1
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Dadwal SS, Papanicolaou GA, Boeckh M. How I prevent viral reactivation in high-risk patients. Blood 2023; 141:2062-2074. [PMID: 36493341 PMCID: PMC10163320 DOI: 10.1182/blood.2021014676] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/10/2022] [Accepted: 11/22/2022] [Indexed: 12/14/2022] Open
Abstract
Preventing viral infections at an early stage is a key strategy for successfully improving transplant outcomes. Preemptive therapy and prophylaxis with antiviral agents have been successfully used to prevent clinically significant viral infections in hematopoietic cell transplant recipients. Major progress has been made over the past decades in preventing viral infections through a better understanding of the biology and risk factors, as well as the introduction of novel antiviral agents and advances in immunotherapy. High-quality evidence exists for the effective prevention of herpes simplex virus, varicella-zoster virus, and cytomegalovirus infection and disease. Few data are available on the effective prevention of human herpesvirus 6, Epstein-Barr virus, adenovirus, and BK virus infections. To highlight the spectrum of clinical practice, here we review high-risk situations that we handle with a high degree of uniformity and cases that feature differences in approaches, reflecting distinct hematopoietic cell transplant practices, such as ex vivo T-cell depletion.
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Affiliation(s)
- Sanjeet S. Dadwal
- Division of Infectious Disease, Department of Medicine, City of Hope National Medical Center, Duarte, CA
| | - Genovefa A. Papanicolaou
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, Cornell University, New York, NY
| | - Michael Boeckh
- Vaccine and Infectious and Clinical Research Divisions, Fred Hutchinson Cancer Center, Seattle, WA
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA
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2
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Delgado A, Guddati AK. Infections in Hospitalized Cancer Patients. World J Oncol 2022; 12:195-205. [PMID: 35059079 PMCID: PMC8734501 DOI: 10.14740/wjon1410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/01/2021] [Indexed: 11/11/2022] Open
Abstract
Cancer patients are at an increased risk of developing infections that are primarily treatment-driven but may also be malignancy-driven. While cancer treatments such as chemotherapy, radiotherapy, and surgery have been known to improve malignancy morbidity and mortality, they also have the potential to weaken immune defenses and induce periods of severe cytopenia. These adverse effects pave the way for opportunistic infections to complicate a hospitalized cancer patient's clinical course. Understanding the risk each patient inherently has for developing a bacterial, fungal, or viral infection is critical to choosing the correct prophylactic treatment in conjunction with their scheduled cancer therapy. This review discusses the most common types of infections found in hospitalized cancer patients as well as the current guidelines for prophylactic and antimicrobial treatment in cancer patients. In addition, it describes the interaction between antibiotics and cancer therapies for consideration when treating infection in a cancer patient.
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Affiliation(s)
- Amanda Delgado
- Division of Hematology/Oncology, Georgia Cancer Center, Augusta University, Augusta, GA 30912, USA
| | - Achuta Kumar Guddati
- Division of Hematology/Oncology, Georgia Cancer Center, Augusta University, Augusta, GA 30912, USA
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3
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Bastard P, Galerne A, Lefevre-Utile A, Briand C, Baruchel A, Durand P, Landman-Parker J, Gouache E, Boddaert N, Moshous D, Gaudelus J, Cohen R, Deschenes G, Fischer A, Blanche S, de Pontual L, Neven B. Different Clinical Presentations and Outcomes of Disseminated Varicella in Children With Primary and Acquired Immunodeficiencies. Front Immunol 2021; 11:595478. [PMID: 33250898 PMCID: PMC7674974 DOI: 10.3389/fimmu.2020.595478] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 10/09/2020] [Indexed: 11/13/2022] Open
Abstract
Primary infection with varicella-zoster virus (VZV) causes chickenpox, a benign and self-limited disease in healthy children. In patients with primary or acquired immunodeficiencies, primary infection can be life-threatening, due to rapid dissemination of the virus to various organs [lung, gastrointestinal tract, liver, eye, central nervous system (CNS)]. We retrospectively described and compared the clinical presentations and outcomes of disseminated varicella infection (DV) in patients with acquired (AID) (n= 7) and primary (PID) (n= 12) immunodeficiencies. Patients with AID were on immunosuppression (mostly steroids) for nephrotic syndrome, solid organ transplantation or the treatment of hemopathies, whereas those with PID had combined immunodeficiency (CID) or severe CID (SCID). The course of the disease was severe and fulminant in patients with AID, with multiple organ failure, no rash or a delayed rash, whereas patients with CID and SICD presented typical signs of chickenpox, including a rash, with dissemination to other organs, including the lungs and CNS. In the PID group, antiviral treatment was prolonged until immune reconstitution after bone marrow transplantation, which was performed in 10/12 patients. Four patients died, and three experienced neurological sequelae. SCID patients had the worst outcome. Our findings highlight substantial differences in the clinical presentation and course of DV between children with AID and PID, suggesting differences in pathophysiology. Prevention, early diagnosis and treatment are required to improve outcome.
