at high risk for severe varicella complications.
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Affiliation(s)
- Mona Marin
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; and
| | - Jessica Leung
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anne A. Gershon
- Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
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Guru V, Radhakrishnan V, Sagar T. Varicella vaccination in children with acute lymphoblastic leukemia: Experience from a pediatric cancer centre in India. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2019. [DOI: 10.1016/j.phoj.2019.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Mould DR, Hutson PR. Critical Considerations in Anticancer Drug Development and Dosing Strategies: The Past, Present, and Future. J Clin Pharmacol 2019; 57 Suppl 10:S116-S128. [PMID: 28921645 DOI: 10.1002/jcph.983] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 06/19/2017] [Indexed: 01/26/2023]
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Varicella zoster immune globulin (VARIZIG) administration up to 10 days after varicella exposure in pregnant women, immunocompromised participants, and infants: Varicella outcomes and safety results from a large, open-label, expanded-access program. PLoS One 2019; 14:e0217749. [PMID: 31269033 PMCID: PMC6608934 DOI: 10.1371/journal.pone.0217749] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 05/09/2019] [Indexed: 12/16/2022] Open
Abstract
Introduction Despite vaccination, there were more than 100,000 annual cases of varicella in the United States in 2013–2014. Individuals at highest risk of developing severe or complicated varicella include immunocompromised people, preterm infants, and pregnant women. Varicella zoster immune globulin (human) (VARIZIG) is recommended by the CDC for postexposure prophylaxis to prevent or attenuate varicella-zoster virus infection in high-risk individuals. Contemporary information on administration of VARIZIG is limited. Methods This open-label, expanded-access program provided VARIZIG to physician-identified, high-risk participants exposed to varicella. Participants included immunocompromised children/adults, infants (preterm, newborns whose mothers had varicella onset within 5 days before or 2 days after delivery, and those aged <1 year), and pregnant women. VARIZIG (125 IU/10 kg [up to 625 IU]) was administered intramuscularly, ideally within 96 hours, but up to 10 days, postexposure. Incidence of varicella rash and severity (>100 pox, pneumonia, or encephalitis) were assessed up to 42 days after administration. Results The varicella outcome population (n = 507) included 263 immunocompromised participants (32 adults, 231 children), 137 pregnant women, 105 infants, and 2 healthy adults with no history of varicella. Varicella incidence was 4.5% in immunocompromised participants, 7.3% in pregnant women, and 11.5% in infants. The incidence of varicella was similar when comparing VARIZIG administration ≤ 96 hours vs > 96 hours (up to 10 days) postexposure in the entire population (6.2% vs. 9.4%, respectively), and also in each subgroup. Of 34 participants with varicella, 5 developed > 100 pox and 1 developed pneumonia and encephalitis. There were no product-related deaths and only 1 serious adverse event (serum sickness) considered probably related to VARIZIG. Conclusion Postexposure administration of VARIZIG was associated with low rates of varicella in high-risk participants, regardless of when administered within 10 days postexposure. VARIZIG was well-tolerated and safe in high-risk participants.
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Nosan G, Paro-Panjan D, Ihan A, Kopitar AN, Čučnik S, Avčin T. Vaccine immune response, autoimmunity and morbidity after neonatal blood exchange transfusion. Vaccine 2019; 37:4076-4080. [PMID: 31160098 DOI: 10.1016/j.vaccine.2019.05.077] [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: 02/14/2019] [Revised: 04/28/2019] [Accepted: 05/26/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION A blood exchange transfusion (BET) is most commonly performed to treat severe neonatal haemolytic disease. A distinct form of blood transfusion adverse reaction is transfusion-related immunomodulation. The purpose of our retrospective single-centre case-control cohort study was to investigate whether a blood exchange transfusion in the neonatal period provokes immunomodulation and affects humoral immune response to vaccination, morbidity and occurrence of autoantibodies. METHODS Study subjects were 74 apparently healthy children, who were born at term as appropriate for gestational age and received four doses of diphtheria and tetanus toxoid vaccine. Forty-one received BET due to neonatal hemolytic disease and no other blood product afterwards, while 33 did not receive any blood products. Analysis of diphtheria, tetanus and autoimmune antibodies was performed and their medical records were analyzed for infectious, allergic, cancerous and autoimmune diseases. RESULTS A clearly exaggerated immune response to diphtheria (1.016 IU/mL, 95% confidence interval (CI) 0.662-1.369 IU/mL vs. 0.515 IU/mL, 95% CI 0.363 to 0.626 IU/mL, P = 0.011) and slightly exaggerated immune response to tetanus vaccine (1.798 IU/mL, 95% CI 1.180-2.416 IU/mL vs. 1.036 IU/mL, 95% CI 0.398-1.673 IU/mL, P = non-specific) were observed in BET subjects. A propensity towards autoimmunity (25.8% vs. 12.5%, P = non-specific) was observed in BET subjects. However, BET in the neonatal period did not influence the occurrence of bacterial, childhood viral diseases with exception of varicella (43.9% vs. 21.2%, P = 0.040), autoimmune and cancer diseases. CONCLUSION BET impacted humoral immune response to diphtheria and tetanus vaccine and occurrence of autoimmune antibodies, but did not affect morbidity and the occurrence of autoimmune diseases. These effects could be related to massive antigenic load of BET and an accelerated priming of immune cells and consequent immunomodulation.
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Affiliation(s)
- Gregor Nosan
- Department of Neonatology, Division of Paediatrics, University Medical Centre Ljubljana, Ljubljana, Slovenia.
| | - Darja Paro-Panjan
- Department of Neonatology, Division of Paediatrics, University Medical Centre Ljubljana, Ljubljana, Slovenia; Department of Paediatrics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Alojz Ihan
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Andreja Nataša Kopitar
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Saša Čučnik
- Department of Rheumatology, Division of Internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia; Chair of Clinical Biochemistry, Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Tadej Avčin
- Department of Paediatrics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; Department of Allergology, Rheumatology and Clinical Immunology, Division of Paediatrics, University Medical Centre Ljubljana, Ljubljana, Slovenia
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Wada-Shimosato Y, Tanoshima R, Hiratoko K, Takeuchi M, Tsujimoto SI, Shiba N, Ito S, Yamanaka T, Ito S. Effectiveness of acyclovir prophylaxis against varicella zoster virus disease after allogeneic hematopoietic cell transplantation: A systematic review and meta-analysis. Transpl Infect Dis 2019; 21:e13061. [PMID: 30756465 DOI: 10.1111/tid.13061] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/28/2019] [Accepted: 02/07/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Varicella zoster virus (VZV) disease is a common complication after hematopoietic cell transplantation (HCT). The mortality rate for disseminated VZV infection is 34%. Acyclovir has been used for the prophylaxis of VZV disease after HCT, but the effectiveness of prophylaxis is controversial. We conducted a meta-analysis of the incidence of VZV disease within the first 1 year after acyclovir prophylaxis had been discontinued and assessed the risk of VZV disease during acyclovir prophylaxis. METHODS Medline, EMBASE plus EMBASE classics, and the Cochrane Central Register of Controlled Trials were used for a systematic search. The inclusion criteria were both randomized controlled trials and cohort studies that described the effectiveness of acyclovir as prophylaxis against VZV disease after allogeneic HCT. RESULTS We included seven studies involving a total of 2265 patients. No mortality by VZV was identified. Acyclovir prophylaxis significantly reduced the rate of VZV infection within the first 1 year after discontinuation (risk ratio: 0.38, 95% confidence interval (CI): 0.29-0.51). The risk of VZV disease during acyclovir prophylaxis was also reduced (risk ratio: 0.17, 95% CI: 0.12-0.24). Both short-term and long-term prophylaxis reduced the incidence of VZV infection (RR: 0.51, 95% CI: 0.30-0.86 vs RR: 0.34, 95% CI: 0.22-0.54). Low-dose acyclovir (<400 mg/d) is sufficient to reduce the risk of VZV disease. CONCLUSION This study showed that acyclovir prophylaxis reduced VZV infection after HCT with no fatal cases and acyclovir prophylaxis is beneficial. No significant adverse effects occurred and no delayed VZV disease was identified.
