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Fullerton HJ, Hills NK, Wintermark M, Dlamini N, Amlie-Lefond C, Dowling MM, Jordan LC, Bernard TJ, Friedman NR, Elkind MSV, Grose C. Evidence of varicella zoster virus (VZV) reactivation in children with arterial ischemic stroke: Results of the VIPS II Study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.26.24307958. [PMID: 38853955 PMCID: PMC11160817 DOI: 10.1101/2024.05.26.24307958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
Background Varicella zoster virus (VZV) has been associated with focal cerebral arteriopathy (FCA) and arterial ischemic stroke (AIS) in childhood. The Vascular effects of Infection in Pediatric Stroke (VIPS) II study aimed to examine this relationship in the modern era when most children in North America and Australia receive VZV vaccination with live, attenuated virus. Methods This 22-center prospective cohort study enrolled 205 children (28 days-18 years) with AIS (2017-2022), collected baseline [hyperacute (≤72 hours; n=194) and acute (4-6 days; n=181)] and convalescent (1-6 weeks; n=74) serum samples. Sites enrolled 95 stroke-free controls with single serum samples. A virology research laboratory measured VZV IgM and IgG titers by an in-house enzyme-linked immunosorbent assay (ELISA). Baseline IgG seropositivity indicated prior exposure (vaccination/infection) and elevated IgM titers indicated recent reactivation. Results Median (IQR) age was 11.6 (5.5-15.6) years for cases and 11.8 (6.8-15.3) years for controls. Baseline serologies indicated prior VZV exposure in 198 cases (97%) and all controls. Parents of cases reported VZV vaccination in 160 (78%) and remote chicken pox in three (1.4%). Twenty cases (9.8%) and three controls (3.1%) had serologic evidence of recent VZV reactivation (p=0.06); all had remote VZV exposure (vaccination in 19 cases and all controls) and all were asymptomatic. Recent VZV reactivation was seen in similar proportions in arteriopathic, cardioembolic, and idiopathic stroke. Of 32 cases of FCA, 4 (12.5%) had recent VZV reactivation, versus no cases of arterial dissection (n=10) or moyamoya (n=16). Conclusions Serologic evidence of recent VZV reactivation (≈1-6 weeks prior to stroke) was present in one in 10 cases of childhood AIS, including those without arteriopathy. Clinically silent VZV reactivation may be a childhood stroke trigger despite widespread vaccination. These cases could represent waning immunity with reactivation of either vaccine virus or wild-type virus after an unrecognized secondary VZV infection.
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Ramachandran P, Grose C. Serious neurological adverse events in immunocompetent children and adolescents caused by viral reactivation in the years following varicella vaccination. Rev Med Virol 2024; 34:e2538. [PMID: 38658176 PMCID: PMC11170866 DOI: 10.1002/rmv.2538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/05/2024] [Accepted: 04/15/2024] [Indexed: 04/26/2024]
Abstract
Serious adverse events following vaccination include medical complications that require hospitalisation. The live varicella vaccine that was approved by the Food and Drug Administration in the United States in 1995 has an excellent safety record. Since the vaccine is a live virus, adverse events are more common in immunocompromised children who are vaccinated inadvertently. This review includes only serious adverse events in children considered to be immunocompetent. The serious adverse event called varicella vaccine meningitis was first reported in a hospitalised immunocompetent child in 2008. When we carried out a literature search, we found 15 cases of immunocompetent children and adolescents with varicella vaccine meningitis; the median age was 11 years. Eight of the children had received two varicella vaccinations. Most of the children also had a concomitant herpes zoster rash, although three did not. The children lived in the United States, Greece, Germany, Switzerland, and Japan. During our literature search, we found five additional cases of serious neurological events in immunocompetent children; these included 4 cases of progressive herpes zoster and one case of acute retinitis. Pulses of enteral corticosteroids as well as a lack of herpes simplex virus antibody may be risk factors for reactivation in immunocompetent children. All 20 children with adverse events were treated with acyclovir and recovered; 19 were hospitalised and one child was managed as an outpatient. Even though the number of neurological adverse events remains exceedingly low following varicella vaccination, we recommend documentation of those caused by the vaccine virus.
