Herpes zoster: A Review of Clinical Manifestations and Management

Public health impact of herpes zoster vaccination on older adults in Singapore: a modeling study

In Singapore, population aging and rising life expectancy are increasing herpes zoster (HZ) burden, which may be reduced by vaccination. The present study modeled the public health impact of HZ vaccination in Singapore using ZOster ecoNomic Analysis (ZONA) model adapted with Singapore-specific key model inputs, where available. Base case analysis was conducted in adults ≥ 50 years of age (YOA), exploring three vaccination strategies (no vaccination, recombinant zoster vaccine [RZV], zoster vaccine live [ZVL]) under mass vaccination setting (30% coverage). Scenario and sensitivity analyses were performed. Out of 1.51 million adults in 2021 (base case population), 406,513 (27.0%) cases of HZ, 68,264 (4.5%) cases of post-herpetic neuralgia (PHN), and 54,949 (3.6%) cases of other complications were projected without vaccination. RZV was estimated to avoid 73,129 cases of HZ, 11,094 cases of PHN, and 9,205 cases of other complications over the subjects' remaining lifetime; ZVL would avoid 17,565 cases of HZ, 2,781 cases of PHN, and 1,834 cases of other complications. The number needed to vaccinate to prevent one case of HZ/PHN was lower for RZV (7/41) than ZVL (26/163). Among all five age-stratified cohorts (50-59/60-64/65-69/70-79/≥80 YOA), RZV (versus no vaccination/ZVL) avoided the largest number of cases in the youngest cohort, 50-59 YOA. Results were robust under scenario and sensitivity analyses. Mass vaccination with RZV is expected to greatly reduce the public health burden of HZ among Singapore individuals ≥ 50 YOA. Findings support value assessment and decision-making regarding public health vaccination strategies for HZ prevention in Singapore.

Ultrasound-Guided Thoracic Paravertebral Injection of Platelet-Rich Plasma for the Treatment of Thoracic Herpes Zoster-Related Pain: A Study Protocol

BACKGROUND

Herpes zoster (HZ), triggered by the reactivation of the varicella-zoster virus, manifests as a painful rash known as zoster-associated pain (ZAP), which can progress to postherpetic neuralgia (PHN). This study evaluates the efficacy and safety of ultrasound-guided thoracic paravertebral injections of platelet-rich plasma (PRP) in managing acute ZAP and preventing PHN.

METHODS

This is a prospective, randomized, controlled, open-label, endpoint-blinded, single-center trial involving 128 participants suffering from zoster-associated pain. Participants will be randomly assigned to the PRP treatment in combination with antiviral therapy group or the antiviral therapy group at a 1:1 ratio. Pain intensity (NRS-11), quality of life (SF-12), sleep quality (PSQI), pain characteristics, skin lesion recovery, average weekly consumption of rescue analgesics, and adverse events will be assessed. Follow-up assessments will be conducted at 1, 3, 6, and 12 months post-intervention to evaluate the incidence rate of PHN, pain intensity, quality of life, sleep quality, and safety.

ETHICS AND DISSEMINATION

Adhering to the 2013 SPIRIT statement and the Declaration of Helsinki, this study has received ethical approval from the relevant committee. Results will be disseminated through scientific journals and conferences, contributing to global data on managing ZAP.

CONCLUSIONS

By comparing PRP with antiviral therapy, this trial seeks to establish a more effective treatment paradigm for reducing acute zoster-associated pain and the incidence of PHN, potentially setting a new standard in therapeutic strategies for HZ.

TRIAL REGISTRATION

This clinical trial is registered with the Chinese Clinical Trial Registry (ChiCTR) at https://www.chictr.org.cn/index.html (Registration Number: ChiCTR2400087248, Registration Date: 2024-07-23).

Latest vaccination trends against herpes zoster within two primary care settings in Crete, Greece: Rates and perception driven determinants

OBJECTIVES

This study aims to estimate the vaccination rate against herpes zoster (HZ) among public Primary Health Care (PHC) visitors eligible for vaccination based on the National guidelines. It also aims to explore the determinants associated with vaccination utilizing the health beliefs model (HBM).

MATERIALS AND METHODS

A cross-sectional study was conducted between October and December 2022. The study took place in two public PHC units in the Heraklion prefecture, Crete, Greece. Eligible participants were visitors of the selected health units aged 60-75 years. The questionnaire elicited information on participants' demographic data, health habits, and chronic illnesses. The HBM tool adapted for HZ vaccination was also used.

RESULTS

Four hundred primary care attendees participated in the study. Most participants were women (58.5%), with a mean age of 68.1 (±4.9) years. Fifteen percent of participants reported a history HZ illness, while 147 (36.8%) reported being vaccinated against HZ. Older age and respiratory illnesses were associated with higher rates of vaccination. Perceived threat (OR: 1.057; 95% CI 1.022-1.093; p=0.001), perceived vaccination benefits (OR: 1.327; 95% CI 1.179-1.492; p<0.0001), and motivation for action (OR: 2.601; 95% CI 2.122-3.187; p<0.0001) increased the odds of receiving HZ vaccination. Conversely, perceived barriers such as safety concerns were found to decrease the odds of HZ vaccination (OR: 0.845; 95% CI 0.803-0.889; p<0.0001).

CONCLUSIONS

This study identified specific determinants positively associated with HZ vaccination, highlighting the need to enhance the education of healthcare professionals in personalized patient counseling.

Efficacy of Ultrasound-Guided Transverse Abdominal Plane Block for Residual Pain After Pulsed Radiofrequency in Abdominal Acute/Subacute Herpes Zoster-Related Pain

BACKGROUND

Pulse radiofrequency (PRF) can reduce the persistent pain of herpes zoster (HZ), but some patients still have residual pain and do not achieve satisfactory results. This study aimed to assess the efficacy of PRF combined with transverse abdominal plane (TAP) block for abdominal acute/subacute HZ-related pain.

METHODS

A total of 137 acute/sub-acute HZ patients with successful PRF treatment were recruited from the Pain Department of Wuhan No. 1 Hospital between January 2018 and January 2020. There were two groups: the transversus abdominis plane group (TAP group, n = 64) and the normal saline group (NS group, n = 60). Pain intensity, sleep quality, and quality of life were quantified using the visual analogue scale (VAS), the five-item questionnaire and scoring system, and the 36-item Short Form Health Survey (SF-36) questionnaire, respectively. Follow-up assessments were conducted at baseline, 1 day, 3 months, 6 months, and 12 months after the block therapy.

RESULTS

Compared to the NS group, the TAP group showed significantly decreased pain scores 1 day, 3 months, 6 months, and 12 months after block therapy (P < .05). The sleep quality scores were lower in the TAP group than that in the NS group at 6 months (5.0 ± 2.4 vs 6.3 ± 3.7, p = .042), and 12 months after therapy (3.1 ± 1.8 vs 4.1 ± 2.4, p = .031). For quality of life, in comparison to NS group participants, those in the TAP group exhibited significantly higher scores (p < .05) for quality of life at 3 months, 6 months, and 12 months follow-up. There was a significant decrease in the proportion of pregabalin and analgesic medications in the TAP group and NS group at 6 and 12 months after treatment compared to Baseline (p < .001). Furthermore, the results showed that there was a significant difference in VAS, sleep quality scores (SQS), and quality of life between the PRF + TAP group and pharmacological therapies group before and 12 months after treatment (p < .05).

CONCLUSION

The TAP block is a promising complementary treatment for acute/subacute HZ patients who have undergone PRF treatment. Combining PRF with the TAP block has the potential to alleviate HZ-related pain, enhance the patients' quality of life, and improve their sleep quality.

Herpes zoster ophthalmicus temporally after COVID-19 vaccination: a systematic review of uncontrolled case reports and case series

Purpose

Herpes zoster ophthalmicus (HZO) following COVID-19 vaccination has been reported previously but the clinical characteristics, onset, treatment, and outcomes of these cases have not been previously systematically reviewed.

Methods

A systematic review, guided by PRISMA guidelines, surveyed PubMed and Embase databases from April 2021 to June 2023 for case reports and series detailing HZO following COVID-19 vaccination. Studies excluded were abstracts, reviews, and clinical trials. A subsequent descriptive analysis was performed, focusing on patient demographics, clinical characteristics, and outcomes.

Results

Sixteen publications involving 27 participants who developed HZO post-COVID-19 vaccination met the inclusion criteria. The onset of HZO averaged 13 days (SD 12) postvaccination, predominantly after the first dose (n = 20/27 HZO cases, 74%). Most patients (70%) had preexisting medical conditions. Antiherpetic antiviral therapy was utilized in all cases, with the majority achieving resolution of cutaneous and ocular symptoms. Long-term sequelae included postherpetic neuralgia in 7.4% of patients.

Conclusion

Cases of HZO following COVID-19 vaccination generally mirror the clinical trajectory of HZO in general. This review focused on case reports describing HZO occurring in an interval postvaccination; neither association nor causation can be addressed methodologically.

