Herpes Zoster

The Incidence of Herpes Zoster Complications: A Systematic Literature Review

INTRODUCTION

The objective of this work was to summarize the incidence of herpes zoster (HZ) complications in different populations.

METHODS

Systematic literature review of PubMed, Embase, and Virtual Health Library records between January 1, 2002 and October 20, 2022 using search strings for HZ, complications, and frequency measurements.

RESULTS

The review included 124 studies, most conducted in the general population (n = 93) and on individuals with comorbidities (n = 41) ≥ 18 years of age. Most studies were conducted in Europe (n = 44), Asia (n = 40), and North America (n = 36). Postherpetic neuralgia (PHN) was the most studied neurological complication. Variable relative PHN incidence was found in the general population (2.6-46.7%) or based on diagnosis: immunocompromised (3.9-33.8%), depression (0-50%), and human immunodeficiency virus (HIV) (6.1-40.2%). High incidence rates were observed in hematological malignancies (HM) and solid organ malignancies (132.5 and 93.7 per 1000 person-years, respectively). Ocular complications were frequently reported with herpes zoster ophthalmicus (HZO). The relative incidence (incidence rate) of HZO in the general population was reported as 1.4-15.9% (0.31-0.35 per 1000 person-years). High relative incidence was observed in HIV (up to 10.1%) and HM (3.2-11.3%). Disseminated HZ was the most frequently reported cutaneous complication. The relative incidence of disseminated HZ was 0.3-8.2% in the general population, 0-0.5% in the immunocompetent, and 0-20.6% in patients with comorbidities. High relative incidence was reported in HM and solid organ transplant (up to 19.3% and 14.8%, respectively).

DISCUSSION

Most reported complications were neurological (n = 110), ocular (n = 48), and cutaneous (n = 38). Few studies stratified complications by age or gender (or both). Incidence appeared higher in select immunocompromised populations. Higher incidence was associated with older age in several studies; the general association with gender was unclear.

CONCLUSIONS

Variable incidence of HZ complications was reported by population subgroup. Further research is required to quantitatively analyze incidence by age, gender, and location.

Associations between Different Antivirals and Hospital-Acquired Acute Kidney Injury in Adults with Herpes Zoster

Key Points

Among intravenous antivirals, acyclovir was associated with the highest risk of hospital-acquired AKI, followed by penciclovir/ganciclovir and foscarnet. The risk of hospital-acquired AKI was dose dependent for intravenous nucleoside analogs.

Background

To examine the association of use of different antivirals with hospital-acquired AKI among Chinese adults with herpes zoster.

Methods

This study selected 3273 adult patients who received antiviral therapy for herpes zoster during hospitalization from the China Renal Data System. We identified and staged AKI using patient-level serum creatinine data according to the Kidney Disease Improving Global Outcomes criteria. We compared the relative risks of hospital-acquired AKI among patients treated with different antivirals using Cox proportional hazards models.

Results

Among 3273 patients, 1480 (45%), 681 (21%), 489 (15%), and 623 (19%) were treated with acyclovir/valacyclovir, ganciclovir, penciclovir/famciclovir, and foscarnet, respectively. During the follow-up period, a total of 111 cases of hospital-acquired AKI occurred, predominantly classified as AKI stage 1. The cumulative incidences of hospital-acquired AKI were 5%, 3%, 3%, and 1% in the patients receiving acyclovir/valacyclovir, ganciclovir, penciclovir/famciclovir, and foscarnet, respectively. Compared with acyclovir/valacyclovir, penciclovir/famciclovir/ganciclovir and foscarnet were associated with a lower risk of hospital-acquired AKI, with an adjusted hazard ratio of 0.59 (95% confidence interval [CI], 0.37 to 0.94) and 0.27 (95% CI, 0.11 to 0.63), respectively. Compared with intravenous acyclovir, intravenous penciclovir/ganciclovir and foscarnet were associated with a lower risk of hospital-acquired AKI with an adjusted hazard ratio of 0.53 (95% CI, 0.29 to 0.98) and 0.31 (95% CI, 0.12 to 0.76), respectively. The associations were consistent across various subgroups and sensitivity analyses.