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Affiliation(s)
- Prashanth Ramachandran
- Peter Doherty Institute for Infection and Immunity, University of Melbourne; Department of Neurology, Royal Melbourne Hospital; and Department of Neurology, St. Vincent’s Hospital, Melbourne, Victoria, Australia
| | - Charles Grose
- Division of Infectious Diseases, Virology Laboratory, Department of Pediatrics, University of Iowa, Iowa City, Iowa, United States
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3
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Coralie R, Ziad C, Christian R, Pierre T, Chantal B, Bruce T, Philippe O. Varicella vaccine meningoencephalitis in a child receiving autologous bone marrow transplantation. Pediatr Transplant 2023; 27:e14562. [PMID: 37395442 DOI: 10.1111/petr.14562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Varicella vaccine, a live-attenuated Oka-strain of varicella zoster virus (VZV), is a recommended childhood vaccine by many countries. As with wild varicella strain, after primary infection, the live-attenuated virus can establish latency in sensory ganglia and reactivate causing vaccine-strain illnesses: herpes zoster (HZ), visceral or peripheral and central nervous system dissemination. We report a case of early reactivation of live-attenuated virus-HZ and meningoencephalitis-in an immunocompromised child. METHODS This is a retrospective descriptive report of a case, in a tertiary pediatric hospital, CHU Sainte-Justine (Montréal, Canada). RESULTS An 18 month-year old girl diagnosed with a primitive neuro-ectodermal tumor (PNET) received the day prior to diagnosis, a first varicella vaccine (MMRV). She received chemotherapy 20 days post MMRV vaccine and autologous bone marrow transplantation 3 months post vaccination. She was considered not eligible, to acyclovir prophylaxis prior transplantation (positive for VZV IgG and negative for herpes simplex virus IgG by ELISA). At day 1 post transplantation, she developed dermatomal HZ and meningoencephalitis. Oka-strain varicella was isolated, she was treated with acyclovir and foscarnet. Neurologic status improved in 5 days. Control of VZV viral load in cerebrospinal fluid showed a slow decrease to from 5.24 log 10 copies/mL to 2.14 log 10 copies/mL in 6 weeks. No relapse was observed. She recovered without neurological sequelae. CONCLUSIONS Our experience highlights the importance of conducting a thorough medical history regarding vaccination and serological status of newly immunocompromised patients. Intensive chemotherapy succeeding live vaccine administration <4 weeks could have influenced early and severe viral reactivation. Early initiation of prophylactic antiviral treatment is questioned in such circumstances.
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Affiliation(s)
- Raad Coralie
- Infectious Diseases Division, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal (QC), Montréal, Canada
| | - Chebel Ziad
- Infectious Diseases Division, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal (QC), Montréal, Canada
| | - Renaud Christian
- Infectious Diseases Division, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal (QC), Montréal, Canada
- Microbiology Division, CHU Sainte-Justine, Université de Montréal (QC), Montréal, Canada
| | - Teira Pierre
- Hematology and Oncology Division, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal (QC), Montréal, Canada
| | - Buteau Chantal
- Infectious Diseases Division, Department of Pediatrics, CHUQ-Université Laval, Québec, Canada
| | - Tapiéro Bruce
- Infectious Diseases Division, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal (QC), Montréal, Canada
| | - Ovetchkine Philippe
- Infectious Diseases Division, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal (QC), Montréal, Canada
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4
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Rand K, He K, Dien Bard J, Braskett M, Mohandas S. The Brief Case: Vaccine strain herpes zoster ophthalmicus and meningoencephalitis in an immunocompetent child. J Clin Microbiol 2023; 61:e0071422. [PMID: 37611239 PMCID: PMC10446867 DOI: 10.1128/jcm.00714-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023] Open
Affiliation(s)
- Katherine Rand
- Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Kaidi He
- Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California, USA
- Division of Infectious Disease, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Jennifer Dien Bard
- Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, California, USA
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Melinda Braskett
- Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California, USA
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Division of Clinical Immunology and Allergy, Childrens Hospital Los Angeles, Los Angeles, California, USA
| | - Sindhu Mohandas
- Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California, USA
- Division of Infectious Disease, Children’s Hospital Los Angeles, Los Angeles, California, USA
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Hao M, Tang J, Ge S, Li T, Xia N. Bacterial-Artificial-Chromosome-Based Genome Editing Methods and the Applications in Herpesvirus Research. Microorganisms 2023; 11:microorganisms11030589. [PMID: 36985163 PMCID: PMC10056367 DOI: 10.3390/microorganisms11030589] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 03/02/2023] Open
Abstract
Herpesviruses are major pathogens that infect humans and animals. Manipulating the large genome is critical for exploring the function of specific genes and studying the pathogenesis of herpesviruses and developing novel anti-viral vaccines and therapeutics. Bacterial artificial chromosome (BAC) technology significantly advanced the capacity of herpesviruses researchers to manipulate the virus genomes. In the past years, advancements in BAC-based genome manipulating and screening strategies of recombinant BACs have been achieved, which has promoted the study of the herpes virus. This review summarizes the advances in BAC-based gene editing technology and selection strategies. The merits and drawbacks of BAC-based herpesvirus genome editing methods and the application of BAC-based genome manipulation in viral research are also discussed. This review provides references relevant for researchers in selecting gene editing methods in herpes virus research. Despite the achievements in the genome manipulation of the herpes viruses, the efficiency of BAC-based genome manipulation is still not satisfactory. This review also highlights the need for developing more efficient genome-manipulating methods for herpes viruses.