Clinical Features of Varicella-Zoster Virus-Associated Anterior Uveitis with or without Ophthalmic Herpes Zoster

PURPOSE

This study aimed to investigate the clinical characteristics, diagnostic markers, and treatment outcomes of varicella-zoster virus-associated anterior uveitis (VZV-AU) with and without ophthalmic herpes zoster (herpes zoster ophthalmicus (HZO) and zoster sine herpete (ZSH), respectively).

METHODS

Clinical records of 47 VZV-AU patients (21 ZSH, 26 hZO) were retrospectively reviewed for clinical findings, medication use, and PCR using aqueous humor (AH) results.

RESULTS

There was no significant difference in age, gender, visual acuity (VA), or intraocular pressure (IOP) between the two groups. At the initial visit, small-to-medium white keratic precipitates (KPs) were significantly more observed in ZSH group than in HZO group, although there was no significant difference in the frequencies of other ocular findings between the two groups. Early antiviral medication use was significantly higher in HZO group (96.2%) than in ZSH group (19.1%). PCR was performed in 85.7% of ZSH and 53.8% of HZO patients. VZV-DNA positivity and viral load were similar between groups. Multivariate analysis revealed a positive correlation between white KPs and VZV viral load in AH. Although the ultimate use of antiviral medication was still less in ZSH group (71.4%), there were no significant differences in VA and IOP at the last visit between the two groups.

CONCLUSION

Patients with ZSH had more white KPs and received less early antiviral medication than those with HZO. However, visual outcomes were similar between the two groups. Small-to-medium white KPs were significantly associated with the viral load of VZV in AH, suggesting that they could be an active marker.

Herpes virus reactivation induced by abrocitinib: A real-world pharmacovigilance analysis of the FDA Adverse Event Reporting System (FAERS) database

PURPOSE

Large real-world studies evaluating the association between abrocitinib and herpes virus reactivation are lacking. This objective of investigation was to delineate the characteristics of abrocitinib-associated herpes virus reactivation through the FDA Adverse Event Reporting System.

RESULTS

Total of 56 reports were distinctly associated with herpes virus reactivation, with serious adverse events accounting for 67.86 %. Several noteworthy findings emerged: (1) female is associated with relatively high risk of herpes virus reactivation. (2) The proportion of herpes virus reactivation cases reported from the United States has decreased significantly compared to the overall reports. (3) The inclusion of dupilumab in combination regimens appeared to be associated with a comparatively reduced risk of herpes virus reactivation, while the risk of regimens containing baricitinib was increased.

CONCLUSION

These findings will help us to identify risk factors for herpes virus activation in atopic dermatitis patients, and facilitate the implementation of targeted measures to prevent and mitigate herpes virus activation.

Efficacy and safety of brivudine for the treatment of herpes zoster: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Brivudine has been used in herpes zoster (HZ) treatment for years, but the safety and efficacy of brivudine are inconclusive. Here we perform a meta-analysis to assess the efficacy, safety, incidence of postherpetic neuralgia of brivudine.

METHODS

Data of randomized controlled Trials (RCTS) were obtained from the databases of both English (PubMed, Embase, and Cochrane Library) and Chinese (China National Knowledge Infrastructure, China Science Journal Database, and WanFang Database) literatures from inception to 12 September 2022. Meta-analyses of efficacy and safety of Brivudine for the treatment of herpes zoster for RCTS were conducted.

RESULTS

The analyses included seven RCTS (2095 patients in experimental group and 2076 patients in control group) in the treatment of HZ with brivudine. It suggested that the brivudine group was superior to the control group in terms of efficacy (p = .0002) and incidence of postherpetic neuralgia (p = .04). But the incidence of adverse reactions has no significant difference between the brivudine and the control groups (p = .22). In addition, subgroup analysis of adverse events also showed that brivudine was about the same safety as other modalities in the treatment of HZ (p > .05).

CONCLUSIONS

Brivudine is effective for HZ. However, the evidence on the safety of brivudine is insufficient.

Clinical profile of herpes zoster-related hospitalizations and complications: A French population-based database study

OBJECTIVE

To estimate the incidence of hospitalization with a diagnosis of herpes zoster (HZ) and post-herpetic neuralgia (PHN) in France between 2013 and 2020, overall and stratified by age-group and immune status.

METHODS

Retrospective observational, database study, using the French hospital discharge database, which includes private and public data for all day-care and inpatient stays. Adults aged ≥18 years, hospitalized between January 1, 2013, and December 31, 2020, with a diagnosis of HZ or PHN, were included.

RESULTS

Overall, 62 077 adults had a first hospitalization with a diagnosis of HZ or PHN during the observation period. HZ and/or PHN incidence ranged between 14.6 and 16.3 hospitalizations/100 000 persons and was highest in people aged ≥80 years (97.6 hospitalizations/100 000 persons). The immunocompromised (IC) population accounted for 22% of the overall study population. IC patients had longer lengths of stay for HZ per episode compared with non-IC patients (15.5 ± 19.4 days vs 12.2 ± 13.5 days) and higher in-patient mortality (8% vs 4%). Average annual hospitalization costs per patient were higher in the IC vs non-IC population (€8018 vs €5603).

CONCLUSIONS

Older age increases hospitalization rates up to 6-fold and IC status increases in-patient mortality up to two-fold.

CLINICAL TRIAL REGISTRATION

The study was conducted by HEVA and data were provided by ATIH according to French regulatory and data protection procedures.

Changing age pattern and diverse outcomes of herpes zoster ophthalmicus: exploring the temporal trend, decrease in incident age and influence of treatment strategies

PURPOSE

Herpes Zoster Ophthalmicus (HZO) is a disease commonly affecting the elderly and immunocompromised. Over the last several years, a trend towards decreasing incident age, albeit with varying clinical features, has been observed. This temporal trend towards the younger age group necessitates a detailed evaluation to determine possible causes of its occurrence in this population.

METHOD

This is a hospital-based retrospective study. 154 datasheets were initially identified. After excluding non-relevant data sheets (88), 56 relevant and complete records were subjected to comprehensive analysis in adherence to the inclusion criteria.

RESULTS

Most commonly affected age group was < 40 years, with the mean age being 38. Conjunctivitis was the most frequent occurrence seen in 82.05%. Keratitis was seen in varying forms as, epithelial (64.44%), stromal (15.3%) & nummular (3.57%). Anterior uveitis in 35.89%, posterior uveitis (retinitis, neuro-retinitis) in 7.69% of cases, posterior segment involvement (rhegmatogenous retinal detachment, optic atrophy) in 8.8%, secondary glaucoma in 28.2%, optic neuritis in 5.3% while orbital apex and cavernous sinus involvement were seen in one case.

CONCLUSION

This study reflects a temporal shift in the incidence of HZO towards the younger age group. The proportion of younger patients with HZO is increasing with some male preponderance. Identifiable factors contributing to potential risk, recurrence, and chronicity of HZO are related to demographics, immune status, dietary, environmental associations, vaccination status, and previous history of recurrences. Reported outcomes can be valuable in understanding the evolving patterns of HZO and improving patient care, public health and vaccination policies.

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

Purpose

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

Patients and Methods

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

Results

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

Conclusion

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

Prevalence of Plantar Warts, Genital Warts, and Herpetic Infections in Greek Competitive Swimmers

Viral outbreaks are common in the sport community. Data regarding the prevalence of plantar warts, genital warts, herpes simplex type 1 (herpes labialis), herpes zoster, and genital herpes in competitive swimmers are lacking in the literature. The purpose of this study was to determine the prevalence of those viral infections among young competitive swimmers participating in Greek swimming clubs. Swimmers' parents and adult swimmers were asked to complete an anonymous questionnaire. In total, 1047 swimmers enrolled in this study. The measured parameters included gender, age, times of infections, and seasons when athletes may be more susceptible to infections. Practicing information such as type of swimming facility, number of training years, average hours of daily training, behaviors in swimming practice, and sunlight exposure was also recorded. All infections showed a significant difference in relation to "age" and "years of training". The gender significance was observed in herpes labialis (p = 0.016) and plantar warts (p = 0.05). The prevalence of all infections in swimmers who use outdoor facilities was higher. Certain behaviors such as walking barefoot on a pool deck and sharing swimming equipment correlate with herpes simplex and plantar warts. Virus infections can affect swimmers of all ages. In our study, plantar warts and herpes labialis are more common in swimmers. Herpes zoster and sexually transmitted viruses are rarer and affect adult swimmers. The impact of cutaneous infections on swimmers can affect performance and well-being. Effective prevention and management are essential to avoid complications. Proper hygiene, medical guidance, and treatment reduce swimmers' exposure to skin viruses.