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Affiliation(s)
- Paul Bastard
- Service de Pédiatrie, Hôpital Jean Verdier, Bondy, AP-HP (Assistance-Publique-Hôpitaux de Paris), France.,Service d'Immunologie et Hématologie Pédiatrique, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Aurélien Galerne
- Service de Pédiatrie, Hôpital Jean Verdier, Bondy, AP-HP (Assistance-Publique-Hôpitaux de Paris), France
| | - Alain Lefevre-Utile
- Service de Pédiatrie, Hôpital Jean Verdier, Bondy, AP-HP (Assistance-Publique-Hôpitaux de Paris), France.,INSERM U976-Human Systems Immunology and Inflammatory Networks, Institut de Recherche de Saint Louis, Paris, France.,Université de Paris, Paris, France
| | - Coralie Briand
- Service de Pédiatrie, Hôpital Jean Verdier, Bondy, AP-HP (Assistance-Publique-Hôpitaux de Paris), France
| | - André Baruchel
- Université de Paris, Paris, France.,Département d'Hématologie Pédiatrique, Hôpital Robert-Debré, AP-HP, Paris, France
| | - Philippe Durand
- Service de Réanimation Pédiatrique, Hôpital du Kremlin-Bicêtre, Kremlin-Bicêtre, France.,Université Paris XI, AP-HP, Paris.,Université Paris Saclay, Saint-Aubin, France
| | - Judith Landman-Parker
- Sorbonne Université, Service de d'Hématologie Oncologie Pédiatrique, Hôpital Armand Trousseau, AP-HP, Paris, France
| | - Elodie Gouache
- Sorbonne Université, Service de d'Hématologie Oncologie Pédiatrique, Hôpital Armand Trousseau, AP-HP, Paris, France
| | - Nathalie Boddaert
- Université de Paris, Paris, France.,Service de Radiologie Pédiatrique, Hôpital Necker Enfants Malades, AP-HP, Université de Paris, Paris, France.,INSERM U1163, Institut IMAGINE, Paris, France
| | - Despina Moshous
- Service d'Immunologie et Hématologie Pédiatrique, Hôpital Necker Enfants Malades, AP-HP, Paris, France.,Université de Paris, Paris, France.,INSERM U1163, Institut IMAGINE, Paris, France
| | - Joel Gaudelus
- Service de Pédiatrie, Hôpital Jean Verdier, Bondy, AP-HP (Assistance-Publique-Hôpitaux de Paris), France.,Sorbonne Paris Nord University, Bobigny, France
| | - Robert Cohen
- ACTIV Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Georges Deschenes
- Service de Néphrologie Pédiatrique, Hôpital Robert-Debré, AP-HP, Paris, France
| | - Alain Fischer
- Service d'Immunologie et Hématologie Pédiatrique, Hôpital Necker Enfants Malades, AP-HP, Paris, France.,Université de Paris, Paris, France.,INSERM U1163, Institut IMAGINE, Paris, France.,Experimental Medicine, Collège de France, Paris, France
| | - Stéphane Blanche
- Service d'Immunologie et Hématologie Pédiatrique, Hôpital Necker Enfants Malades, AP-HP, Paris, France.,Université de Paris, Paris, France
| | - Loïc de Pontual
- Service de Pédiatrie, Hôpital Jean Verdier, Bondy, AP-HP (Assistance-Publique-Hôpitaux de Paris), France.,Sorbonne Paris Nord University, Bobigny, France
| | - Bénédicte Neven
- Service d'Immunologie et Hématologie Pédiatrique, Hôpital Necker Enfants Malades, AP-HP, Paris, France.,Université de Paris, Paris, France.,INSERM U1163, Institut IMAGINE, Paris, France
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4
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Clinicopathologic Features of Varicella Zoster Virus Infection of the Upper Gastrointestinal Tract. Am J Surg Pathol 2021; 45:209-214. [PMID: 32826528 DOI: 10.1097/pas.0000000000001576] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Reactivation of latent varicella zoster virus (VZV) may be limited to a dermatome or involve multiple organs, including the gastrointestinal tract. Although gastrointestinal manifestations of disseminated zoster have been likened to those of herpes simplex virus (HSV), histologic features of VZV-related injury to the tubular gut are not well-documented. We performed this study to describe the clinicopathologic features of VZV-related gastrointestinal