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Affiliation(s)
- Mengling Hao
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, Department of Laboratory Medicine, School of Public Health, Xiamen University, Xiamen 361102, China
| | - Jiabao Tang
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, Department of Laboratory Medicine, School of Public Health, Xiamen University, Xiamen 361102, China
| | - Shengxiang Ge
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, Department of Laboratory Medicine, School of Public Health, Xiamen University, Xiamen 361102, China
- Xiang An Biomedicine Laboratory, Xiamen 361102, China
- NMPA Key Laboratory for Research and Evaluation of Infectious Disease Diagnostic Technology, School of Public Health, Xiamen University, Xiamen 361102, China
| | - Tingdong Li
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, Department of Laboratory Medicine, School of Public Health, Xiamen University, Xiamen 361102, China
- Xiang An Biomedicine Laboratory, Xiamen 361102, China
- NMPA Key Laboratory for Research and Evaluation of Infectious Disease Diagnostic Technology, School of Public Health, Xiamen University, Xiamen 361102, China
- Correspondence:
| | - Ningshao Xia
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, Department of Laboratory Medicine, School of Public Health, Xiamen University, Xiamen 361102, China
- Xiang An Biomedicine Laboratory, Xiamen 361102, China
- NMPA Key Laboratory for Research and Evaluation of Infectious Disease Diagnostic Technology, School of Public Health, Xiamen University, Xiamen 361102, China
- The Research Unit of Frontier Technology of Structural Vaccinology of Chinese Academy of Medical Sciences, Xiamen 361102, China
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Mo ZJ, Huang SJ, Qiu LX, Li CG, Yu XJ, Li MQ, Chen Z, Zhong GH, Pan DQ, Huang LR, Lv BJ, Cui XL, Song QQ, Jia JZ, Han JL, Wang W, Zhu H, Cheng T, Su YY, Li YM, Ye XZ, Wu T, Zhang J, Xia NS. Safety and immunogenicity of a skin- and neuro-attenuated live vaccine for varicella: a randomized, double-blind, controlled, dose-escalation and age de-escalation phase 1 clinical trial. THE LANCET REGIONAL HEALTH - WESTERN PACIFIC 2023. [DOI: 10.1016/j.lanwpc.2023.100707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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Meningitis without Rash after Reactivation of Varicella Vaccine Strain in a 12-Year-Old Immunocompetent Boy. Vaccines (Basel) 2023; 11:vaccines11020309. [PMID: 36851187 PMCID: PMC9964174 DOI: 10.3390/vaccines11020309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/16/2023] [Accepted: 01/27/2023] [Indexed: 01/31/2023] Open
Abstract
Acute neurologic complications from Varicella-Zoster-Virus reactivation occur in both immunocompromised and immunocompetent patients. In this report, we describe a case of a previously healthy immunocompetent boy who had received two doses of varicella vaccine at 1 and 4 years. At the age of 12 he developed acute aseptic meningitis caused by vaccine-type varicella-zoster-virus without concomitant skin eruptions. VZV-vaccine strain DNA was detected in the cerebrospinal fluid. The patient made a full recovery after receiving intravenous acyclovir therapy. This disease course documents another case of a VZV vaccine-associated meningitis without development of a rash, i.e., a form of VZV infection manifesting as "zoster sine herpete".
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Grose C, Shaban A, Fullerton HJ. Common Features Between Stroke Following Varicella in Children and Stroke Following Herpes Zoster in Adults : Varicella-Zoster Virus in Trigeminal Ganglion. Curr Top Microbiol Immunol 2023; 438:247-272. [PMID: 34224015 DOI: 10.1007/82_2021_236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The cerebral arteries are innervated by afferent fibers from the trigeminal ganglia. Varicella-zoster virus (VZV) frequently resides in the trigeminal ganglion. Reports of arterial ischemic stroke due to VZV cerebral vasculopathy in adults after herpes zoster have been described for decades. Reports of arterial ischemic stroke due to post-varicella cerebral arteriopathy in children have also been described for decades. One rationale for this review has been post-licensure studies that have shown an apparent protective effect from stroke in both adults who have received live zoster vaccine and children who have received live varicella vaccine. In this review, we define common features between stroke following varicella in children and stroke following herpes zoster in adults. The trigeminal ganglion and to a lesser extent the superior cervical ganglion are central to the stroke pathogenesis pathway because afferent fibers from these two ganglia provide the circuitry by which the virus can travel to the anterior and posterior circulations of the brain. Based on studies in pseudorabies virus (PRV) models, it is likely that VZV is carried to the cerebral arteries on a kinesin motor via gE, gI and the homolog of PRV US9. The gE product is an essential VZV protein.