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Affiliation(s)
- Yuko Wada-Shimosato
- Department of Pediatrics, Yokohama City University School of Medicine, Yokohama, Japan
| | - Reo Tanoshima
- Department of Pediatrics, Yokohama City University School of Medicine, Yokohama, Japan
| | - Kanako Hiratoko
- Department of Pediatrics, Yokohama City University School of Medicine, Yokohama, Japan
| | - Masanobu Takeuchi
- Department of Pediatrics, Yokohama City University School of Medicine, Yokohama, Japan
| | - Shin-Ichi Tsujimoto
- Department of Pediatrics, Yokohama City University School of Medicine, Yokohama, Japan
| | - Norio Shiba
- Department of Pediatrics, Yokohama City University School of Medicine, Yokohama, Japan
| | - Shinya Ito
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Takeharu Yamanaka
- Department of Biostatistics, Yokohama City University School of Medicine, Yokohama, Japan
| | - Shuichi Ito
- Department of Pediatrics, Yokohama City University School of Medicine, Yokohama, Japan
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Abstract
BACKGROUND Immunocompromised patients exposed to varicella may experience significant morbidity and a 7% mortality rate. Management and outcome of an outbreak of varicella infection among hospitalized pediatric hemato-oncology patients using the guidelines of the American Academy of Pediatrics Committee on Infectious Diseases are presented. METHODS This retrospective study describes an outbreak of varicella infection between February 2011 and June 2011. Data were retrieved from the patients' files. Positive polymerase chain reaction results for varicella zoster virus from vesicular skin lesions were used for the diagnosis of varicella infection. RESULTS Twelve pediatric hemato-oncology patients experienced 13 episodes of varicella infection, 11 underwent 1 episode each and 1 patient had 2 episodes. All exposed patients without immunity received varicella zoster immune globulins or intravenous immunoglobulin and were isolated as recommended by the guidelines. Infected patients received intravenous acyclovir. One patient with acute lymphoblastic leukemia at induction chemotherapy died. All the other patients survived. CONCLUSIONS Our experience in the management of hospitalized immunocompromised patients exposed to varicella was that a positive IgG serology did not confer protection after exposure to varicella infection and thus can not serve as a marker for immunity. Unlike the isolation period sufficient for immunocompetent patients, crusted lesions can be contagious and thus require extended isolation for immunocompromised patients. Patients receiving rituximab are at greater risk of having persistent or recurrent disease. Studies with a larger sample size should be performed to better assess the management of immunocompromized patients exposed to varicella.
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Denny JT, Rocke ZM, McRae VA, Denny JE, Fratzola CH, Ibrar S, Bonitz J, Tse JT, Cohen S, Mellender SJ, Kiss GK. Varicella Pneumonia: Case Report and Review of a Potentially Lethal Complication of a Common Disease. J Investig Med High Impact Case Rep 2018; 6:2324709618770230. [PMID: 29707592 PMCID: PMC5912273 DOI: 10.1177/2324709618770230] [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: 12/14/2017] [Revised: 03/06/2018] [Accepted: 03/18/2018] [Indexed: 01/31/2023] Open
Abstract
Varicella zoster virus causes varicella (chickenpox). It can be reactivated endogenously many years later to cause herpes zoster (shingles). Although varicella is usually a benign disease in healthy children, it resulted in over 11 000 hospitalizations and over 100 deaths every year, in all ages, in the United States. Morbidity was considerably worse in older teenagers and adults. Between 5% and 15% of cases of adult chickenpox will produce some form of pulmonary illness. Progression to pneumonia risk factors include pregnancy, age, smoking, chronic obstructive pulmonary disease, and immunosuppression. Typically, pulmonary symptoms occur 1 to 6 days after varicella zoster infection. They often include cough, fever, and dyspnea. Treatment is a 7-day course of intravenous acyclovir for varicella pneumonia. Early intervention may modify the course of this complication. This review illustrates practical features with a case of a 34-year-old female with severe varicella pneumonia. Despite the lack of significant past medical history and absence of immunosuppression, her pneumonia worsened and by using continuous positive airway pressure mask, intubation was avoided. More important, the radiographic progression of severe varicella pneumonia is shown. This highlights how a common disease of varicella can progress in an adult and manifest with significant organ malfunction.
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Affiliation(s)
| | - Zoe M Rocke
- St. George's University, St. George, Grenada
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17
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Warren-Gash C, Forbes H, Breuer J. Varicella and herpes zoster vaccine development: lessons learned. Expert Rev Vaccines 2017; 16:1191-1201. [PMID: 29047317 PMCID: PMC5942150 DOI: 10.1080/14760584.2017.1394843] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 10/17/2017] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Before vaccination, varicella zoster virus (VZV), which is endemic worldwide, led to almost universal infection. This neurotropic virus persists lifelong by establishing latency in sensory ganglia, where its reactivation is controlled by VZV-specific T-cell immunity. Lifetime risk of VZV reactivation (zoster) is around 30%. Vaccine development was galvanised by the economic and societal burden of VZV, including debilitating zoster complications that largely affect older individuals. Areas covered: We describe the story of development, licensing and implementation of live attenuated vaccines against varicella and zoster. We consider the complex backdrop of VZV virology, pathogenesis and immune responses in the absence of suitable animal models and examine the changing epidemiology of VZV disease. We review the vaccines' efficacy, safety, effectiveness and coverage using evidence from trials, observational studies from large routine health datasets and clinical post-marketing surveillance studies and outline newer developments in subunit and inactivated vaccines. Expert commentary: Safe and effective, varicella and zoster vaccines have already made major inroads into reducing the burden of VZV disease globally. As these live vaccines have the potential to reactivate and cause clinical disease, developing alternatives that do not establish latency is an attractive prospect but will require better understanding of latency mechanisms.