Ultrasound combined with DSA-guided pulsed radiofrequency for perineal herpes zoster pain management: clinical outcomes and complications

Background

Herpes zoster (HZ) in the perineal area is a rare disease. There are limited treatment options for this disease. This study aimed to assess the efficacy of ultrasound combined with digital subtraction angiography (DSA)-guided pulsed radiofrequency (PRF) for perineal herpes zoster-related pain.

Methods

Two hundred and twelve patients with perineal HZ were enrolled at the pain department. From January 1, 2018 to December 30, 2019, patients with HZ in the perineal area were treated with PRF under DSA guidance, and from January 1, 2020 to October 30, 2023, patients with HZ in the perineal area were treated with PRF under ultrasound combined with DSA guidance. The included patients were divided into two groups: DSA group and ultrasound + DSA group. The visual analog scale (VAS), central sensitization inventory (CSI), sleep quality scores (SQS), the 36-Item Short Form Health Survey questionnaire (SF-36) at baseline and after the PRF treatment were analyzed to evaluate clinical efficacy.

Results

The mean VAS scores, CSI scores, SQS, and SF-36 scores were statistically significantly lower after treatment compared to baseline (p < 0.001). There was no significant change in VAS scores, CSI scores, SQS, and SF-36 scores between the DSA group and the ultrasound + DSA group (p > 0.05). The time it took from the start of the puncture to the successful puncture was significantly shorter in the ultrasound + DSA group compared to the DSA group (41.2 ± 21.2 vs. 48.1 ± 20.3, p = 0.035). The ultrasound + DSA group had a higher percentage of satisfaction with the procedure than the DSA group (90/99, 90.9% vs. 62/78, 79.5%, p = 0.030). A total of 27 postoperative complications occurred. The incidence of puncture site hematoma was significantly higher in the DSA group (10/78, 12.8%) than that in the ultrasound + DSA group (4/99, 4.0%) (p = 0.032).

Conclusion

PRF can reduce pain from HZ in the perineal region, alleviate central sensitization, enhance sleep quality, and improve overall quality of life. When PRF is performed under ultrasound guidance combined with DSA, it shortens the puncture time and reduces the risk of hematoma formation at the puncture site, making it the recommended method for clinical use.

The relationship between pain duration characteristics and pain intensity in herpes zoster-related pain: a single-center retrospective study

Background

The varicella-zoster virus (VZV) can cause herpes zoster (HZ), which may progress to postherpetic neuralgia (PHN), leading to severe inflammatory responses and pain.

Objective

This study investigates the relationship between pain duration characteristics and pain intensity in patients with herpes zoster-related pain, hypothesizing that persistent pain correlates with higher pain intensity compared to intermittent pain.

Methods

A retrospective study was conducted at the Second Affiliated Hospital of Guangxi Medical University, China. Data from patients treated for herpes zoster-related pain between January 2019 and February 2024 were analyzed. Pain intensity was measured using the Numerical Rating Scale (NRS-11), and pain duration was categorized as intermittent or persistent. Multivariate regression models were used to assess the association between pain duration and intensity, adjusting for potential confounders.

Results

A total of 840 patients were included. Persistent pain was significantly associated with higher NRS-11 scores compared to intermittent pain (β = 0.71, 95% CI 0.50-0.91, p < 0.001). Subgroup analyses showed that persistent pain was associated with higher pain intensity in both acute HZ and PHN patients (HZ: β = 0.71, 95% CI 0.45-0.96, p < 0.001; PHN: β = 0.76, 95% CI 0.40-1.13, p < 0.001). Inflammatory markers, such as C-reactive protein (CRP) and white blood cell count, were positively correlated with pain intensity.

Conclusion

Pain duration significantly impacts pain intensity in HZ patients. Considering pain duration is crucial for effective pain management. Further research should explore the mechanisms underlying persistent pain to develop better treatment strategies.

Abdominal Pseudohernia Caused by Zoster Sine Herpete

Abdominal pseudohernia is a rare clinical condition characterized by an abnormal bulging of the abdominal wall. We present a 56-year-old male patient diagnosed with abdominal pseudohernia caused by zoster sine herpete (ZSH). The patient initially presented with a right abdominal wall bulging at the Th10 dermatome area. The patient did not experience any pain or rash at the site, and the ultrasonography (US) did not reveal any tumor or hernia. Computed tomography (CT) was taken in another hospital, but it failed to provide a diagnosis. During the second visit, we performed standing ultrasonography and detected the thinning of the abdominal muscle. To diagnose abdominal pseudohernia, the key point is to detect the muscle thinning between the affected site and the healthy side.

The Role of Moist Dressings in the Management of Herpes Zoster With Scalp Involvement: A Case Report

Comprehensive management, including antivirals and pain control, is crucial for mitigating complications and improving patient outcomes in herpes zoster. Moist wound dressings, specifically hydrocoll, effectively reduce pain, and promote healing in herpes zoster with scalp involvement, as demonstrated in the case of a 76-year-old male.

The continuous increase in the number of newly medically attended cases of herpes zoster did not accelerate during the coronavirus disease 2019 pandemic in Kanagawa, Japan

Possible changes in the epidemiology of herpes zoster (HZ) since the emergence of the coronavirus disease 2019 (COVID-19) pandemic is an unfolding topic. The number of newly medically attended cases (NMAC) of HZ during the pandemic in Kanagawa Prefecture, Japan, was quantitatively investigated using a claims database. The study period was from April 2017 to March 2022. The number of NMAC of HZ showed a continuously increasing trend throughout the study period, which could be attributed to population aging. Autoregressive integrated moving average modeling and forecasting revealed that the increase in the actual number of NMAC of HZ since the start of the pandemic was generally similar to that predicted based on a model fitted using data from the pre-pandemic period, but at a slightly reduced pace. This slowdown suggests that refraining from medical visits during the pandemic affected HZ surveillance.

A central and peripheral dual neuromodulation strategy in pain management of zoster-associated pain

Spinal cord stimulation (SCS) has shown effectiveness in relieving zoster-associated pain (ZAP), but some patients still experience moderate or severe pain after SCS treatment. This study aims to evaluate the impact of SCS combined with dorsal root ganglion (DRG) pulsed radiofrequency (PRF) as a dual neuromodulation strategy on the prognosis of ZAP. The clinical records of patients diagnosed with ZAP who underwent SCS (SCS group) or SCS combined with PRF (SCS + PRF group) at The Third Xiangya Hospital, Central South University, were retrospectively analyzed to compare the effectiveness of the two treatment approaches for ZAP. Outcome measures included changes in Visual Analog Scale (VAS) scores before and after neuromodulation treatment, response rates, and incidence of progression to postherpetic neuralgia (PHN).13 SCS patients and 15 SCS + PRF patients were analyzed. Admission VAS scores were similar (P = 0.934). Upon discharge, no significant differences in VAS or response rates were observed (P > 0.05). However, at 6-month follow-up, the SCS + PRF group had lower VAS scores (1.53 ± 1.06 vs. 3.23 ± 1.50, P < 0.001) and a lower proportion of residual moderate pain (P = 0.041). None in the SCS + PRF group progressed to PHN in the acute/subacute phases, differing significantly from the SCS group (P = 0.038).Therefore, SCS combined with DRG PRF is feasible and effective in the treatment of ZAP. This dual neuromodulation strategy may be a more appropriate regimen for the treatment of ZAP.

Exploring the association between chronic prostatitis and the risk of herpes zoster in a cohort study in Taiwan

OBJECTIVE

The aim of the cohort research was to study the association between chronic prostatitis and the probability of herpes zoster in Taiwan.

METHODS

Using the National Health Insurance Research Database (NHIRD) of Taiwan, we selected male persons newly diagnosed with chronic prostatitis aged 20-84 years between 2013 and 2020. These male persons were then matched with a non-prostatitis group who did not have a diagnosis of prostatitis by using 1:1 propensity score matching on age and relevant comorbidities. All participants were observed either until a new diagnosis of herpes zoster was noted or until the completion of the study period in 2020. Cox proportional hazards regression analysis was employed to study the hazard ratio (HR) and 95% confidence interval (CI) for the risk of herpes zoster associated with chronic prostatitis.

RESULTS

A total of 69 239 participants with chronic prostatitis and 69 239 participants with non-prostatitis were included in the analysis. The incidence rate of herpes zoster was higher in participants with chronic prostatitis compared to the non-prostatitis group (8.03 per 1000 person-years for chronic prostatitis group versus 4.74 per 1000 person-years for non-prostatitis group, incidence rate ratio = 1.69, and 95%CI = 1.59-1.81). After adjusting for co-variables, participants with chronic prostatitis were found to have a higher risk of developing herpes zoster compared to the non-prostatitis group (adjusted HR = 1.69, 95%CI = 1.59-1.81, and p < 0.001).

CONCLUSION

This cohort research suggests that people with chronic prostatitis may have a greater risk of developing herpes zoster compared to the non-prostatitis group in Taiwan. Preventive strategies, such as the administration of the herpes zoster vaccine, might be beneficial in people with chronic prostatitis.