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Affiliation(s)
- Charles Grose
- Division of Infectious Diseases and Virology Laboratory, Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA.
- University Hospital/Room BT2001, 200 Hawkins Drive, Iowa City, IA, 52242, USA.
| | - Amir Shaban
- Division of Cerebrovascular Diseases, Department of Neurology, University of Iowa, Iowa City, Iowa, USA
| | - Heather J Fullerton
- Division of Child Neurology and Pediatric Brain Center, Department of Neurology, University of California San Francisco, San Francisco, California, USA
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9
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Grose C. Metagenomic sequencing of cerebrospinal fluid from children with meningitis. EBioMedicine 2022; 84:104287. [PMID: 36152521 PMCID: PMC9508405 DOI: 10.1016/j.ebiom.2022.104287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 09/08/2022] [Indexed: 11/06/2022] Open
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10
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Aoki Y, Tanaka T, Mizushiro N, Kitazawa K. A Case of Aseptic Meningitis Without Rash Possibly Associated With Varicella Vaccine. Cureus 2022; 14:e25375. [PMID: 35765392 PMCID: PMC9233734 DOI: 10.7759/cureus.25375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 11/05/2022] Open
Abstract
Varicella-zoster virus (VZV) may cause aseptic meningitis in the pediatric age group. We describe a pediatric case of aseptic meningitis with a substantial increase of the paired serum antibody to VZV in which the child did not have skin rash during the course of illness. The patient was a 13-year-old boy without any history of exposure to VZV who was admitted with headache, vomiting, and low-grade fever. He had received one dose of varicella vaccine derived from the Oka/Biken strain (vOka) at the age of one year. Cerebrospinal fluid (CSF) analysis on admission revealed an elevated white blood cell count at 609/mm3 with 99.6% mononuclear cells. As his symptoms resolved after lumbar puncture alone, he was discharged on the seventh day of hospitalization without receiving any specific medication. Serum VZV-IgG titer was found to be substantially elevated after two weeks. VZV infection and reactivations associated with vaccination, as well as past infections, should be included in the differential diagnoses of pediatric aseptic meningitis, even in the absence of skin rash in the entire course. Polymerase chain reaction (PCR) testing for VZV DNA in CSF should be performed in all cases, if available.
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Wang W, Pan D, Cheng T, Zhu H. Rational Design of a Skin- and Neuro-Attenuated Live Varicella Vaccine: A Review and Future Perspectives. Viruses 2022; 14:848. [PMID: 35632591 PMCID: PMC9144592 DOI: 10.3390/v14050848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/18/2022] [Accepted: 04/18/2022] [Indexed: 11/21/2022] Open
Abstract
Primary varicella-zoster virus (VZV) infection causes varicella, which remains a prominent public health concern in children. Current varicella vaccines adopt the live-attenuated Oka strain, vOka, which retains the ability to infect neurons, establish latency and reactivate, leading to vaccine-associated zoster in some vaccinees. Therefore, it is necessary to develop a safer next-generation varicella vaccine to help reduce vaccine hesitancy. This paper reviews the discovery and identification of the skin- and neuro-tropic factor, the open reading frame 7 (ORF7) of VZV, as well as the development of a skin- and neuro-attenuated live varicella vaccine comprising an ORF7-deficient mutant, v7D. This work could provide insights into the research of novel virus vaccines based on functional genomics and reverse genetics.
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Affiliation(s)
- Wei Wang
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Life Sciences, School of Public Health, Xiamen University, Xiamen 361102, China; (W.W.); (D.P.)
| | - Dequan Pan
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Life Sciences, School of Public Health, Xiamen University, Xiamen 361102, China; (W.W.); (D.P.)
| | - Tong Cheng
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Life Sciences, School of Public Health, Xiamen University, Xiamen 361102, China; (W.W.); (D.P.)