injury. We identified 6 such patients with VZV infection. All involved the upper gastrointestinal tract, affecting the esophagus (n=3), stomach (n=2), or both (n=1). All patients were immunocompromised adults with hematologic malignancies (n=5) or a heart transplant (n=1); 3 with hematologic malignancies had received stem cell transplants. Five patients had cutaneous and gastrointestinal zoster; 1 had gastrointestinal disease alone. When compared with 14 HSV-related esophagitis controls, there were several notable differences. VZV caused hemorrhagic ulcers with nodularity or erythema, whereas HSV produced round, shallow ulcers on a background of nearly normal mucosa (P=0.01). VZV-related ulcers featured fibrin-rich, pauci-inflammatory exudates compared with the macrophage-rich exudates of HSV (P=0.003). The cytopathic changes of VZV were present at all levels of the squamous epithelium, especially in a peripapillary distribution. In contrast, HSV inclusions were located in the superficial layers (P=0.003) and detached keratinocytes. Unlike HSV, VZV involved the stomach, producing hemorrhage accompanied by striking apoptosis in the deep glands. We conclude that VZV produces unique patterns of gastrointestinal injury that facilitate its diagnosis. Recognition of gastrointestinal VZV infection is important because it heralds potentially life-threatening disseminated disease.
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5
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Vassia V, Croce A, Ravanini P, Leutner M, Saglietti C, Fangazio S, Quaglia M, Smirne C. Unusual presentation of fatal disseminated varicella zoster virus infection in a patient with lupus nephritis: a case report. BMC Infect Dis 2020; 20:538. [PMID: 32703300 PMCID: PMC7376941 DOI: 10.1186/s12879-020-05254-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 07/14/2020] [Indexed: 11/26/2022] Open
Abstract
Background The risk of life-threatening complications, such as visceral disseminated varicella zoster virus (VZV) infection, is greater in immunosuppressed individuals, such as systemic lupus erythematosus (SLE) patients. Case presentation Here, a case is reported of a Caucasian woman diagnosed with lupus nephritis and anti-phospholipid syndrome, who was subjected to mycophenolate mofetil and high-dose steroid remission-induction therapy. Two months later she developed abdominal pain followed by a fatal rapid multi-organ failure. As no typical skin rashes were evident, death was initially attributed to catastrophic anti-phospholipid syndrome. However, autopsy and virological examinations on archival material revealed a disseminated VZV infection. Conclusions Overall, this case highlights the importance of having a high clinical suspicion of fatal VZV infections in heavily immunosuppressed SLE patients even when typical signs and symptoms are lacking.
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Affiliation(s)
- Veronica Vassia
- Department of Translational Medicine, DiMet, Università del Piemonte Orientale, via Solaroli 17, 28100, Novara, Italy
| | - Alessandro Croce
- Department of Translational Medicine, DiMet, Università del Piemonte Orientale, via Solaroli 17, 28100, Novara, Italy
| | - Paolo Ravanini
- Laboratory of Molecular Virology, AOU Maggiore della Carità, Novara, Italy
| | - Monica Leutner
- Histopathology Unit, AOU Maggiore della Carità, Novara, Italy
| | | | - Stefano Fangazio
- Department of Translational Medicine, DiMet, Università del Piemonte Orientale, via Solaroli 17, 28100, Novara, Italy
| | - Marco Quaglia
- Department of Translational Medicine, DiMet, Università del Piemonte Orientale, via Solaroli 17, 28100, Novara, Italy
| | - Carlo Smirne
- Department of Translational Medicine, DiMet, Università del Piemonte Orientale, via Solaroli 17, 28100, Novara, Italy.