8. Herpes zoster and post herpetic neuralgia

INTRODUCTION

Patients suffering from postherpetic neuralgia (PHN) report unilateral chronic pain in one or more dermatomes after an acute herpes zoster (HZ) infection. The incidence of acute HZ ranges between three and five patients per 1000 person-years. In one out of four patients, acute HZ-related pain will transition into PHN. PHN can be very disabling for patients and reduce quality of life. Additionally, the treatment of PHN is characterized by high failure rates. The aim of this review is to give an update on the previous practical guideline published in 2011 and revised in 2015 (published in 2019) and to provide an overview of current interventional treatment options for HZ infection and PHN.

METHODS

The literature on the diagnosis and treatment of HZ and PHN was systematically reviewed and summarized.

RESULTS

The most important treatment for acute HZ-related pain is antiviral therapy within 72 h of symptom onset. Additional symptomatic treatment options are analgesic drugs according to the WHO pain ladder, tricyclic antidepressants (eg, nortriptyline), and antiepileptic drugs (eg, gabapentin). If pain is not sufficiently reduced, interventional treatment such as an epidural injection with local anesthetics and corticosteroids or pulsed radiofrequency of the dorsal root ganglion (DRG) are options. Treatment for PHN is preferably transdermal capsaicin, lidocaine, or oral drugs such as antidepressants or antiepileptics.

CONCLUSIONS

Treatment of acute HZ-related pain especially PHN is challenging. Besides the conventional treatment for PHN, interventional management is considered a new treatment option. PRF of DRG seems to be the most promising interventional management.

Truncated VZV gE Induces High-Titer Neutralizing Antibodies in Mice

Backgrounds: A contemporary public health challenge is the increase in the prevalence rates of herpes zoster (HZ) worldwide. Methods: In this work, the gE gene structure was analyzed using bioinformatics techniques, and three plasmids of varying lengths, tgE537, tgE200, and tgE350, were expressed in Chinese hamster ovary (CHO) cells. These proteins were used to immunize BALB/c mice with Al/CpG adjuvant; ELISPOT and FCM were used to evaluate cellular immunity; and ELISA, VZV microneutralization, and FAMA assays were performed to detect antibody titers. Results: Target protein concentrations of 1.8 mg/mL for tgE537, 0.15 mg/mL for tgE200 and 0.65 mg/mL for tgE350 were effectively produced. The ability of the three protein segments to stimulate CD4+ and CD8+ T cells, as well as to cause lymphocytes to secrete IFN-γ and IL-4, did not significantly differ from one another. Both tgE537 and tgE350 were capable of generating VZV-specific antibodies and neutralizing antibodies, while tgE350 had the highest neutralizing antibody titer (4388). There was no equivalent humoral immune response induced by tgE200. Conclusions: The results of this investigation provide the groundwork for the creation of HZ recombinant vaccines using truncated proteins as antigens.

Varicella‑zoster virus‑associated meningitis followed peripheral facial palsy: A case report

Although central nervous system infection following varicella zoster virus infection is relatively common, subsequent peripheral nervous system infection is comparatively rare. The present case documents a case of meningitis after varicella-zoster virus (VZV) infection, which was then followed by peripheral facial palsy. Specifically, a 54-year-old female patient was first admitted to Shengli Oilfield Central Hospital (Dongying, China) with headache and fever. Physical examination revealed herpes that formed along the intercostal nerve in the left forebreast, armpit and back. Subsequently, neurological examination found cervical resistance in more than three fingers (neck resistance of less than two transverse fingers is not evidence of meningeal irritation; the neck resistance of this patient was approximately three transverse fingers, so the patient was presumed to be positive for meningeal irritation, highly suggestive of meningitis) and Kernig sign was positive. There were no significant abnormalities according to brain MRI and lumbar puncture pressure was 330 mmH2O. In addition, the leukocyte count was 734x106/l, 50% monocyte count, 50% multinucleated cells, chloride levels of 109.1 mmol/l, protein levels of 235 mg/dl and glucose levels of 4.18 mmol/l in the cerebrospinal fluid. DNA and RNA metagenomic detection of pathogenic microorganisms in the cerebrospinal fluid revealed the presence of VZV. The patient was therefore treated with acyclovir, ceftriaxone, mannitol and methylprednisolone, but then developed right peripheral facial palsy at 10 days after treatment. This complication was not found in the literature, and the occurrence of facial neuritis was unexpected. The active period of VZV virus was 21 days, and the patient had herpes 5 days before admission. The active period of the virus was considered to have subsided and the patient was in the recovery period. Moreover, the results of lumbar puncture showed that the white blood cells, the proportion of neutrophils and the protein in cerebrospinal fluid were all decreasing, which also indicated that the patient had entered the recovery period. The patient was discharged 18 days after admission. In conclusion, observations from the present case suggested that the clinical manifestations of VZV infection can be complex and varied, requiring the clinician to have an accurate understanding of its disease progression and treatment.

Atypical Presentation of Disseminated Varicella Zoster Virus Infection Mimicking Bullous Pemphigoid

Varicella-zoster virus (VZV) infection typically presents as a mild, self-limiting illness in children but can be severe and life-threatening in adults, particularly those who are immunocompromised. Atypical presentations, including hemorrhagic, necrotizing, and bullous forms, can complicate diagnosis and lead to delays in appropriate treatment. We present a case of a disseminated bullous VZV infection in an immunocompromised patient with cancer. The patient, initially misdiagnosed with bullous pemphigoid, was treated with oral steroids. The patient's condition progressed to acute respiratory distress syndrome, and she ultimately succumbed to the infection. This case underscores the importance of considering VZV as a differential diagnosis in immunocompromised patients presenting with bullous lesions. Early recognition and appropriate antiviral therapy are crucial for improving outcomes and preventing severe complications.

Mechanism and future prospect of treatment of facial paralysis caused by herpes zoster virus infection with acupuncture combined with medicine: A review

Herpes zoster virus infectious facial paralysis is caused by the reactivation and replication of varicella-zoster virus, which leads to herpetic inflammatory lesions, resulting in peripheral facial paralysis associated with herpes rash in the auricle and external ear, and vestibular cochlear dysfunction. It is also known as Ramsey-Hunter syndrome (Hunt syndrome). Facial paralysis caused by herpes zoster is difficult to cure due to its easy loss of treatment and mistreatment. Cause a greater burden on the patient's body and mind. However, the treatment of Western medicine has lagged behind and there are many adverse reactions, which cannot be completely cured, and new alternatives are urgently needed. This article briefly reviews the advantages and disadvantages of modern medical treatment of Hunt syndrome. This paper expounds the unique ideas of traditional Chinese medicine in the treatment of Hunt syndrome from the perspectives of antiviral, antibacterial, improving blood circulation, protecting cardiovascular, cerebrovascular, and nerve. This article discusses the superiority of traditional Chinese medicine in the treatment of Hunt syndrome from 2 aspects of Chinese medicine therapy and acupuncture therapy, and points out the feasibility of combined treatment of acupuncture and traditional Chinese medicine. So as to provide a new treatment for Hunt syndrome.

Critical Chest Wall Necrotizing Fasciitis Triggered by Herpes Zoster: A Case Report

BACKGROUND Necrotizing fasciitis is an aggressive type of skin and soft tissue infection that results in necrosis of subcutaneous tissues, including muscle and fascia. Mixed bacteria, including gas-forming organisms, are usually identified. This report describes a 55-year-old male diabetic patient with herpes zoster involving the thoracic dermatomes complicated by skin infection, necrotizing fasciitis, chest wall abscess, and sepsis. CASE REPORT A 55-year-old man with diabetes mellitus presented with thoracic herpes zoster, initially treated with acyclovir and topical agents. He developed swelling, pain, and fever over the left chest, which was unresponsive to topical treatment. Investigations revealed elevated white blood cells and gas on chest X-ray. Computed tomography confirmed a 13×6×11-cm abscess with gas between the latissimus dorsi and serratus anterior muscles, suggesting necrosis. He received intravenous amoxicillin/clavulanic acid and metronidazole and underwent urgent surgical drainage, yielding 200 mL of pus. Cultures identified antibiotic-sensitive Staphylococcus aureus and Clostridium perfringens. Histopathology confirmed necrotizing tissue with acute bacterial inflammation. He was treated postoperatively with dressings and vacuum-assisted closure, followed by sutures, and was discharged in good condition after 16 days. CONCLUSIONS This case underscores the aggressive nature and potential complications of necrotizing soft tissue infections in patients with diabetes mellitus and herpes zoster. Prompt recognition, early intervention with appropriate antibiotics, and surgical drainage are crucial in managing such infections effectively. The successful use of vacuum-assisted closure therapy underscores its role in facilitating wound healing after debridement. Clinicians should maintain vigilance for necrotizing infections in similar high-risk patients to ensure early intervention and improve clinical outcomes.