| | - Hua Zhu
- Department of Microbiology and Molecular Genetics, New Jersey Medical School, Rutgers University, Newark, NJ 070101, USA
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12
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Development of a skin- and neuro-attenuated live vaccine for varicella. Nat Commun 2022; 13:824. [PMID: 35149692 PMCID: PMC8837607 DOI: 10.1038/s41467-022-28329-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 01/18/2022] [Indexed: 12/14/2022] Open
Abstract
Varicella caused by the primary infection of varicella-zoster virus (VZV) exerts a considerable disease burden globally. Current varicella vaccines consisting of the live-attenuated vOka strain of VZV are generally safe and effective. However, vOka retains full neurovirulence and can establish latency and reactivate to cause herpes zoster in vaccine recipients, raising safety concerns. Here, we rationally design a live-attenuated varicella vaccine candidate, v7D. This virus replicates like wild-type virus in MRC-5 fibroblasts and human PBMCs, the carrier for VZV dissemination, but is severely impaired for infection of human skin and neuronal cells. Meanwhile, v7D shows immunogenicity comparable to vOka both in vitro and in multiple small animal species. Finally, v7D is proven well-tolerated and immunogenic in nonhuman primates. Our preclinical data suggest that v7D is a promising candidate as a safer live varicella vaccine with reduced risk of vaccine-related complications, and could inform the design of other herpes virus vaccines. Current varicella vaccines retain neurovirulence and can establish latency and reactivate. Here, the authors present preclinical results of a rationally-designed, skin- and neuro-attenuated varicella vaccine candidate, v7D, showing its attenuation in human skin and neuronal cells and its immunogenicity in small animal models and nonhuman primates
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Adducchio S, Reyes I, Chikkannaiah M, Rasch M, Kumar G. Bilateral Ptosis, Zosteriform Rash and Flaccid Bladder in a 10-Year-old boy. Child Neurol Open 2022; 9:2329048X221079429. [PMID: 35174255 PMCID: PMC8841934 DOI: 10.1177/2329048x221079429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 01/07/2022] [Accepted: 01/13/2022] [Indexed: 11/17/2022] Open
Abstract
We present a case report of a 10-year-old completely immunized boy presenting with a 2-week history of bilateral eyelid drooping, fatigue followed by bladder and bowel paralysis. This was followed by the appearance of a vesicular painful and itchy rash which directed further diagnosis and treatment as it was consistent with a varicella reactivation rash. This case is a very important addition to the current body of literature on varicella-related neurological complications. It outlines that varicella reactivation can present in completely vaccinated, immunocompetent young children as a neurological syndrome affecting the autonomic nervous system primarily and the rash can occur a few weeks later after presentation of the neurological symptoms.
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Affiliation(s)
| | - Irma Reyes
- Dayton Children’s Hospital, Dayton, Ohio, USA
- Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | - Mahesh Chikkannaiah
- Dayton Children’s Hospital, Dayton, Ohio, USA
- Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | - Matthew Rasch
- Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | - Gogi Kumar
- Dayton Children’s Hospital, Dayton, Ohio, USA
- Wright State University Boonshoft School of Medicine, Dayton, Ohio
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Skripchenko E, Zheleznikova G, Skripchenko N, Alekseeva L, Goleva O, Bessonova T, Zhirkov A. Immunopatological and genetic aspects of pathogenesis of CNS lesions in VZV infection. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:46-56. [DOI: 10.17116/jnevro202212210146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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15
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Al-Qahtani SM, Shati AA, Alqahtani YA, Ali AS. Etiology, Clinical Phenotypes, Epidemiological Correlates, Laboratory Biomarkers and Diagnostic Challenges of Pediatric Viral Meningitis: Descriptive Review. Front Pediatr 2022; 10:923125. [PMID: 35783317 PMCID: PMC9249085 DOI: 10.3389/fped.2022.923125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 05/25/2022] [Indexed: 12/04/2022] Open
Abstract
Meningitis is an inflammation of the brain and spinal cord meninges caused by infectious and non-infectious agents. Infectious agents causing meningitis include viruses, bacteria, and fungi. Viral meningitis (VM), also termed aseptic meningitis, is caused by some viruses, such as enteroviruses (EVs), herpesviruses, influenza viruses, and arboviruses. However, EVs represent the primary cause of VM. The clinical symptoms of this neurological disorder may rapidly be observed after the onset of the disease, or take prolonged time to develop. The primary clinical manifestations of VM include common flu-like symptoms of headache, photophobia, fever, nuchal rigidity, myalgia, and fatigue. The severity of these symptoms depends on the patient's age; they are more severe among infants and children. The course of infection of VM varies between asymptomatic, mild, critically ill, and fatal disease. Morbidities and mortalities of VM are dependent on the early recognition and treatment of the disease. There were no significant distinctions in the clinical phenotypes and symptoms between VM and meningitis due to other causative agents. To date, the pathophysiological mechanisms of VM are unclear. In this scientific communication, a descriptive review was performed to give an overview of pediatric viral meningitis (PVM). PVM may occasionally result in severe neurological consequences such as mental retardation and death. Clinical examinations, including Kernig's, Brudzinski's, and nuchal rigidity signs, were attempted to determine the clinical course of PVM with various success rates revealed. Some epidemiological correlates of PVM were adequately reviewed and presented in this report. They were seen depending mainly on the causative virus. The abnormal cytological and biochemical features of PVM were also discussed and showed potentials to distinguish PVM from pediatric bacterial meningitis (PBM). The pathological, developmental, behavioral, and neuropsychological complications of PVM were also presented. All the previously utilized techniques for the etiological diagnosis of PVM which include virology, serology, biochemistry, and radiology, were presented and discussed to determine their efficiencies and limitations. Finally, molecular testing, mainly PCR, was introduced and showed 100% sensitivity rates.