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Affiliation(s)
- Charlotte Warren-Gash
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Harriet Forbes
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Judith Breuer
- Division of Infection and Immunity, University College London, London, UK
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18
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Levin MJ, Bresnitz E, Popmihajlov Z, Weinberg A, Liaw KL, Willis E, Curtis JR. Studies with herpes zoster vaccines in immune compromised patients. Expert Rev Vaccines 2017; 16:1217-1230. [PMID: 29053937 DOI: 10.1080/14760584.2017.1395703] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The active component of the herpes zoster vaccine (ZVL), licensed for people ≥50 years of age, is a live attenuated varicella-zoster virus. ZVL is contraindicated for immune compromised individuals, with limited regard to the degree of immunosuppression. Areas covered: This review evaluates phase I and II and observational studies for ZVL, and published reports of the off-label use of ZVL, for conditions and therapies for which investigators considered the risk-benefit for using ZVL to be favorable. It also discusses exploratory trials of ZVL for additional immune compromising conditions, and summarizes clinical guidelines from many countries and professional societies that are based upon recent investigations. Studies in immune compromised patients of investigational vaccines that do not contain live virus are reviewed. Expert commentary: It is likely that past and ongoing research with ZVL will define immune compromising diseases and/or therapies for which the risk-benefit for using ZVL vaccine is favorable. The main variables to consider in this assessment in immune compromised patients are safety, immunogenicity, protection against herpes zoster, and persistence of protection. Vaccination against herpes zoster prior to suppressing immunity is an important clinical strategy, although efficacy of this approach has not been evaluated in a clinical trial.
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Affiliation(s)
- Myron J Levin
- a Section of Pediatric Infectious Diseases, Departments of Pediatrics and Medicine , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | | | | | - Adriana Weinberg
- a Section of Pediatric Infectious Diseases, Departments of Pediatrics and Medicine , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | | | | | - Jeffrey R Curtis
- c Division of Clinical Immunology and Rheumatology , University of Alabama , Birmingham , AL , USA
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Abstract
The most common specimens from immunocompromised patients that are analyzed for detection of herpes simplex virus (HSV) or varicella-zoster virus (VZV) are from skin lesions. Many types of assays are applicable to these samples, but some, such as virus isolation and direct fluorescent antibody testing, are useful only in the early phases of the lesions. In contrast, nucleic acid (NA) detection methods, which generally have superior sensitivity and specificity, can be applied to skin lesions at any stage of progression. NA methods are also the best choice, and sometimes the only choice, for detecting HSV or VZV in blood, cerebrospinal fluid, aqueous or vitreous humor, and from mucosal surfaces. NA methods provide the best performance when reliability and speed (within 24 hours) are considered together. They readily distinguish the type of HSV detected or the source of VZV detected (wild type or vaccine strain). Nucleic acid detection methods are constantly being improved with respect to speed and ease of performance. Broader applications are under study, such as the use of quantitative results of viral load for prognosis and to assess the efficacy of antiviral therapy.
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20
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Gershon AA. Is chickenpox so bad, what do we know about immunity to varicella zoster virus, and what does it tell us about the future? J Infect 2017; 74 Suppl 1:S27-S33. [PMID: 28646959 PMCID: PMC5726865 DOI: 10.1016/s0163-4453(17)30188-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Varicella and zoster continue to cause significant morbidity and even mortality in children and adults. Complications include bacterial superinfection, central nervous system manifestations such as meningitis, encephalitis, and cerebellar ataxia, and pain syndromes especially post herpetic neuralgia. Many developed countries but not all, are now administering live attenuated varicella vaccine routinely, with a decrease in the incidence of disease, providing personal and herd immunity. There is some controversy, however, in some countries concerning whether a decrease in the circulation of wild type virus will result in loss of immunity to VZV in persons who have already had varicella. This manuscript reviews the complications of varicella and zoster in detail, the reasons for development of vaccines against these diseases, complications of vaccinations, and mechanisms by which immunity to this virus develops and is maintained. There are strong indications that the best way to control disease and spread of this virus is by vaccination against both.
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Affiliation(s)
- Anne A Gershon
- Columbia University College of Physicians and Surgeons, 630 West 168th Street, New York, NY 10032, USA.
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21
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Bozzola E, Gattinara GC, Bozzola M, Mirante N, Masci M, Rossetti C, Krzystofiak A, Nicolosi L, Cutrera R, Lancella L, Tozzi AE, Villani A. Varicella associated pneumoniae in a pediatric population. Ital J Pediatr 2017; 43:49. [PMID: 28558810 PMCID: PMC5450302 DOI: 10.1186/s13052-017-0366-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 05/17/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Varicella pneumonia has been studied extensively in adults; it may also affect children and may require hospitalization. METHODS We examined pneumonia complications in children hospitalized for varicella, over a 13 year period. RESULTS Pneumonia occurred in 8.2% of children hospitalized for varicella. The median length of hospitalization was 6 days. No statistically significant difference in length of stay was detected between immunodepressed children and previously healthy children. The hospitalization was on average shorter in patients who started antiviral therapy within 24 h of varicella onset. None of the included patients had been previously immunized for varicella. CONCLUSIONS Our results support the need for increased awareness of current varicella prevention recommendations among both immunocompetent and immunodepressed individuals. In children affected by varicella, prompt antiviral therapy may be indicated to reduce the number of days of hospitalization.
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Affiliation(s)
- Elena Bozzola
- University/hospital Department of Pediatrics, Pediatric and Infectious Diseases Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Guido Castelli Gattinara
- University/hospital Department of Pediatrics, Pediatric and Infectious Diseases Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Mauro Bozzola
- Internal Medicine and Therapeutics Department, Pediatrics and Adolescentology Unit, University of Pavia, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Nadia Mirante
- University/hospital Department of Pediatrics, Pediatric and Infectious Diseases Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marco Masci
- University/hospital Department of Pediatrics, Pediatric and Infectious Diseases Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Chiara Rossetti
- University/hospital Department of Pediatrics, Pediatric and Infectious Diseases Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Andrzej Krzystofiak
- University/hospital Department of Pediatrics, Pediatric and Infectious Diseases Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Luciana Nicolosi
- University/hospital Department of Pediatrics, Pediatric and Infectious Diseases Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Renato Cutrera
- University/hospital Department of Pediatrics, Pulmonology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Laura Lancella
- University/hospital Department of Pediatrics, Pediatric and Infectious Diseases Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alberto Eugenio Tozzi
- Sanitary Direction, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.,IRCCS Bambino Gesù Children Hospital, Rome, Italy
| | - Alberto Villani
- University/hospital Department of Pediatrics, Pediatric and Infectious Diseases Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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22
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Kim SK, Kim MC, Han SB, Kim SK, Lee JW, Chung NG, Cho B, Jeong DC, Kang JH, Kim HK. Clinical characteristics and outcomes of varicella zoster virus infection in children with hematologic malignancies in the acyclovir era. Blood Res 2016; 51:249-255. [PMID: 28090487 PMCID: PMC5234238 DOI: 10.5045/br.2016.51.4.249] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 05/08/2016] [Accepted: 08/29/2016] [Indexed: 01/17/2023] Open
Abstract
Background Although intravenous acyclovir therapy is recommended for varicella zoster virus (VZV) infection in immunocompromised children, the clinical characteristics and outcomes of VZV infection in the acyclovir era have rarely been reported. Methods The medical records of children diagnosed with varicella or herpes zoster virus, who had underlying hematologic malignancies, were retrospectively reviewed, and the clinical characteristics and outcomes of VZV infection were evaluated. Results Seventy-six episodes of VZV infection (herpes zoster in 57 and varicella in 19) were identified in 73 children. The median age of children with VZV infection was 11 years (range, 1-17), and 35 (46.1%) episodes occurred in boys. Acute lymphoblastic leukemia was the most common underlying malignancy (57.9%), and 90.8% of the episodes occurred during complete remission of the underlying malignancy. Acyclovir was administered for a median of 10 days (range, 4-97). Severe VZV infection occurred in 16 (21.1%) episodes. Although the finding was not statistically significant, a previous history of hematopoietic cell transplantation (HCT) appeared to be associated with the development of more severe episodes of herpes zoster (P=0.075). Conclusion Clinical characteristics of VZV infection in immunocompromised children were not significantly different from those without it, and clinical outcomes improved after the introduction of acyclovir therapy. However, risk factors for severe VZV infection require further investigation in a larger population and a prospective setting.