Herpes zoster as the initial manifestation of varicella-zoster virus infection in a healthy toddler

Herpes zoster (HZ), commonly known as shingles, is a painful blistering rash in dermatomal distribution, caused by the reactivation of varicella-zoster virus (VZV) that was acquired during a primary varicella infection. While commonly afflicting adults, cases of HZ in paediatric patients are infrequently reported. Such cases are predominantly reported in children who have had prior exposure to VZV, either during pregnancy, early childhood or have been vaccinated with live attenuated VZV. This report presents the first known case to our knowledge of HZ as the initial manifestation of a VZV infection in an immunocompetent toddler in the UK. The report details the chronology of the infection event and discusses the clinical context behind HZ presentations in paediatrics globally. It provides a compelling illustration of the uncommon presentation of VZV infection in an immunocompetent child devoid of antecedent virus exposure, thus meriting acknowledgement and potentially further investigation as to the cause.

Immunity to Varicella Zoster Virus in Healthcare Workers: A Systematic Review and Meta-Analysis (2024)

Healthcare workers (HCWs) are occupationally exposed to varicella zoster virus (VZV), and their inappropriate vaccination status could contribute to an outbreak involving both professionals and the patients they care for, with a potential impact on the general population. Therefore, since 2007, the Advisory Committee on Immunization Practices (ACIP) recommends that all HCWs have evidence of immunity against varicella. The present meta-analysis was therefore designed to collect the available evidence on the seronegative status of VZV among HCWs. PubMed, Scopus, and Embase databases were searched without backward limit for articles reporting on the seroprevalence of VZV among HCWs, and all articles meeting the inclusion criteria were included in a random-effect meta-analysis model. From 1744 initial entries, a total of 58 articles were included in the quantitative analysis (publication range: 1988 to 2024), for a pooled sample of 71,720 HCWs. Moreover, the included studies reported on seroprevalence data on measles (N = 36,043 HCWs) and rubella (N = 22,086 HCWs). Eventually, the pooled seronegative status for VZV was estimated to be 5.72% (95% confidence interval [95% CI] 4.59 to 7.10) compared to 6.91% (95% CI 4.79 to 9.87) for measles and 7.21% (5.36 to 9.64) for rubella, with a greater risk among subjects younger than 30 years at the time of the survey (risk ratio [RR] 1.434, 95% CI 1.172 to 1.756). Interestingly, medical history of either VZV infection/vaccination had low diagnostic performances (sensitivity 76.00%; specificity 60.12%; PPV of 96.12% but PNV of 18.64%). In summary, the available data suggest that newly hired HCWs are increasingly affected by low immunization rates for VZV but also for measles and rubella, stressing the importance of systematically testing test newly hired workers for all components of the measles-pertussis-rubella-varicella vaccine.

"Bloomy rind sign" in varicella-zoster virus brainstem meningoencephalitis

The bloomy rind sign, characterized by band-like abnormalities along the surface of the brainstem on magnetic resonance imaging without contrast enhancement, has been considered a specific imaging marker for leptomeningeal metastasis from lung adenocarcinoma. In this study, we describe the case of an 85-year-old male with a 3-week history of headache, fever, and progressive cognitive impairment. The patient was diagnosed with varicella-zoster virus brainstem meningoencephalitis and magnetic resonance imaging revealed hyperintensities along the brainstem surface on fluid-attenuated inversion recovery and diffusion-weighted imaging that mimicked a bloomy rind sign. However, the patient showed no signs of lung cancer or meningeal carcinomatosis. This case suggests that the bloomy rind sign is not exclusive to leptomeningeal metastasis but can also be observed in other conditions, such as central nervous system infections.

[Clinical presentation and treatment of herpes zoster and postherpetic neuralgia]

Herpes zoster (HZ) is a common disease caused by reactivation of varicella zoster virus. Diagnosis is usually based on the typical clinical presentation. Standard treatment includes antiviral, topical and analgesic therapies. As a complication, postherpetic neuralgia (PHN) can result from acute HZ infection, particularly in older and/or immunocompromised people. This can seriously impair the quality of life of those affected and requires adequate analgesia. In addition to the genesis, clinical presentation and treatment recommendations for HZ and PHN, this article also deals in particular with the vaccination prophylaxis recommended by the standing vaccination commission of the Robert Koch Institute (STIKO).

The effect of recombinant zoster vaccine on patients with chronic obstructive pulmonary diseases: A multi-institutional propensity score-matched cohort study

Although the recombinant zoster vaccine (RZV) has demonstrated efficacy in reducing the risk of herpes zoster (HZ) for individuals aged 50 years and older, its effectiveness in patients with chronic obstructive pulmonary disease (COPD) remains uncertain. This study was conducted to assess the effect of RZV on the risk of HZ in COPD patients. A multi-institutional propensity score-matched retrospective cohort study was conducted using the TriNetX Research network, including individuals aged 40 years or older with COPD from January 1, 2018, to December 31, 2022. Patients with a history of HZ or prior zoster vaccination were excluded. The primary outcome was HZ occurrence, with secondary outcomes including severe and nonsevere HZ. After propensity score matching, each 17 431 patients receiving RZV and unvaccinated patients were included. The vaccinated group had a significantly lower risk of HZ compared to the unvaccinated group (HR, 0.62; [95% confidence intervals] 95% CI, 0.51-0.75, p < 0.01). Similar risk reductions were observed for nonsevere HZ (HR, 0.61; 95% CI, 049-0.75, p < 0.01) and severe HZ (HR, 0.53; 95% CI, 0.38-0.73, p < 0.01). Further subgroup analyses demonstrated consistent risk reductions across age (50-59, 60-69, 70-79, and ≥80 years), sex, and comorbidities, except for individual aged 40-49 years. This study confirms the effectiveness of RZV in reducing HZ risk in patients with COPD aged 50 years and older, supporting its administration in this population. However, vaccination rates remain low, highlighting the need for improved vaccination strategies in this high-risk group. Efforts to enhance vaccine uptake are warranted to reduce HZ morbidity.

Herpes zoster ophthalmicus following recombinant zoster vaccine: A case report and brief literature review

Purpose

Immunizations have long been pivotal in preventing diseases like HZ (herpes zoster), caused by VZV (varicella zoster virus). This study aims to evaluate the efficacy and safety of the RZV (recombinant zoster vaccine) compared to the ZVL (zoster vaccine live) and to report rare adverse events following RZV administration.

Observation

Herein, we report an unusual case of a 59-year-old man who developed a V1-limited rash with a positive HZ PCR (polymerase chain reaction) test following administration of RZV in the United States.

Conclusion

The development of RZV has significantly improved the prevention of HZ compared to ZVL. Nevertheless, rare adverse events, such as dermatomal reactions, underscore the importance of ongoing monitoring and research into the immunomodulatory effects of RZV. Physicians should continue to administer the RZV to patients but be cognizant that reactivation may rarely subsequently occur.

Case Presentation

The patient with a history of benign prostatic hyperplasia was treated at an outside hospital two days after receiving the RZV complaining of paresthesia and a rash on his nasolacrimal area and forehead. The patient presented to the ED (emergency department), 9 days post-vaccination due to persistence of his symptoms despite use of amoxicillin, valacyclovir, and an unidentified eye drop. The dose of valacyclovir was increased, and he completed 1 g TID (three times a day) PO (per orally) for 10 days with subsequent resolution of symptoms. A positive PCR test confirmed the diagnosis of HZ. Topical mupirocin ointment was initiated and the patient was referred for ophthalmologic evaluation.

Impact of Herpes Zoster and Postherpetic Neuralgia on the Quality of Life in China: A Prospective Study

Background

Herpes zoster (HZ) and postherpetic neuralgia (PHN) significantly affect patients' quality of life (QoL). Cultural differences may lead to different patient-reported outcomes across countries. The current study aims to evaluate the detrimental impact of HZ and PHN on QoL in China.

Methods

This prospective study was conducted from January 2020 to April 2023. We used the Zoster Brief Pain Inventory (ZBPI) and 5-level EuroQol-5 Dimension (EQ-5D-5L) questionnaire to assess the QoL of HZ and PHN patients. Patients were required to complete the questionnaires at 15, 30, 60, and 90 days after the onset of the HZ rash. Additional questionnaires were administered at 120, 150, and 180 days for those who developed PHN within three months of the rash's onset.

Results

A cohort of 633 patients with a median age of 63 years were included in the study. The mean delay from the appearance of the initial HZ rash to the first medical consultation was 5.1 ± 2.8 days. Approximately 30% of the HZ patients (189/633) went on to develop PHN. For patients with HZ who did not progress to PHN, the ZBPI worst pain score and impaired QoL had nearly resolved by day 90 post-rash onset. Conversely, there was no significant improvement in the ZBPI worst pain score and QoL for those with PHN, even by day 180 post-rash onset.