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Affiliation(s)
- Saleh M Al-Qahtani
- Department of Child Health, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Ayed A Shati
- Department of Child Health, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Youssef A Alqahtani
- Department of Child Health, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Abdelwahid Saeed Ali
- Department of Microbiology and Clinical Parasitology, College of Medicine, King Khalid University, Abha, Saudi Arabia
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Abstract
Here, we present a previously healthy adolescent with aseptic meningitis without skin rash caused by varicella vaccine derived from the Oka/Biken strain; the patient received a single dose of varicella vaccine at 1 year of age. Pediatricians should be aware of the potential for reactivation of varicella vaccine derived from the Oka/Biken strain, which can cause aseptic meningitis in vaccinated children even in the absence of a skin rash.
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Ishimaru S, Kawamura Y, Miura H, Shima S, Ueda A, Watanabe H, Mutoh T, Yoshikawa T. Detection of human herpesviruses in cerebrospinal fluids collected from patients suspected of neuroinfectious diseases. J Neurovirol 2021; 28:92-98. [PMID: 34970721 DOI: 10.1007/s13365-021-01040-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 11/21/2021] [Accepted: 12/09/2021] [Indexed: 11/28/2022]
Abstract
The full spectrum of human herpesviruses (HHV)-associated neuroinfectious diseases in immunocompetent adults remains unclear. Hence, we sought to elucidate the epidemiology and clinical features of these diseases. The study subjects were patients over 16 years old suspected of neuroinfectious diseases who underwent spinal tap performed by neurologists in our university hospital between April 2013 and March 2018. The presence of seven HHV DNAs in cerebrospinal fluid (CSF) was determined by real-time PCR. HHV DNAs were detected in 33 (10.2%) of the 322 patients. The most frequently detected herpesvirus was varicella zoster virus (VZV) (19 patients), followed by HHV-6 (four patients), herpes simplex virus (HSV)-1 (three patients), HSV-2 (three patients), and Epstein-Barr virus (two patients). HHV DNAs were detected in CSF collected from patients with various neuroinfectious diseases, including myelitis, peripheral neuritis, encephalitis, and meningitis. All patients with HSV-1 DNA had encephalitis, whereas all patients with HSV-2 DNA had meningitis. Eleven of the 19 patients with VZV DNA had meningitis. Patients with VZV-associated encephalitis (median age, 80 years) were significantly older than non-encephalitis patients (median age, 60.5 years) (P = 0.046). Although post-herpetic neuralgia was observed in seven (54%) of the 13 patients with VZV and without encephalitis, no such neurological sequela was observed in the four encephalitis patients. In conclusion, HHVs were associated with approximately 10% of neuroinfectious diseases in this cohort. VZV was the most common pathogen, probably due to the large number of VZV meningitis patients. In addition, patients with VZV-associated meningitis were significantly younger than patients with VZV-associated encephalitis.
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Affiliation(s)
- Soichiro Ishimaru
- Department of Pediatrics, Fujita Health University School of Medicine, 1-98, Kutsukake-cho, Dengakugakubo, Toyoake, Aichi, 470-1192, Japan
| | - Yoshiki Kawamura
- Department of Pediatrics, Fujita Health University School of Medicine, 1-98, Kutsukake-cho, Dengakugakubo, Toyoake, Aichi, 470-1192, Japan.