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Affiliation(s)
- Seul-Ki Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Min Chae Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Beom Han
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea.; The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seong Koo Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea.; The Catholic Blood and Marrow Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Wook Lee
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea.; The Catholic Blood and Marrow Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Nack-Gyun Chung
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea.; The Catholic Blood and Marrow Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bin Cho
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea.; The Catholic Blood and Marrow Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dae Chul Jeong
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea.; The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Han Kang
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea.; The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hack-Ki Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea.; The Catholic Blood and Marrow Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Varicella Vaccination of Children With Leukemia Without Interruption of Maintenance Therapy: A Danish Experience. Pediatr Infect Dis J 2016; 35:e348-e352. [PMID: 27753768 DOI: 10.1097/inf.0000000000001279] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Varicella-zoster virus (VZV) can be fatal or cause severe complications in children with acute lymphoblastic leukemia (ALL). This analysis set out to investigate the morbidity and mortality of VZV vaccination without interruption of maintenance therapy in children with ALL. METHODS Files of 73 seronegative children with ALL were examined for data regarding VZV vaccination and infection, and long-term seroconversion was measured. Criteria before VZV vaccination were (1) seronegative, (2) in complete remission, (3) age ≥ 1.0 year, (4) lymphocyte count ≥ 0.6 × 10/L at time of vaccination and (5) receiving maintenance therapy. RESULTS Forty-five children were vaccinated. No child died or experienced serious adverse events due to VZV vaccination. Nine children developed late chickenpox despite vaccination. Long-term protection was found in 86% of children not receiving acyclovir and 78% of the entire population. Long-term seroconversion was found in 52% of the children. There were no severe cases of varicella infection. Acyclovir prophylaxis postvaccination was associated with an increased risk of late chickenpox [hazard ratio = 5.40 (1.43, 20.41), P = 0.01]. In contrast, a vaccine-induced rash reduced the risk of late chickenpox [hazard ratio = 0.08 (0.01, 0.66), P = 0.02]. No child had interruption of maintenance therapy at the time of vaccination, but 33% experienced discontinuation of therapy due to vaccine-induced rash. Dexamethasone was associated with an increased risk of vaccine-induced rash [hazard ratio = 2.9 (1.21, 6.90), P = 0.02]. CONCLUSIONS This analysis indicates that VZV vaccination is feasible and justified in seronegative children with ALL, in countries where VZV vaccination is not part of the national vaccination program.
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Streng A, Wiegering V, Liese JG. Varicella in pediatric oncology patients in the post-vaccine era-Analysis of routine hospital data from Bavaria (Germany), 2005-2011. Pediatr Hematol Oncol 2016; 33:468-479. [PMID: 27960646 DOI: 10.1080/08880018.2016.1245805] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Varicella in oncology patients can result in serious complications. We analyzed trends in hospitalization rates and characteristics of pediatric oncology and non-oncology patients hospitalized with varicella during the first 7 years after introduction of routine varicella vaccination. Our data included children <17 years of age with an International Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) main or secondary discharge diagnosis of varicella identified by annual database queries in 22-29 pediatric hospitals in Bavaria (Germany) in 2005-2011. Of a total of 1,245 varicella-associated hospitalizations, 42 children (median age 4 years, interquartile range 3-5) had an underlying malignancy (67% with acute lymphoblastic leukemia). Overall, additional diagnoses potentially associated with varicella were reported less often in oncology than in non-oncology varicella patients (62% vs. 77%, p = 0.041), suggesting earlier hospitalization of high-risk patients. Acute hematological diagnoses (29% vs. 3%, p < 0.001) and coinfections (invasive 12% vs. 2%, p = 0.001; noninvasive 19% vs. 8%, p = 0.019) were more frequent, whereas neurological (5% vs. 19%, p = 0.023) and upper respiratory tract diagnoses (2% vs. 16%, p = 0.014) were less frequent in oncology compared to non-oncology varicella patients. Oncology varicella patients showed a longer hospital stay (median 5 vs. 3 days, p < 0.001). Hospitalization rates in non-oncology varicella patients declined constantly since 2006, from 114.8 (2006) to 30.5 (2011) per 1,000 pediatric beds. The rates of varicella-associated hospitalizations in oncology patients indicated an overall decreasing trend (3.8, 1.9, 4.6, 3.5, 0.4, 2.1 and 0.6 cases per 1,000 pediatric beds in 2005-2011). Thus, pediatric oncology patients potentially profit from herd protection effects, resulting from increasing vaccine coverage in the general population.
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Affiliation(s)
- Andrea Streng
- a Department of Paediatrics , University of Würzburg , Würzburg , Germany
| | - Verena Wiegering
- a Department of Paediatrics , University of Würzburg , Würzburg , Germany
| | - Johannes G Liese
- a Department of Paediatrics , University of Würzburg , Würzburg , Germany
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25
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Varicella with rapidly progressive hepatitis presenting with multiple hepatic nodules in a child with acute leukemia. J Infect Chemother 2016; 22:822-825. [PMID: 27496601 DOI: 10.1016/j.jiac.2016.07.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 06/28/2016] [Accepted: 07/08/2016] [Indexed: 12/14/2022]
Abstract
Abdominal pain may precede the characteristic varicella skin lesions in immunocompromised patients with visceral varicella. The absence of skin lesions may delay timely diagnosis and treatment of varicella for those patients. Furthermore, abdominal imaging findings to provide information to diagnose visceral varicella have rarely been reported. Varicella was diagnosed in a 5-year-old boy with acute lymphoblastic leukemia complaining of fever and abdominal pain followed by papulovesicular skin lesions. Later, the patient was found to have rapidly progressive acute hepatitis, and abdominal computed tomography showed multiple hypodense hepatic nodules. The patient was treated with intravenous acyclovir, intravenous immunoglobulin, and empirical antibiotic and antifungal therapy. However, his fever and abdominal pain persisted, and a laparoscopic liver biopsy was performed to differentiate other causes of the persisting symptoms. Eventually, the patient was diagnosed with visceral varicella based on histopathologic findings. In conclusion, visceral varicella should be considered in immunocompromised patients with abdominal pain and multiple hypodense hepatic nodules on abdominal imaging studies. However, bacteria, fungi, and tuberculosis can produce similar imaging findings; therefore, a biopsy may be necessary in patients not responding to antiviral therapy.