Conclusion

Both HZ and PHN significantly impaired patients' QoL. However, the impairment caused by PHN was more severe in both intensity and duration.

Causal effect of lifestyle and metabolic indicator with herpes zoster: a two-sample Mendelian randomization study

Background

Previous observational studies have reported certain causal relationships between factors such as smoking, alcohol consumption, obesity, physical activity, metabolic disorders, and the incidence of herpes zoster (HZ). However, there is controversy regarding the observed results across different studies. Our objective was to investigate the causal effects of these risk factors on the risk of herpes zoster through a Mendelian randomization analysis using two-sample bidirectional approaches.

Methods

We conducted two-sample bidirectional Mendelian randomization analyses to explore the causal relationships between different lifestyles, obesity assessment indices, metabolic indicators, and the risk of herpes zoster. All exposure and outcome data were sourced from publicly available data from genome-wide association studies.

Results

In the inverse-variance weighted (IVW) analysis, body mass index (BMI) (OR: 1.160, 95% CI: 1.030-1.307, p = 0.014), Body fat percentage (BFP) (OR: 1.241, 95% CI: 1.050-1.467, p = 0.011), and whole body fat mass (WBFM) (OR: 1.199, 95% CI: 1.057-1.362, p = 0.005) exhibited positive associations with the risk of HZ. However, usual walking pace (UWP) (OR: 0.498, 95% CI: 0.254-0.976, p = 0.042) demonstrated a significant negative correlation with HZ risk. Other factors including alcohol intake frequency, smoking initiation, smoking status, insomnia, and sleep duration did not show significant causal relationships with HZ.

Conclusion

Mendelian randomization studies revealed that BMI, BFP, and WBFM are risk factors for HZ. UWP showed a protective effect against HZ. These findings provide a straightforward method for evaluating future clinical practices aiming to develop personalized management strategies and assess high-risk populations for HZ.

Heterologous Prime-Boost Immunization Strategies Using Varicella-Zoster Virus gE mRNA Vaccine and Adjuvanted Protein Subunit Vaccine Triggered Superior Cell Immune Response in Middle-Aged Mice

Purpose

Heterologous immunization using different vaccine platforms has been demonstrated as an efficient strategy to enhance antigen-specific immune responses. In this study, we performed a head-to-head comparison of both humoral and cellular immune response induced by different prime-boost immunization regimens of mRNA vaccine and adjuvanted protein subunit vaccine against varicella-zoster virus (VZV) in middle-aged mice, aiming to get a better understanding of the influence of vaccination schedule on immune response.

Methods

VZV glycoprotein (gE) mRNA was synthesized and encapsulated into SM-102-based lipid nanoparticles (LNPs). VZV-primed middle-aged C57BL/6 mice were then subjected to homologous and heterologous prime-boost immunization strategies using VZV gE mRNA vaccine (RNA-gE) and protein subunit vaccine (PS-gE). The antigen-specific antibodies were evaluated using enzyme-linked immunosorbent assay (ELISA) analysis. Additionally, cell-mediated immunity (CMI) was detected using ELISPOT assay and flow cytometry. Besides, in vivo safety profiles were also evaluated and compared.

Results

The mRNA-loaded lipid nanoparticles had a hydrodynamic diameter of approximately 130 nm and a polydispersity index of 0.156. Total IgG antibody levels exhibited no significant differences among different immunization strategies. However, mice received 2×RNA-gE or RNA-gE>PS-gE showed a lower IgG1/IgG2c ratio than those received 2×PS-gE and PS-gE> RNA-gE. The CMI response induced by 2×RNA-gE or RNA-gE>PS-gE was significantly stronger than that induced by 2×PS-gE and PS-gE> RNA-gE. The safety evaluation indicated that both mRNA vaccine and protein vaccine induced a transient body weight loss in mice. Furthermore, the protein vaccine produced a notable inflammatory response at the injection sites, while the mRNA vaccine showed no observable inflammation.

Conclusion

The heterologous prime-boost strategy has demonstrated that an mRNA-primed immunization regimen can induce a better cell-mediated immune response than a protein subunit-primed regimen in middle-aged mice. These findings provide valuable insights into the design and optimization of VZV vaccines with the potentials to broaden varicella vaccination strategies in the future.

Impact of twelve immunization-preventable infectious diseases on population health using disability-adjusted life years (DALYs) in Spain

BACKGROUND

The objective of this study is to estimate the burden of selected immunization-preventable infectious diseases in Spain using the Burden of Communicable Diseases in Europe (BCoDE) methodology, as well as focusing on the national immunization programme and potential new inclusions.

METHODS

The BCoDE methodology relies on an incidence and pathogen-based approach to calculate disease burden via disability-adjusted life year (DALY) estimates. It considers short and long-term sequelae associated to an infection via outcome trees. The BCoDE toolkit was used to populate those trees with Spanish-specific incidence estimates, and de novo outcome trees were developed for four infections (herpes zoster, rotavirus, respiratory syncytial virus [RSV], and varicella) not covered by the toolkit. Age/sex specific incidences were estimated based on data from the Spanish Network of Epidemiological Surveillance; hospitalisation and mortality rates were collected from the Minimum Basic Data Set. A literature review was performed to design the de novo models and obtain the rest of the parameters. The methodology, assumptions, data inputs and results were validated by a group of experts in epidemiology and disease modelling, immunization and public health policy.

RESULTS

The total burden of disease amounted to 163.54 annual DALYs/100,000 population. Among the selected twelve diseases, respiratory infections represented around 90% of the total burden. Influenza exhibited the highest burden, with 110.00 DALYs/100,000 population, followed by invasive pneumococcal disease and RSV, with 25.20 and 10.57 DALYs/100,000 population, respectively. Herpes zoster, invasive meningococcal disease, invasive Haemophilus influenza infection and hepatitis B virus infection ranked lower with fewer than 10 DALYs/100,000 population each, while the rest of the infections had a limited burden (< 1 DALY/100,000 population). A higher burden of disease was observed in the elderly (≥ 60 years) and children < 5 years, with influenza being the main cause. In infants < 1 year, RSV represented the greatest burden.

CONCLUSIONS

Aligned with the BCoDE study, the results of this analysis show a persisting high burden of immunization-preventable respiratory infections in Spain and, for the first time, highlight a high number of DALYs due to RSV. These estimates provide a basis to guide prevention strategies and make public health decisions to prioritise interventions and allocate healthcare resources in Spain.

Global herpes zoster burden in adults with asthma: a systematic review and meta-analysis

BACKGROUND

Asthma is a common respiratory disease, which may be associated with an increased risk of herpes zoster (HZ), often a debilitating disease associated with severe pain. This is the first systematic review with the objective of summarising evidence on HZ burden in adults with asthma.

METHODS

A global systematic literature review and meta-analysis was conducted (MEDLINE and Embase, 2003-2024) on HZ burden (incidence, risk and complications) in adults (≥18 years) with asthma.

RESULTS

There were 19 studies included on HZ outcomes in adults with asthma. Pooled HZ incidence per 1000 person-years was 5.71 (95% CI 4.68-6.96) in adults aged ≥18 years (4.20 (95% CI 3.09-5.70) in those aged <60 years versus 10.33 (95% CI 9.17-11.64) in those aged ≥60 years). The pooled rate ratio for developing HZ was 1.23 (95% CI 1.11-1.35) in those aged ≥18 years and 1.36 (95% CI 1.15-1.61) in those aged ≥50 years. The risk of HZ was higher in people with asthma using systemic corticosteroids, long-acting β-agonists plus inhaled corticosteroids and "add-on therapy". Asthma was also associated with an increased risk of post-herpetic neuralgia (OR 1.21, 95% CI 1.06-1.37) and HZ ophthalmicus (OR 1.9, 95% CI 1.1-3.2). Differences in study design, setting, case definitions and follow-up durations led to heterogeneity.

CONCLUSIONS

This systematic literature review and meta-analysis found that adults with asthma have an increased risk of HZ, with higher risks in older age groups and in those on certain treatments, such as oral corticosteroids. HZ vaccines are available for adults, including those with comorbidities such as asthma, and can be considered as part of integrated respiratory care.

Sequence analysis of isolated strains of herpes zoster virus among patients with shingles

Background and Objectives

Herpes zoster, or shingles, is caused by the varicella-zoster virus (VZV), which initially presents as chickenpox in children. VZV is a global health concern, especially in winter and spring, affecting 10-20% of adults over 50 and posing a 30% risk for the general population. This study used PCR to detect VZV, confirming results with duplicated DNA samples and identifying 234 bp fragments by targeting the gpB gene.

Materials and Methods

This study examined 50 herpes zoster cases from October 2020 to April 2021, involving 30 males and 20 females aged 10 to 90, diagnosed by dermatologists. Data were collected via a questionnaire. PCR detected VZV by amplifying the gpB and MCP genes from skin lesion samples. Six positive 234-bp PCR products were sequenced at Macrogen Inc. in Seoul, South Korea.