| | - Hiroki Miura
- Department of Pediatrics, Fujita Health University School of Medicine, 1-98, Kutsukake-cho, Dengakugakubo, Toyoake, Aichi, 470-1192, Japan
| | - Sayuri Shima
- Department of Neurology, Fujita Health University School of Medicine, 1-98, Kutsukake-cho, Dengakugakubo, Toyoake, Aichi, 470-1192, Japan
| | - Akihiro Ueda
- Department of Neurology, Fujita Health University School of Medicine, 1-98, Kutsukake-cho, Dengakugakubo, Toyoake, Aichi, 470-1192, Japan
| | - Hirohisa Watanabe
- Department of Neurology, Fujita Health University School of Medicine, 1-98, Kutsukake-cho, Dengakugakubo, Toyoake, Aichi, 470-1192, Japan
| | - Tatsuro Mutoh
- Department of Neurology, Fujita Health University School of Medicine, 1-98, Kutsukake-cho, Dengakugakubo, Toyoake, Aichi, 470-1192, Japan
| | - Tetsushi Yoshikawa
- Department of Pediatrics, Fujita Health University School of Medicine, 1-98, Kutsukake-cho, Dengakugakubo, Toyoake, Aichi, 470-1192, Japan
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Meningitis Caused by the Live Varicella Vaccine Virus: Metagenomic Next Generation Sequencing, Immunology Exome Sequencing and Cytokine Multiplex Profiling. Viruses 2021; 13:v13112286. [PMID: 34835092 PMCID: PMC8620440 DOI: 10.3390/v13112286] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/04/2021] [Accepted: 11/05/2021] [Indexed: 11/21/2022] Open
Abstract
Varicella vaccine meningitis is an uncommon delayed adverse event of vaccination. Varicella vaccine meningitis has been diagnosed in 12 children, of whom 3 were immunocompromised. We now report two additional cases of vaccine meningitis in twice-immunized immunocompetent children and we perform further testing on a prior third case. We used three methods to diagnose or investigate cases of varicella vaccine meningitis, none of which have been used previously on this disease. These include metagenomic next-generation sequencing and cytokine multiplex profiling of cerebrospinal fluid and immunology exome analysis of white blood cells. In one new case, the diagnosis was confirmed by metagenomic next-generation sequencing of cerebrospinal fluid. Both varicella vaccine virus and human herpesvirus 7 DNA were detected. We performed cytokine multiplex profiling on the cerebrospinal fluid of two cases and found ten elevated biomarkers: interferon gamma, interleukins IL-1RA, IL-6, IL-8, IL-10, IL-17F, chemokines CXCL-9, CXCL-10, CCL-2, and G-CSF. In a second new case, we performed immunology exome sequencing on a panel of 356 genes, but no errors were found. After a review of all 14 cases, we concluded that (i) there is no common explanation for this adverse event, but (ii) ingestion of an oral corticosteroid burst 3–4 weeks before onset of vaccine meningitis may be a risk factor in some cases.
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Li Z, Yao Y, Lu X, Liu J, Huang Z, Sun X, Lu Y. Impact of a two-dose varicella immunization program on the incidence of varicella: a multi-year observational study in Shanghai, China. Expert Rev Vaccines 2021; 20:1177-1183. [PMID: 34343035 DOI: 10.1080/14760584.2021.1963236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND It remains hesitant to include a two-dose varicella vaccine (VarV) in a national routine immunization program in China. We aimed to quantify the impact of the two-dose VarV on varicella incidence in Shanghai. RESEARCH DESIGN AND METHODS We directly extracted the data of varicella cases and VarV doses in 2013-2020 in Shanghai, and then estimated the effects of two-dose VarV using a Serfling model. RESULTS A two-dose VarV immunization program has been extensively implemented since October 2017 and become free since August 2018 in Shanghai. Before and after this program, varicella cases significantly declined in children (P < 0.01), whereas did not in adults aged >18 years (P = 0.22). Compared to the predicted number of varicella cases, actual number was significantly lower by 8% in 2018 and 28% in 2019. Among children aged 4-6 years, the reduction in varicella cases was largest. Moreover, there was a significant reduction in varicella cases throughout 2020 (P < 0.001), in which the decrease due to social distancing for the COVID-19 was 54%. CONCLUSIONS A two-dose VarV immunization program may further reduce approximately one-third of varicella cases in Shanghai. Children <4 years and adults benefit less in this program, which warrants enhancing the immunization.