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26
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Leuvenink R, Aeschlimann F, Baer W, Berthet G, Cannizzaro E, Hofer M, Kaiser D, Schroeder S, Heininger U, Woerner A. Clinical course and therapeutic approach to varicella zoster virus infection in children with rheumatic autoimmune diseases under immunosuppression. Pediatr Rheumatol Online J 2016; 14:34. [PMID: 27256096 PMCID: PMC4890263 DOI: 10.1186/s12969-016-0095-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 05/16/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND To analyze the clinical presentation and complications of varicella zoster virus (VZV) infection in children with rheumatic diseases treated with immunosuppressive medication such as biological disease-modifying antirheumatic drugs (bDMARDs) and/or conventional disease-modifying antirheumatic drugs (cDMARDs), and to analyze the therapeutic approach to VZV infections with respect to the concomitant immunosuppressive treatment. METHODS Retrospective multicenter study using the Swiss Pediatric Rheumatology registry. Children with rheumatic diseases followed in a Swiss center for pediatric rheumatology and treated with cDMARD and/or bDMARD with a clinical diagnosis of varicella or herpes zoster between January 2004 and December 2013 were included. RESULTS Twenty-two patients were identified, of whom 20 were treated for juvenile idiopathic arthritis, 1 for a polyglandular autoimmune syndrome type III, and 1 for uveitis. Of these 22 patients, 16 had varicella and 6 had herpes zoster. Median age at VZV disease was 7.6 years (range 2 to 17 years), with 6.3 years (range 2 to 17 years) for those with varicella and 11.6 years (range 5 to 16 years) for those with herpes zoster. The median interval between start of immunosuppression and VZV disease was 14.1 months (range 1 to 63 months). Two patients had received varicella vaccine (1 dose each) prior to start of immunosuppression. Concomitant immunosuppressive therapy was methotrexate (MTX) monotherapy (n = 9) or bDMARD monotherapy (n = 2), or a combination of bDMARD with prednisone, MTX or Leflunomide (n = 11). Four patients experienced VZV related complications: cellulitis in 1 patient treated with MTX, and cellulitis, sepsis and cerebellitis in 3 patients treated with biological agents and MTX combination therapy. Six children were admitted to hospital (range of duration: 4 to 9 days) and 12 were treated with valaciclovir or aciclovir. CONCLUSION The clinical course of varicella and herpes zoster in children under immunosuppression is variable, with 4 (18 %) of 22 children showing a complicated course. Thorough assessment of VZV disease and vaccination history and correct VZV vaccination according to national guidelines at diagnosis of a rheumatic autoimmune disease is essential to minimize VZV complications during a later immunosuppressive treatment.
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Affiliation(s)
- Raphael Leuvenink
- University of Basel Medical School, Basel, Switzerland ,Pediatric Rheumatology, University of Basel Children’s Hospital, Spitalstrasse 33, CH – 4031 Basel, Switzerland
| | | | - Walter Baer
- Department of Pediatrics, Hospital of Chur, Chur, Switzerland
| | - Gerald Berthet
- Department of Pediatrics, Hospital of Aarau, Aarau, Switzerland
| | | | - Michael Hofer
- Unité romande de rhumatologie pédiatrique, CHUV, University of Lausanne and HUG, Geneva, Switzerland
| | - Daniela Kaiser
- Department of Pediatrics, Hospital of Lucerne, Lucerne, Switzerland
| | | | - Ulrich Heininger
- Pediatric Rheumatology, University of Basel Children’s Hospital, Spitalstrasse 33, CH – 4031 Basel, Switzerland
| | - Andreas Woerner
- Pediatric Rheumatology, University of Basel Children's Hospital, Spitalstrasse 33, CH - 4031, Basel, Switzerland.
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Noronha V, Ostwal V, Ramaswamy A, Joshi A, Nair R, Banavali SD, Prabhash K. Chicken pox infection in patients undergoing chemotherapy: A retrospective analysis from a tertiary care center in India. J Infect Public Health 2016; 10:8-13. [PMID: 26970699 DOI: 10.1016/j.jiph.2015.12.016] [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: 08/29/2015] [Revised: 12/10/2015] [Accepted: 12/19/2015] [Indexed: 10/22/2022] Open
Abstract
There is paucity of data on the incidence, severity and management of chicken pox in patients receiving active chemotherapy for cancer. From October 2010 to October 2011, patients were included in this study if they developed a chicken pox infection during their chemotherapy. The details of patients' cancer diagnosis and treatment along with clinical and epidemiological data of the chicken pox infections were assessed from a prospectively maintained database. Twenty-four patients had a chicken pox infection while receiving chemotherapy and/or radiotherapy. The median age of the patients was 21 years, and two-thirds of the patients had solid tumor malignancies. Overall, eight (33%) patients had complications, six (25%) patients had febrile neutropenia, four (17%) had diarrhea/mucositis, and four (17%) had pneumonia. The median time for recovery of the infection and complications in the patients was 9.5 days (5-29 days), whereas for neutropenic patients, it was 6.5 days (3-14 days). The median time for recovery from chicken pox infections in neutropenic patients was 10 days (5-21 days), compared with 8.5 days (0-29 days) in non-neutropenic patients (P=0.84). The median time for recovery from infections was 8.5 days in patients with comorbidities (N=4), which was the same for patients with no comorbidities. The clinical presentation and complication rates of chicken pox in cancer patients, who were on active chemotherapy, are similar to the normal population. The recovery from a varicella infection and complications may be delayed in patients with neutropenia. The varicella infection causes a therapy delay in 70% of patients. Aggressive antiviral therapy, supportive care and isolation of the index cases remain the backbone of treatment.
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Affiliation(s)
- Vanita Noronha
- Department of Medical Oncology, Tata Memorial Center, Parel, Mumbai, India
| | - Vikas Ostwal
- Department of Medical Oncology, Tata Memorial Center, Parel, Mumbai, India.
| | - Anant Ramaswamy
- Department of Medical Oncology, Tata Memorial Center, Parel, Mumbai, India
| | - Amit Joshi
- Department of Medical Oncology, Tata Memorial Center, Parel, Mumbai, India
| | - Reena Nair
- Department of Medical Oncology, Tata Medical Centre, Kolkata, India
| | - Shripad D Banavali
- Department of Medical Oncology, Tata Memorial Center, Parel, Mumbai, India
| | - Kumar Prabhash
- Department of Medical Oncology, Tata Memorial Center, Parel, Mumbai, India
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Caniza MA, Odio C, Mukkada S, Gonzalez M, Ceppi F, Chaisavaneeyakorn S, Apiwattanakul N, Howard SC, Conter V, Bonilla M. Infectious complications in children with acute lymphoblastic leukemia treated in low-middle-income countries. Expert Rev Hematol 2015. [PMID: 26211675 DOI: 10.1586/17474086.2015.1071186] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Infections are the most important cause of morbidity and mortality in children treated for acute lymphoblastic leukemia (ALL). The rates of infection-associated mortality are up to 10-times higher in low- and middle-income countries (LMIC) than in high-income countries. The prevention, early recognition and management of infectious complications is especially challenging in LMIC because of disease and poverty-related factors, as well as the shortage of trained personnel, supplies, diagnostic tools and adequate organizational infrastructure. Children in LMIC with ALL, who are frequently underweight, are at increased risk of community-acquired pathogens, nosocomial multidrug-resistant pathogens and opportunistic microorganisms. This review summarizes the challenges of managing the major categories of infections in children receiving treatment for ALL and provides updated practical recommendations for preventing and managing these infections in LMIC.