Results

Six DNA samples with 234 bp amplicons were sequenced, showing 99-100% similarity to human alpha herpesvirus sequences in the gpB gene. NCBI BLAST matched these sequences to a reference (GenBank acc. MT370830.1), assigning accession numbers LC642111, LC642112, and LC642113. Eight nucleic acid substitutions caused amino acid changes in the gpB protein: isoleucine to threonine, serine to isoleucine, and threonine to Proline. These variants were deposited in NCBI GenBank as gpB3 samples.

Conclusion

The study found high sequence similarity to known VZV sequences, identifying six nucleic acid variations and eight SNPs. Notable amino acid changes in the gpB protein were deposited in NCBI GenBank as the gpB3 sample.

Association Between Coronary Artery Disease and Herpes Zoster: A Cohort Study in Taiwan

Background

Coronary artery disease (CAD) and herpes zoster represent significant health burdens, and their potential interrelationships remain understudied. This cohort study aimed to address the existing knowledge gap by systematically exploring whether people with CAD are at increased risk for developing herpes zoster.

Methods

Using the 2006-2015 claims data of the National Health Insurance Program in Taiwan, we identified participants aged ≥20 years with a new diagnosis of CAD as the CAD group. We selected sex- and age-matched participants without CAD as the non-CAD group. The incidence rate of herpes zoster at the end of follow-up was calculated. A multivariable Cox proportional hazards regression model was used to measure the hazard ratio and 95% CI for herpes zoster associated with covariables.

Results

The overall incidence rate of herpes zoster was 1.14-fold greater in the CAD group as compared with the non-CAD group (6.52 vs 5.74 per 1000 person-years; 95% CI, 1.08-1.20). After controlling for covariables, the adjusted hazard ratio of herpes zoster was 1.21 (95% CI, 1.14-1.27) for the CAD group as compared with the non-CAD group.

Conclusions

This cohort study provides valuable insights into the potential association between CAD and the risk of developing herpes zoster. The findings may have implications for preventive strategies of herpes zoster in people with CAD. Further research and collaboration with diverse groups will be critical to validate and extend our findings.

Computed Tomography-Guided Dorsal Root Ganglion Ozone Injection Combined With Pulsed Radiofrequency for Acute Herpes Zoster Neuralgia Treatment of Middle-aged and Elderly People: A Randomized, Double-blinded, Controlled Trial

OBJECTIVES

To investigate the efficacy and safety of pulsed radiofrequency of the dorsal root ganglion combined with ozone injection for treating acute herpes zoster (HZ) neuralgia in middle-aged and elderly adults.

METHODS

A total of 164 middle-aged and elderly patients with acute HZ were randomly assigned to 2 groups: the pulsed radiofrequency combined with ozone injection group (group A) and the pulsed radiofrequency group (group B). The therapeutic effects were evaluated using Numeric Rating Scale (NRS) scores and the average doses of gabapentin (mg/d) preoperatively and 1 day, 2 weeks, 4 weeks, 12 weeks, and 24 weeks postoperatively. The incidence of clinically significant postherpetic neuralgia (PHN) and complications in the 2 groups were recorded.

RESULTS

The data showed that the NRS scores and the doses of gabapentin after treatment were significantly lower when compared with the baseline values in both groups. Compared with group B, the NRS scores and the doses of postoperative gabapentin were significantly lower in group A. The incidence of PHN was significantly lower at weeks 4, 12, and 24 in group A than in group B. No adverse reactions occurred in either of the 2 groups post-treatment.

CONCLUSIONS

The results indicated that ozone injection in the dorsal root ganglion combined with pulsed radiofrequency therapy was more effective in treating acute HZ neuralgia in middle-aged and elderly adults. It provides patients with longer-lasting pain relief, decreased incidence of PHN and the doses of medication, and improved quality of life than with Pulsed Radiofrequency treatment.

Development of a Prediction Model and Corresponding Scoring Table for Postherpetic Neuralgia Using Six Machine Learning Algorithms: A Retrospective Study

INTRODUCTION

Postherpetic neuralgia (PHN), a complication of herpes zoster, significantly impacts the quality of life of affected patients. Research indicates that early intervention for pain can reduce the occurrence or severity of PHN. This study aims to develop a predictive model and scoring table to identify patients at risk of developing PHN following acute herpetic neuralgia, facilitating informed clinical decision-making.

METHODS

We conducted a retrospective review of 524 hospitalized patients with herpes zoster at The First Affiliated Hospital of Zhejiang Chinese Medical University from December 2020 to December 2023 and classified them according to whether they had PHN, collecting a comprehensive set of 30 patient characteristics and disease-related indicators, 5 comorbidity indicators, 2 disease score values, and 10 serological indicators. Relevant features associated with PHN were identified using the least absolute shrinkage and selection operator (LASSO). Then, the patients were divided into a training set and a test set in a 4:1 ratio, with comparability tested using univariate analysis. Six models were established in the training set using machine learning methods: support vector machines, logistic regression, random forest, k-nearest neighbor, gradient boosting, and neural network. The performance of these models was evaluated in the test set, and a nomogram based on logistic regression was used to create a PHN prediction score table.

RESULTS

Eight non-zero characteristic variables selected from the LASSO regression results were included in the model, including age [area under the curve (AUC) = 0.812, p < 0.001], Numerical Rating Scale (NRS) (AUC = 0.792, p < 0.001), receiving treatment time (AUC = 0.612, p < 0.001), rash recovery time (AUC = 0.680, p < 0.001), history of malignant tumor (AUC = 0.539, p < 0.001), history of diabetes (AUC = 0.638, p < 0.001), varicella-zoster virus immunoglobulin M (AUC = 0.620, p < 0.001), and serum nerve-specific enolase (AUC = 0.659, p < 0,001). The gradient boosting model outperformed other classifier models on the test set with an AUC of 0.931, 95% confidence interval (CI) (0.882-0.980), accuracy of 0.886 (95% CI 0.809-0.940). In the test set, our predictive scoring table achieved an AUC of 0.820 (95% CI 0.869-0.970) with accuracy of 0.790 (95% CI 0.700-0.864).

CONCLUSION

This study presents a methodology for predicting the development of postherpetic neuralgia in shingles patients by analyzing historical case data, employing various machine learning techniques, and selecting the optimal model through comparative analysis. In addition, a logistic regression model has been used to create a scoring table for predicting the postherpetic neuralgia.

Increased Risk of Herpes Zoster Infection in Patients with Celiac Disease 50 Years Old and Older

BACKGROUND

Celiac Disease (CD) is associated with increased susceptibility to certain bacterial and viral infections. Herpes zoster (HZ) is a viral infection that can be prevented by immunization. In the US, the vaccine is recommended for adults ≥ 50 or ≥ 19 with certain at-risk conditions, not including CD.

AIMS

We aimed to determine if adult patients aged < 50 or ≥ 50 years with CD had a higher risk of developing HZ.

METHODS

We designed a retrospective cohort study. CD was defined as patients with the ICD-10 code for CD and positive Celiac serology. Patients with negative serology and lacking CD ICD-10 codes served as controls. Patients who had HZ before CD diagnosis were excluded. We formed two sub-cohorts, those aged < 50 (cohort 1) and aged ≥ 50 years (cohort 2), and evaluated HZ infection at 10-year follow-up. To account for confounding variables, we performed 1:1 propensity score matching (PSM).

RESULTS

Following PSM, cohort 1 had 6,826 CD patients, and cohort 2 had 5,337 CD patients and respective matched controls. After ten years of follow-up, in cohort 1, 62 CD patients developed HZ versus 57 controls, RR: 1.09 (CI: 0.76-1.56, p-value = 0.64). In cohort 2, 200 CD patients developed HZ versus 159 controls, RR: 1.2 (CI: 1.02-1.54, p-value = 0.03).

CONCLUSION

There was no significant difference in the likelihood of getting HZ in CD patients < 50, although CD patients ≥ 50 had a modestly increased risk. Our findings do not support routine early vaccination for HZ in CD, and the vaccine should be offered at age 50.

Cost-Effectiveness Analysis of Herpes Zoster Vaccination in a Chinese Population: Recombinant Subunit Vaccine versus Live Attenuated Vaccine

BACKGROUND

Currently, the recombinant subunit vaccine and live attenuated vaccine in the prevention of herpes zoster are approved for marketing in China. This study aims to evaluate the cost-effectiveness of the recombinant subunit vaccine and the live attenuated vaccine in the Chinese population.

METHODS

A decision tree-Markov analysis model was utilized to estimate expected costs and quality-adjusted life years (QALYs), comparing the lifetime cost-effectiveness of vaccination with the recombinant subunit vaccine (London, United Kingdom, Shingrix, GSK) to that of the live attenuated vaccine (Changchun, China, Ganwei, Changchun Bcht) in the Chinese population, with the primary outcome measure being the incremental cost-effectiveness ratio (ICER).