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6
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Ohmoto A, Fuji S. Infection profiles of different chemotherapy regimens and the clinical feasibility of antimicrobial prophylaxis in patients with DLBCL. Blood Rev 2020; 46:100738. [PMID: 32747325 DOI: 10.1016/j.blre.2020.100738] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 06/18/2020] [Accepted: 07/14/2020] [Indexed: 12/23/2022]
Abstract
Various chemotherapy regimens are used to treat patients with diffuse large B-cell lymphoma (DLBCL). However, treatment-related toxicity with a focus on infectious disease has not been fully reviewed. Several phase 3 trials have demonstrated different rates of febrile neutropenia (FN) between regimens (e.g. dose-adjusted (DA) EPOCH-R vs. R-CHOP). With heterogeneous patient characteristics, a combination regimen of lenalidomide or ibrutinib with R-CHOP exhibited promising efficacy with moderate infectious toxicity. While R-bendamustine is feasible for patients who don't tolerate other forms of chemotherapy, clinical data indicate increased opportunistic infections under prolonged lymphopenia. The usefulness of prophylactic antibiotics/antifungal agents in DLBCL patients is controversial owing to shorter and less severe neutropenia than with the induction regimen for acute leukemia or hematopoietic stem-cell transplantation. Prophylactic granulocyte-colony stimulating factor is recommended for intensive regimens such as DA-EPOCH-R, R-DHAP, or R-ICE. Regardless of multiple studies about FN incidence, studies focusing on microbiologic events are limited, and further investigations are warranted.
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Affiliation(s)
- Akihiro Ohmoto
- Division of Medical Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 1358550, Japan
| | - Shigeo Fuji
- Department of Hematology, Osaka International Cancer Institute, Osaka 5418567, Japan.
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7
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Toffaha A, El Ansari W, Ramzee AF, Afana M, Aljohary H. Rare presentation of primary varicella zoster as fatal fulminant hepatitis in adult on low-dose,short-term steroid: Case report. Ann Med Surg (Lond) 2019; 48:115-117. [PMID: 31763037 PMCID: PMC6864176 DOI: 10.1016/j.amsu.2019.10.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 10/31/2019] [Indexed: 12/27/2022] Open
Abstract
Background Varicella zoster virus presents clinically as primary (chickenpox) or secondary (herpes zoster) infection. Cutaneous and extracutaneous dissemination may occur, usually in immunocompromised patients. VZV hepatitis that progresses to fulminant hepatic failure is very rare and fatal. To the best of our knowledge, 9 cases have been reported to date, of which 7 were in immunocompromised adults, and only one patient was on short duration steroid therapy. Presentation of case We present a 26-year old man who was admitted initially with acute abdomen as query persistent biliary colic. Later, he showed clinical and laboratory findings of VZV hepatitis that progressed rapidly despite maximal medical ICU support and he expired on day 3 of admission. Conclusions Acute VZV infection may present as fulminant hepatitis. The presentation may initially be challenging for the diagnosis and should be considered if the patient has been in contact with a sick case. Low dose corticosteroid could carry a risk for fatal VZV fulminant hepatitis and should be used very cautiously especially with VZV patients' contacts. Further causative relationships remain to be established.
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Affiliation(s)
- Ali Toffaha
- Department of General Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Walid El Ansari
- Department of Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,College of Medicine, Qatar University, Doha, Qatar.,School of Health and Education, University of Skövde, Skövde, Sweden
| | - A F Ramzee
- Department of General Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Mohammad Afana
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Hesham Aljohary
- Department of General Surgery, Hamad Medical Corporation, Doha, Qatar
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8
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Jariwala R, Zeitler K, Riddle ND, Sriaroon C. Multi-organ involvement secondary to varicella zoster virus, herpes simplex virus and cytomegalovirus in an immunocompromised patient. BMJ Case Rep 2019; 12:12/3/e228150. [PMID: 30936341 DOI: 10.1136/bcr-2018-228150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
The use of immunosuppressing agents can act as a catalyst for viral reactivation, promoting systemic infection with organ involvement. Current literature remains sparse on this topic but does provide individual case reports involving single viruses. We present the case of an immunocompromised patient with skin lesions, pancreatitis, colitis and hepatitis. Work-up revealed varicella zoster virus, which likely put the patient at risk for multi-organ involvement, as well as clinical suspicion of other implicated viruses, specifically herpes simplex virus and cytomegalovirus. A high clinical index of suspicion along with biopsy guidance for viral involvement in immunocompromised patients is crucial for early diagnosis and treatment of these conditions.