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Affiliation(s)
- Miguela A Caniza
- a 1 Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
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30
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Vacunas frente al virus de la varicela zóster. Enferm Infecc Microbiol Clin 2015; 33:411-23. [DOI: 10.1016/j.eimc.2015.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 05/20/2015] [Indexed: 01/28/2023]
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31
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Royer DJ, Cohen A, Carr D. The Current State of Vaccine Development for Ocular HSV-1 Infection. EXPERT REVIEW OF OPHTHALMOLOGY 2015; 10:113-126. [PMID: 25983856 DOI: 10.1586/17469899.2015.1004315] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
HSV-1 continues to be the leading cause of infectious corneal blindness. Clinical trials for vaccines against genital HSV infection have been ongoing for more than three decades. Despite this, no approved vaccine exists, and no formal clinical trials have evaluated the impact of HSV vaccines on eye health. We review here the current state of development for an efficacious HSV-1 vaccine and call for involvement of ophthalmologists and vision researchers.
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Affiliation(s)
- D J Royer
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center
| | - A Cohen
- Ophthalmology, University of Oklahoma Health Sciences Center
| | - Djj Carr
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center ; Ophthalmology, University of Oklahoma Health Sciences Center
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32
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Germinario C, Gallone MS, Cappelli MG, Tafuri S. Clinical benefits of routine varicella vaccination for adults. Hum Vaccin Immunother 2015; 11:1426-8. [PMID: 25970524 PMCID: PMC4514254 DOI: 10.1080/21645515.2015.1030559] [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: 02/26/2015] [Accepted: 03/12/2015] [Indexed: 10/23/2022] Open
Abstract
Varicella is a highly contagious disease caused by varicella zoster virus. In children, it is generally a mild to moderate illness while it is often more severe in adults, with serious complications as dehydration, pneumonia, bleeding problems, infection or inflammation of the brain, secondary bacterial infections, sepsis, toxic shock syndrome, bone infections, joint infections and deaths. Some groups of adults are at major risk of complications, in particular immunocompromised persons as subjects with impaired humoral immunity and who is receiving systemic steroids, persons who live or work in environments in which transmission of varicella is likely, health-care personnel and pregnant women. After the introduction of Universal Mass Vaccination (UMV), the first mathematical models suggested that vaccination will lead to a shift in the average age at infection from children to adults with an increasing numbers of complicated forms, nevertheless new models predicted that, although an upward shift in the age at infection may occur, the overall morbidity due to varicella is likely to decrease. Current literature seems to suggest that for public health authorities the key action to prevent an increase of varicella incidence among adults is to achieve high vaccination coverage among babies and adolescents in countries who adopted UMV.
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Affiliation(s)
- Cinzia Germinario
- Department of Biomedical Science and Human Oncology; “Aldo Moro” University of Bari; Bari, Italy
| | - Maria Serena Gallone
- Department of Biomedical Science and Human Oncology; “Aldo Moro” University of Bari; Bari, Italy
| | - Maria Giovanna Cappelli
- Department of Biomedical Science and Human Oncology; “Aldo Moro” University of Bari; Bari, Italy
| | - Silvio Tafuri
- Department of Biomedical Science and Human Oncology; “Aldo Moro” University of Bari; Bari, Italy
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33
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Patel SR, Bate J, Maple PAC, Brown K, Breuer J, Heath PT. Varicella zoster immune status in children treated for acute leukemia. Pediatr Blood Cancer 2014; 61:2077-9. [PMID: 24789692 DOI: 10.1002/pbc.25086] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 04/09/2014] [Indexed: 11/07/2022]
Abstract
Children treated for acute leukemia are at increased risk of severe infection with varicella zoster virus (VZV). We studied the VZV sero-status of children with acute leukemia prior to starting chemotherapy and after completion of chemotherapy. VZV sero-status was assessed using time resolved fluorescence immunoassay (TRFIA) before starting treatment and 6 months after completion of treatment. Prior to starting treatment for acute leukemia, a significant proportion of children (35%) are VZV seronegative. On completion of treatment most patients maintained protective VZV antibody levels; however, 35% had reduced/loss VZV antibody to a level considered non-protective and susceptible to VZV infection.
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Affiliation(s)
- Soonie R Patel
- Paediatric Department, Croydon University Hospital, Croydon, UK
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Varicella-zoster virus and virus DNA in the blood and oropharynx of people with latent or active varicella-zoster virus infections. J Clin Virol 2014; 61:487-95. [PMID: 25453570 DOI: 10.1016/j.jcv.2014.09.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 09/04/2014] [Accepted: 09/14/2014] [Indexed: 12/28/2022]
Abstract
Varicella-zoster virus (VZV) can be detected in the blood from approximately 5 days before to 4 days after varicella. VZV DNA, primarily in T-lymphocytes, is detected as early as 8-10 days prior to rash and can persist for a week. The duration and magnitude of VZV DNAemia correlates with immune status and the efficacy of antiviral therapy. VZV DNA is also readily detected in the oropharynx just prior to rash and for 1-2 weeks thereafter. Detection of VZV DNA in blood and saliva has been useful for diagnosis and prognosis in atypical cases of varicella. Herpes zoster (HZ) is also characterized by VZV DNAemia at onset and for many weeks thereafter, and VZV DNA is present in the oropharynx shortly after HZ onset. Detection of VZV DNA in blood and saliva facilitates the diagnosis of zoster sine herpete and other atypical manifestations of VZV reactivation, such as neurologic syndromes when cerebrospinal fluid is not available, Bell's palsy, and atypical pain syndromes. VZV DNA is sometimes present in the blood and saliva of asymptomatic individuals. In total these observations extend understanding of the pathophysiology and epidemiology of VZV, and increasingly contribute to the clinical management of VZV infections.
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35
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Vaccination recommendations for patients with neuromuscular disease. Vaccine 2014; 32:5893-900. [PMID: 25223270 DOI: 10.1016/j.vaccine.2014.09.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 08/28/2014] [Accepted: 09/02/2014] [Indexed: 12/17/2022]
Abstract
Neuromuscular diseases (NMDs) encompass a broad spectrum of conditions. Because infections may be relevant to the final prognosis of most NMDs, vaccination appears to be the simplest and most effective solution for protecting NMD patients from vaccine-preventable infections. However, very few studies have evaluated the immunogenicity, safety, tolerability, and efficacy of different vaccines in NMD patients; therefore, detailed vaccination recommendations for NMD patients are not available. Here, we present vaccination recommendations from a group of Italian Scientific Societies for optimal disease prevention in NMD patients that maintain high safety levels. We found that NMD patients can be classified into two groups according to immune function: patients with normal immunity and patients who are immunocompromised, including those who intermittently or continuously take immunosuppressive therapy. Patients with normal immunity and do not take immunosuppressive therapy can be vaccinated as healthy subjects. In contrast, immunocompromised patients, including those who take immunosuppressive therapy, should receive all inactivated vaccines as well as influenza and pneumococcal vaccines; these patients should not be administered live attenuated vaccines. In all cases, the efficacy and long-term persistence of immunity from vaccination in NMD patients can be lower than in normal subjects. Household contacts of immunocompromised NMD patients should also be vaccinated appropriately.