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Affiliation(s)
- Zhi Li
- Division Of Immunization, Shanghai Municipal Center For Disease Control And Prevention, Shanghai China
| | - Ye Yao
- Department Of Biostatistics, Ministry Of Education Key Laboratory Of Public Health Safety, School Of Public Health, Fudan University, Shanghai, China
| | - Xinyue Lu
- Department Of Epidemiology, Ministry Of Education Key Laboratory Of Public Health Safety, School Of Public Health, Fudan University, Shanghai China
| | - Jiechen Liu
- Division Of Immunization, Shanghai Municipal Center For Disease Control And Prevention, Shanghai China
| | - Zhuoying Huang
- Division Of Immunization, Shanghai Municipal Center For Disease Control And Prevention, Shanghai China
| | - Xiaodong Sun
- Division Of Immunization, Shanghai Municipal Center For Disease Control And Prevention, Shanghai China
| | - Yihan Lu
- Department Of Epidemiology, Ministry Of Education Key Laboratory Of Public Health Safety, School Of Public Health, Fudan University, Shanghai China
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Varicella-Zoster Meningitis in an Immunocompetent Male without Fever or Rash. Case Rep Infect Dis 2021; 2021:9940393. [PMID: 34035968 PMCID: PMC8118730 DOI: 10.1155/2021/9940393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 04/17/2021] [Accepted: 04/20/2021] [Indexed: 11/27/2022] Open
Abstract
Varicella-Zoster virus (VZV) is a human herpesvirus that primarily causes chickenpox and can reactivate later in life. Chickenpox occurs mostly in children and is characterized by a typical generalized vesicular rash. Following the primary infection, VZV can remain latent and can reactivate decades later to produce Zoster, being more common in the elderly as well as immunosuppressed individuals. The diagnosis of both the primary and reactivation is mostly clinical from the typical rash. However, when presentations are atypical, it leads to diagnostic challenges. We report an unusual case of VZ reactivation in an immunocompetent young adult presenting without fever, zoster rash, or neuralgia. The diagnosis was established by a positive polymerase chain reaction (PCR) performed on cerebrospinal fluid samples. The patient was treated with acyclovir and responded very well. The diagnosis of VZ meningitis is challenging in the absence of typical features of Zoster rash and requires a high index of suspicion.
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21
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Shang BS, Hung CJJ, Lue KH. Herpes Zoster in an Immunocompetent Child without a History of Varicella. Pediatr Rep 2021; 13:162-167. [PMID: 33916031 PMCID: PMC8167658 DOI: 10.3390/pediatric13020022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 11/30/2022] Open
Abstract
Herpes zoster is a relatively rare infectious disease in the pediatric population, as compared with adults, which is due to the reactivation of latent Varicella-Zoster virus. We report a 7-year-old child without any history of varicella, who first experienced skin pain and later presented skin lesions in dermatomal distribution. Finally, the patient was diagnosed with herpes zoster. We aim to emphasize that herpes zoster could occur in immunocompetent children and may be due to the reactivation of the vaccine strain or previous subclinical infection.
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Affiliation(s)
- Bing-Shiau Shang
- Department of Pediatrics, Chung Shan Medical University Hospital, Taichung City 402, Taiwan;
- Department of Medicine, Chung Shan Medical University, Taichung City 402, Taiwan;
| | - Cheng-Jui Jamie Hung
- Department of Medicine, Chung Shan Medical University, Taichung City 402, Taiwan;
| | - Ko-Huang Lue
- Department of Pediatrics, Chung Shan Medical University Hospital, Taichung City 402, Taiwan;
- Department of Medicine, Chung Shan Medical University, Taichung City 402, Taiwan;
- Correspondence:
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22
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Corticosteroids Contribute to Serious Adverse Events Following Live Attenuated Varicella Vaccination and Live Attenuated Zoster Vaccination. Vaccines (Basel) 2021; 9:vaccines9010023. [PMID: 33418856 PMCID: PMC7825138 DOI: 10.3390/vaccines9010023] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 12/28/2020] [Accepted: 01/01/2021] [Indexed: 12/28/2022] Open
Abstract
Corticosteroids, when given in high dosages, have long been recognized as a risk factor for severe infection with wild-type varicella-zoster virus in both children and adults. The goal of this review is to assess the degree to which both low-dosage and high-dosage corticosteroids contribute to serious adverse events (SAEs) following live varicella vaccination and live zoster vaccination. To this end, we examined multiple published reports of SAEs following varicella vaccination (VarivaxTM) and zoster vaccination (ZostavaxTM). We observed that five of eight viral SAEs following varicella vaccination, including two deaths, occurred in children receiving corticosteroids, while one of three fatal viral SAEs following live zoster vaccination occurred in an adult being treated with low-dosage prednisone. The latter death after live zoster vaccination occurred in a 70 year-old man with rheumatoid arthritis, being treated with prednisone 10 mg daily. Thus, corticosteroids contributed to more severe infectious complications in subjects immunized with each of the two live virus vaccines. Further, when we surveyed the rheumatology literature as well as individual case reports, we documented examples where daily dosages of 7.5–20 mg prednisone were associated with increased rates of severe wild-type varicella-zoster virus infections in children and adults.
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