RESULTS

In the base-case analysis, the ICERs for the recombinant subunit vaccine ranged by age from USD 3428 to USD 5743 per QALY, while the ICERs for the live attenuated vaccine ranged from USD 4017 to USD 18,254 per QALY, compared with no vaccination. Among all age groups, the category of 60 to 69 years was the optimal age for vaccination. The results were most sensitive to changes in herpes zoster incidence, vaccine efficacy, and discount rate. Even with a two-dose compliance rate of 20% for the recombinant subunit vaccine, vaccination remained cost-effective. ZVL would need to reduce costs by at least 12.2% compared to RZV to have a cost-effectiveness advantage.

CONCLUSIONS

The recombinant subunit vaccine and the live attenuated vaccine were both cost-effective in the Chinese population, but, relatively, the recombinant subunit vaccine had a greater advantage in disease prevention and cost-effectiveness in all age groups above 50 years.

Turning the Tide against Herpes Zoster in Rheumatoid Arthritis Patients Treated with JAK Inhibitors

Objectives: This study aimed to evaluate the incidence of Herpes Zoster (HZ) in patients with rheumatoid arthritis (RA) treated with Janus kinase inhibitors (JAKi), and to predict potential risk factors for HZ development. Methods: We retrospectively analysed medical records from RA patients at our rheumatology unit who met the 2010 ACR/EULAR criteria for RA and were receiving JAKi. The incidence and course of HZ were assessed through chart review and supplementary phone interviews. Results: A total of 198 JAKi-treated patients were monitored for an average of 18.5 months. Nine subjects experienced HZ, resulting in an incidence of 2.95 per 100 patient-years. No demographic or treatment-related differences were found among patients who developed HZ and those who did not. Disease duration (OR: 1.06, 95% CI: 1.01-1.12), time on JAKi treatment (OR: 1.04, 95% CI: 1.009-1.073), higher disease activity at JAKi initiation (OR: 4.16, 95% CI: 1.07-16.17), and at 3-month follow-up (OR: 6.0, 95% CI: 1.35-26.60) were identified as predictors of HZ occurrence. Thirty-six patients received vaccination against HZ, and none reported adverse reactions or flare-ups during a mean follow-up of 9.6 months. Conclusions: The incidence of HZ aligns with published data, suggesting that disease and treatment duration, as well as disease activity, are significant predictors of HZ in RA patients on JAKi therapy. Vaccination against HZ proved to be safe and effective, underscoring its potential protective value in this patient population.

Herpes Zoster and Post-Herpetic Neuralgia-Diagnosis, Treatment, and Vaccination Strategies

INTRODUCTION

Herpes zoster is caused by the reactivation of latent varicella infection within the sensory ganglia, caused by the varicella-zoster virus (VZV). The disease is classically characterized by a painful unilateral vesicular eruption. Complications of the disease include herpes zoster ophthalmicus, Ramsay Hunt syndrome, acute retinal necrosis, and post-herpetic neuralgia. In this paper, we discuss the epidemiology, pathogenesis, clinical features, diagnosis, management, and vaccination strategies of herpes zoster and post-herpetic neuralgia.

METHOD

This paper was developed with input from specialists from Singapore's public sectors-dermatologists, family physicians, and infectious diseases specialists.

RESULTS

The diagnosis of herpes zoster is clinical and can be aided with laboratory investigations. Early initiation of antivirals, within 72 h of onset, can reduce the severity and duration of the condition and decrease the intensity of pain. In patients with a high risk of post-herpetic neuralgia, early initiation of anticonvulsants or tricyclic antidepressants can be considered. Herpes zoster is highly preventable, with the advent of the recombinant zoster vaccine (RZV) providing an overall vaccine efficacy of 97.2%. Procedures such as epidural blocks and subcutaneous or intracutaneous injections of local anesthetics and steroids can be considered for patients with a high risk of post-herpetic neuralgia to reduce its incidence.

CONCLUSION

This article serves as a guideline for clinicians in the diagnosis, investigations, management, and prevention of herpes zoster. With the majority of adults in Singapore currently at risk of developing herpes zoster due to varicella immunization being only introduced in 2020, it is important for clinicians to recognize and manage herpes zoster appropriately.

A case of herpes zoster secondary to monkeypox in a young man

A 19-year-old young man presented with prodromal symptoms including fever and sore throat, followed by the development of scattered rashes in the perianal and penile regions. Monkeypox (MPX) was confirmed using polymerase chain reaction (PCR) of lesions. On the third day after complete resolution of the initial rash, the patient developed a new rash, which was diagnosed as secondary herpes zoster (HZ). Therefore, clinicians should not only focus on the accurate diagnosis of monkeypox, but also be alert to secondary herpes zoster.

Enantioselective Synthesis of β-l-5-[(E)-2-Bromovinyl)-1-((2S,4S)-2-(hydroxymethyl)-1,3-(dioxolane-4-yl) Uracil)] (l-BHDU) via Chiral Pure l-Dioxolane

β-l-5-((E)-2-Bromovinyl)-1-((2S,4S)-2-(hydroxymethyl)-1,3-(dioxolane-4-yl) uracil (l-BHDU, 17) is a potent and selective inhibitor of the varicella-zoster virus (VZV). l-BHDU (17) has demonstrated excellent anti-VZV activity and is a preclinical candidate to treat chickenpox, shingles (herpes zoster), and herpes simplex virus 1 (HSV-1) infections. Its monophosphate prodrug (POM-l-BHDU-MP, 24) demonstrated an enhanced pharmacokinetic and antiviral profile. POM-l-BHDU-MP (24), in vivo, effectively reduced the VZV viral load and was effective for the topical treatment of VZV and HSV-1 infections. Therefore, a viable synthetic procedure for developing POM-l-BHDU-MP (24) is needed. In this article, an efficient approach for the synthesis of l-BHDU (17) from a readily available starting material is described in 7 steps. An efficient and practical methodology for both chiral pure l- & d-dioxolane 11 and 13 were developed via diastereomeric chiral amine salt formation. Neutralization of the amine carboxylate salt of l-dioxolane 10 provides enantiomerically pure l-dioxane 11 (ee ≥ 99%). Optically pure 11 was utilized to construct the final nucleoside l-BHDU (17) and its monophosphate ester prodrug (POM-l-BHDU-MP, 24). Notably, the reported process eliminates expensive chiral chromatography for the synthesis of chiral pure l- & d-dioxolane, which offers avenues for the development and structure-activity relationship studies of l- & d-dioxolane-derived nucleosides.

Bone morphogenetic protein 4 derived from the cerebrospinal fluid in patients with postherpetic neuralgia induces allodynia via the crosstalk between microglia and astrocyte

INTRODUCTION

During postherpetic neuralgia (PHN), the cerebral spinal fluid (CSF) possesses the capability to trigger glial activation and inflammation, yet the specific changes in its composition remain unclear. Recent findings from our research indicate elevations of central bone morphogenetic protein 4 (BMP4) during neuropathic pain (NP), serving as an independent modulator of glial cells. Herein, the aim of the present study is to test the CSF-BMP4 expressions and its role in the glial modulation in the process of PHN.

METHODS

CSF samples were collected from both PHN patients and non-painful individuals (Control) to assess BMP4 and its antagonist Noggin levels. Besides, intrathecal administration of both CSF types was conducted in normal rats to evaluate the impact on pain behavior, glial activity, and inflammation.; Additionally, both Noggin and STAT3 antagonist-Stattic were employed to treat the PHN-CSF or exogenous BMP4 challenged cultured astrocytes to explore downstream signals. Finally, microglial depletion was performed prior to the PHN-CSF intervention so as to elucidate the microglia-astrocyte crosstalk.

RESULTS

BMP4 levels were significantly higher in PHN-CSF compared to Control-CSF (P < 0.001), with a positive correlation with pain duration (P < 0.05, r = 0.502). Comparing with the Control-CSF producing moderate paw withdrawal threshold (PWT) decline and microglial activation, PHN-CSF further exacerbated allodynia and triggered both microglial and astrocytic activation (P < 0.05). Moreover, PHN-CSF rather than Control-CSF evoked microglial proliferation and pro-inflammatory transformation, reinforced iron storage, and activated astrocytes possibly through both SMAD159 and STAT3 signaling, which were all mitigated by the Noggin application (P < 0.05). Next, both Noggin and Stattic effectively attenuated BMP4-induced GFAP and IL-6 upregulation, as well as SMAD159 and STAT3 phosphorylation in the cultured astrocytes (P < 0.05). Finally, microglial depletion diminished PHN-CSF induced astrogliosis, inflammation and endogenous BMP4 expression (P < 0.05).

CONCLUSION

Our study highlights the role of CSF-BMP4 elevation in glial activation and allodynia during PHN, suggesting a potential therapeutic avenue for future exploration.