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Abstract
Infectious complications remain a significant issue in the care of patients with hematologic malignancies. Inherent immune defects related to the primary disease process are present in patients with disorders such as chronic lymphocytic leukemia, multiple myeloma, hairy cell leukemia, and Hodgkin lymphoma. Therapy-related immunosuppression is also commonplace in these patients. This includes not only treatment-related neutropenia, but also defects in cell-mediated immunity, such as those that occur with purine analog therapy. In this chapter, we will review the pathogenesis of infection in these disorders, as well as the spectrum of infectious complications seen and suggested strategies for the prevention of infection.
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37
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Rubin LG, Levin MJ, Ljungman P, Davies EG, Avery R, Tomblyn M, Bousvaros A, Dhanireddy S, Sung L, Keyserling H, Kang I. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis 2013; 58:e44-100. [PMID: 24311479 DOI: 10.1093/cid/cit684] [Citation(s) in RCA: 548] [Impact Index Per Article: 49.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
An international panel of experts prepared an evidenced-based guideline for vaccination of immunocompromised adults and children. These guidelines are intended for use by primary care and subspecialty providers who care for immunocompromised patients. Evidence was often limited. Areas that warrant future investigation are highlighted.
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Affiliation(s)
- Lorry G Rubin
- Division of Pediatric Infectious Diseases, Steven and Alexandra Cohen Children's Medical Center of New York of the North Shore-LIJ Health System, New Hyde Park
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38
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Gershon AA, Gershon MD. Pathogenesis and current approaches to control of varicella-zoster virus infections. Clin Microbiol Rev 2013; 26:728-43. [PMID: 24092852 PMCID: PMC3811230 DOI: 10.1128/cmr.00052-13] [Citation(s) in RCA: 127] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Varicella-zoster virus (VZV) was once thought to be a fairly innocuous pathogen. That view is no longer tenable. The morbidity and mortality due to the primary and secondary diseases that VZV causes, varicella and herpes zoster (HZ), are significant. Fortunately, modern advances, including an available vaccine to prevent varicella, a therapeutic vaccine to diminish the incidence and ameliorate sequelae of HZ, effective antiviral drugs, a better understanding of VZV pathogenesis, and advances in diagnostic virology have made it possible to control VZV in the United States. Occult forms of VZV-induced disease have been recognized, including zoster sine herpete and enteric zoster, which have expanded the field. Future progress should include development of more effective vaccines to prevent HZ and a more complete understanding of the consequences of VZV latency in the enteric nervous system.
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39
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Recombinant varicella-zoster virus vaccines as platforms for expression of foreign antigens. Adv Virol 2013; 2013:219439. [PMID: 23843791 PMCID: PMC3697282 DOI: 10.1155/2013/219439] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 06/05/2013] [Indexed: 11/17/2022] Open
Abstract
Varicella-zoster virus (VZV) vaccines induce immunity against childhood chickenpox and against shingles in older adults. The safety, efficacy, and widespread use of VZV vaccines suggest that they may also be effective as recombinant vaccines against other infectious diseases that affect the young and the elderly. The generation of recombinant VZV vaccines and their evaluation in animal models are reviewed. The potential advantages and limitations of recombinant VZV vaccines are addressed.
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40
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Inokuchi R, Nakamura K, Sato H, Shinohara K, Aoki Y, Doi K, Gunshin M, Ishii T, Matsubara T, Hiruma T, Nakajima S, Yahagi N. Bronchial ulceration as a prognostic indicator for varicella pneumonia: case report and systematic literature review. J Clin Virol 2013; 56:360-4. [PMID: 23290884 DOI: 10.1016/j.jcv.2012.12.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 10/31/2012] [Accepted: 12/10/2012] [Indexed: 11/26/2022]
Abstract
Adult varicella pneumonia is a common and serious complication of varicella zoster virus (VZV) infection in pregnant woman and immunocompromised individuals, with mortality rates of 30-50%. The poor prognosis is attributable to very aggressive disease progression and delayed onset of treatment. Here, we present a case of varicella pneumonia in a 69-year-old woman following long-term immunosuppressive treatment for kidney transplant. Respiratory failure developed within 3 d after admission for skin rash, and the patient died 28 d later despite acyclovir and foscarnet treatment. The autopsy showed extensive mucosal airway ulcerations from the pharynx to the main bronchi and numerous VZV-infected cells. We searched PubMed, Web of Science, and EMBASE (1980 through February 2012), as well as several medical report databases created by Japanese healthcare professionals, for all reported cases of varicella pneumonia for which bronchoscopy findings were documented. Twenty-four cases were included and we found that patients with limited or shallow ulcers had favorable outcomes, whereas patients with vast and deep ulcerations had fatal outcomes. These findings indicate that bronchoscopy findings, particularly those showing bronchial involvement, may be useful for evaluating varicella pneumonia.
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Affiliation(s)
- Ryota Inokuchi
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
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41
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42
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Abstract
Varicella zoster virus (VZV) is a highly successful human pathogen, which is never completely eliminated from the host. VZV causes two clinically distinct diseases, varicella (chickenpox) during primary infection and herpes zoster (shingles) following virus reactivation from latency. Throughout its lifecycle the virus encounters the innate and adaptive immune response, and in order to prevent eradication it has developed many mechanisms to evade and overcome these responses. This review will provide a comprehensive overview of the host immune response to VZV infection, during the multiple stages of the virus lifecycle and at key sites of VZV infection. We will also briefly describe some of the strategies employed by the virus to overcome the host immune response and the ongoing challenges in further elucidating the interplay between VZV and the host immune response in an attempt to lead to better therapies and a ‘second generation’ vaccine for VZV disease.