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Affiliation(s)
- Ripal Jariwala
- Department of Pharmacy, Tampa General Hospital, Tampa, Florida, USA
| | - Kristen Zeitler
- Department of Pharmacy, Tampa General Hospital, Tampa, Florida, USA
| | - Nicole D Riddle
- USF Pathology, Ruffolo, Hooper and Associates, Tampa, Florida, USA
| | - Chakrapol Sriaroon
- Division of Pulmonaryand Critical Care Medicine, University of South Florida, Tampa, Florida, USA
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9
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Mishra AK, Sahu KK, James A. Disseminated herpes zoster following treatment with benralizumab. CLINICAL RESPIRATORY JOURNAL 2019; 13:189-191. [PMID: 30666793 DOI: 10.1111/crj.12998] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 12/29/2018] [Accepted: 01/12/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Disseminated herpes zoster infection occurs mostly in immunocompromised hosts. There have been recent reports of disseminated zoster with chemotherapeutic regimens and newer monoclonal antibodies. CASE REPORT The present case describes a 61-year-old patient presenting with disseminated herpes zoster after initiation of benralizumab, an anti-IL-5 monoclonal antibody for severe persistent asthma. His initial vesicular lesions limited to left lumbar dermatomes progressed extensively resulting in dissemination on his body. The diagnosis was confirmed with PCR and he had remarkable clinical improvement with acyclovir and supportive medical management. CONCLUSION Clinical trials have reported an association of mepolizumab, another anti-IL-5 monoclonal antibody with herpes zoster. This report of herpes zoster following initiation of benralizumab might suggest a possibility of a class effect of anti-IL-5 monoclonal antibody.
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Affiliation(s)
- Ajay Kumar Mishra
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts
| | - Kamal Kant Sahu
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts
| | - Atem James
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts
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10
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Oh J, Jeon Y, Jo D. Disseminated herpes zoster involving bladder and severe inappropriate antidiuretic hormone in a immunocompetent elderly patient - A case report -. Anesth Pain Med (Seoul) 2018. [DOI: 10.17085/apm.2018.13.1.98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jinyoung Oh
- Department of Anesthesiology and Pain Medicine, The Catholic University of Korea, Daejeon St. Mary's Hospital, Daejeon, Korea
| | - Younggyung Jeon
- Department of Anesthesiology and Pain Medicine, The Catholic University of Korea, Daejeon St. Mary's Hospital, Daejeon, Korea
| | - Daehyun Jo
- Department of Anesthesiology and Pain Medicine, The Catholic University of Korea, Daejeon St. Mary's Hospital, Daejeon, Korea
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11
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Picod A, Corre E, Maury E, Duriez P, Hoyeau N, Coppo P. Acute pancreatitis in immunocompromised patients: beware of varicella zoster virus primo-infection. Clin Case Rep 2017; 5:1261-1263. [PMID: 28781838 PMCID: PMC5538212 DOI: 10.1002/ccr3.1053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 05/21/2017] [Accepted: 05/26/2017] [Indexed: 11/13/2022] Open
Abstract
Varicella zoster virus (VZV) primo‐infection can be severe in the elderly and in immunocompromised patients. Atypical presentations are not uncommon and may mislead the diagnosis and delay adequate treatment. Valacyclovir prophylaxis should be systematically proposed in immunocompromised patients.
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Affiliation(s)
- Adrien Picod
- Service d'HématologieGroupe Hospitalier Paris‐EstHôpital Saint‐AntoineParisFrance
| | - Elise Corre
- Service d'HématologieGroupe Hospitalier Paris‐EstHôpital Saint‐AntoineParisFrance
| | - Eric Maury
- Service de Réanimation polyvalenteGroupe Hospitalier Paris‐EstHôpital Saint‐AntoineParisFrance
- Université Pierre et Marie Curie (UPMC)Univ Paris 6ParisFrance
| | - Paul Duriez
- Service d'Anatomie et cytologie pathologiqueGroupe Hospitalier Paris‐EstHôpital Saint‐AntoineParisFrance
| | - Nadia Hoyeau
- Service d'Anatomie et cytologie pathologiqueGroupe Hospitalier Paris‐EstHôpital Saint‐AntoineParisFrance
| | - Paul Coppo
- Service d'HématologieGroupe Hospitalier Paris‐EstHôpital Saint‐AntoineParisFrance
- Université Pierre et Marie Curie (UPMC)Univ Paris 6ParisFrance
- Centre de références des Microangiopathies thrombotiquesGroupe Hospitalier Paris‐EstHôpital Saint‐AntoineParisFrance
- Inserm U1170Institut Gustave RoussyVillejuifFrance
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