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Affiliation(s)
- Megan Steain
- Discipline of Infectious Diseases & Immunology, The University of Sydney, NSW, Australia
- Centre for Virus Research, Westmead Millennium Institute, NSW, Australia
| | - Barry Slobedman
- Discipline of Infectious Diseases & Immunology, The University of Sydney, NSW, Australia
- Centre for Virus Research, Westmead Millennium Institute, NSW, Australia
| | - Allison Abendroth
- Discipline of Infectious Diseases & Immunology, The University of Sydney, NSW, Australia
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44
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45
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Merindol N, Salem Fourati I, Brito RM, Grenier AJ, Charrier E, Cordeiro P, Caty M, Mezziani S, Malette B, Duval M, Alfieri C, Ovetchkine P, Le Deist F, Soudeyns H. Reconstitution of protective immune responses against cytomegalovirus and varicella zoster virus does not require disease development in pediatric recipients of umbilical cord blood transplantation. THE JOURNAL OF IMMUNOLOGY 2012; 189:5016-28. [PMID: 23034171 DOI: 10.4049/jimmunol.1201759] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
CMV and varicella zoster virus (VZV) are significant causes of morbidity and mortality following umbilical cord blood transplantation (UCBT). However, the kinetics of reconstitution and protective potential of antiviral cell-mediated immune responses following UCBT remain poorly characterized. In this study, the reconstitution of CMV- and VZV-specific T cell responses was assessed using IFN-γ ELISPOT in 28 children who underwent UCBT to treat hematological or inherited disorders. Barely detectable in the first 3 mo posttransplantation, CMV- and VZV-specific T cell responses were observed in 30.4% and 40.3% of study subjects after 36 mo of follow-up. Four of five CMV-seropositive subjects developed detectable levels of circulating CMV DNA (DNAemia), and 5 of 17 VZV-seropositive patients experienced herpes zoster during the posttransplant period. Four CMV-seronegative subjects developed IFN-γ responses against CMV, and four subjects developed a VZV-specific IFN-γ response without clinical signs of infection. No CMV- or VZV-related events were observed in study subjects following the development of CMV- or VZV-specific responses > 150 spot-forming units/10(6) PBMCs, consistent with T cell-mediated protection. Finally, famciclovir prophylaxis did not strictly prevent the reconstitution of the VZV-specific T cell repertoire, because the frequency of T cells producing IFN-γ in response to VZV Ags reached levels consistent with protection in two nonzoster subjects. Monitoring of CMV- and VZV-specific cell-mediated immunity could inform immunocompetence and guide the initiation and cessation of antiherpetic prophylaxis in UCBT recipients.
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Affiliation(s)
- Natacha Merindol
- Unité d'Immunopathologie Virale, Centre de Recherche du Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec H3T 1C5, Canada
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46
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Affiliation(s)
- Marion Roderick
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, 23 Hillview, Henleaze, Bristol BS9 4QD, UK
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47
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Sengupta N, Booy R, Schmitt HJ, Peltola H, Van-Damme P, Schumacher RF, Campins M, Rodrigo C, Heikkinen T, Seward J, Jumaan A, Finn A, Olcén P, Thiry N, Weil-Olivier C, Breuer J. Varicella vaccination in Europe: are we ready for a universal childhood programme? Eur J Pediatr 2008; 167:47-55. [PMID: 17334784 DOI: 10.1007/s00431-007-0424-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2006] [Accepted: 01/15/2007] [Indexed: 01/30/2023]
Abstract
Safe and effective vaccines against varicella zoster virus (VZV), the aetiological agent of varicella and shingles, have been available in Europe for the last 5-10 years. The USA has had a universal childhood vaccination policy since 1995 and this has resulted in a dramatic decrease in the incidence, morbidity and mortality related to varicella. The economic and medical burden of VZV has led to discussions regarding both the desirability and feasibility of a similar routine immunisation policy for all European children. This article examines the epidemiology of varicella in Europe and how the data emerging from the USA can be used to achieve adequate prevention of the disease. It looks into the current evidence of the health economic evaluation of universal varicella vaccination and explores the concerns surrounding such a policy, including the postulated impact on the incidence of zoster. In conclusion, the Society of Independent European Vaccination Experts (SIEVE) recommends that the immunisation of susceptible adolescents needs to be urgently implemented, in addition to the current recommendations targeting high-risk patients, their close contacts with a negative history of varicella and seronegative health-care workers. A universal policy, optimally incorporating a two-dose schedule, will be needed to finally reduce the burden of disease of varicella from a societal point of view. The SIEVE recommends the implementation of such a policy as soon as financially and practically possible.
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Affiliation(s)
- Nitu Sengupta
- Centre for Child Health, Royal London Hospital, 38 New Road, Whitechapel, London, E1 2AX, UK.
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48
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Jean-Philippe P, Freedman A, Chang MW, Steinberg SP, Gershon AA, LaRussa PS, Borkowsky W. Severe varicella caused by varicella-vaccine strain in a child with significant T-cell dysfunction. Pediatrics 2007; 120:e1345-9. [PMID: 17974726 DOI: 10.1542/peds.2004-1681] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
In March 1995, the US Food and Drug Administration approved a live attenuated varicella vaccine for use in healthy children 12 months to 12 years old. We report here an 18-month-old girl with cell-mediated immunodeficiency who developed a severe vaccine-associated rash and clinical evidence of vaccine-associated pneumonia 1 month after inadvertent receipt of varicella vaccine.
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Affiliation(s)
- Patrick Jean-Philippe
- Department of Pediatrics, New York University School of Medicine, New York, New York, USA.
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49
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Campsall PA, Au NHC, Prendiville JS, Speert DP, Tan R, Thomas EE. Detection and genotyping of varicella-zoster virus by TaqMan allelic discrimination real-time PCR. J Clin Microbiol 2004; 42:1409-13. [PMID: 15070981 PMCID: PMC387589 DOI: 10.1128/jcm.42.4.1409-1413.2004] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
A proportion of individuals vaccinated with live attenuated Oka varicella-zoster virus (VZV) vaccine subsequently develop attenuated chicken pox and/or herpes zoster. To determine whether postvaccination varicella infections are caused by vaccine or wild-type virus, a simple method for distinguishing the vaccine strain from wild-type virus is required. We have developed a TaqMan real-time PCR assay to detect and differentiate wild-type virus from Oka vaccine strains of VZV. The assay utilized two fluorogenic, minor groove binding probes targeted to a single nucleotide polymorphism in open reading frame 62 that distinguishes the Oka vaccine from wild-type strains. VZV DNA could be genotyped and quantified within minutes of thermocycling completion due to real-time monitoring of PCR product formation and allelic discrimination analysis. The allelic discrimination assay was performed in parallel with two standard PCR-restriction fragment length polymorphism (RFLP) methods on 136 clinical and laboratory VZV strains from Canada, Australia, and Japan. The TaqMan assay exhibited a genotyping accuracy of 100% and, when compared to both PCR-RFLP methods, was 100 times more sensitive. In addition, the method was technically simpler and more rapid. The TaqMan assay also allows for high-throughput genotyping, making it ideal for epidemiologic study of the live attenuated varicella vaccine.
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Affiliation(s)
- Paul A Campsall
- Department of Pathology and Laboratory Medicine, University of British Columbia and Children's & Women's Health Centre of British Columbia, Canada
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Dass R, Singh S, Kumar V, Vaiphei K, Agrawal S, Saeed T, Minz RW. Varicella glomerulonephritis mimicking microscopic polyangiitis. Rheumatol Int 2004; 24:362-4. [PMID: 14740169 DOI: 10.1007/s00296-003-0429-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2003] [Accepted: 11/10/2003] [Indexed: 01/01/2023]
Abstract
Varicella in childhood is usually a self-limiting illness with few complications. Varicella nephritis is an uncommon entity and seen mostly in immunocompromized individuals. We report a 14-year-old boy with juvenile rheumatoid arthritis who developed varicella nephritis and in whom the renal manifestations preceded the skin lesions by 1 week. This is an extremely unusual occurrence, and only one case has been described before. Such a presentation can mimic the clinical features of microscopic polyangiitis.
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Affiliation(s)
- Rashna Dass
- Advanced Pediatric Center, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
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