Conclusions

Among antiviral therapies for herpes zoster, we found different risks of hospital-acquired AKI among the patients receiving different antivirals, in particular, those administered intravenously. Among intravenous antivirals, acyclovir was associated with the highest risk of hospital-acquired AKI, followed by penciclovir/ganciclovir and foscarnet. Confirmation studies with large samples from other populations are warranted.

A bibliometric analysis and visualization of acupuncture and moxibustion therapy for herpes zoster and postherpetic neuralgia

OBJECTIVE

To identify major contributors, current research status, and to forecast research trends and future development prospects on acupuncture and moxibustion therapy for herpes zoster (HZ) and postherpetic neuralgia (PHN).

METHODS

A systematic search was conducted on the China National Knowledge Infrastructure (CNKI), Weipu, WanFang databases, and the Web of Science Core Collection (WoSCC), PubMed, and Scopus databases. The search strategy included relevant terms for HZ, PHN, acupuncture, and moxibustion. The reference type was limited to articles or reviews, with a publication date from January 1, 2014 to December 31, 2023. Data analysis was performed using CiteSpace software, focusing on author, institution, source, and keyword distributions, and temporal trends.

RESULTS

A total of 1612 publications were identified from both Chinese and English databases. The analysis revealed a rising trend in publication numbers in the English database, with a significant increase observed in 2020. In the Chinese database, publication activity exhibited two peaks in 2019 and 2023. Guohua Lin and Jingchun Zeng were the most prolific authors in the Chinese and English databases, respectively. The Chengdu University of TCM and Zhejiang Chinese Medicine University were the most active institutions. The keyword analysis revealed "herpes zoster" as the most frequent keyword in the Chinese database, while "postherpetic neuralgia," "acupuncture," and "management" were prominent in the English database. The study also identified several therapeutic approaches, including fire needle therapy and electroacupuncture, which have shown efficacy in treating HZ and PHN. Animal studies provided insights into the mechanisms of these therapies, suggesting potential modulation of neuroinflammatory markers and intracellular signaling pathways.

CONCLUSION

The bibliometric analysis underscores the growing interest in acupuncture and moxibustion therapy for HZ and PHN. It highlights the contributions of key authors and institutions while pinpointing potential areas for future research. The study advocates for the necessity of large-scale, multi-center clinical trials and further basic mechanical research to optimize these therapies. Moreover, it also emphasizes the importance of international collaboration to strengthen the evidence base and expand the global impact of this traditional treatment modality.

Herpes zoster infection in pregnancy: features and consequences

Herpes (varicella) zoster (HZ) infection occurs in 4 people per 1000 in the general US population (irrespective of prior varicella infection and vaccination status) each year and has been the subject of scientific inquiry for decades. The consequences of infection are myriad and may depend on the dermatome of involvement as well as host factors such as age, comorbidities, prior treatment or immunization, and immunologic status. Pregnancy is associated with an altered immune and hormonal status in the mother. While maternal HZ infection during pregnancy is not uncommon, the implications for both mother and child are not well established, although multiple studies of perinatal maternal HZ infection suggest no intrauterine transmission to the fetus. We review the current literature on herpes zoster infection in pregnancy, including epidemiology, diagnosis, potential immunologic sequelae, and strategies for prevention and treatment.

Postoperative abdominal herpes zoster complicated by intestinal obstruction: A case report

BACKGROUND

Intestinal obstruction is a common occurrence in clinical practice. However, the occurrence of herpes zoster complicated by intestinal obstruction after abdominal surgery is exceedingly rare. In the diagnostic and treatment process, clinicians consider it crucial to identify the primary causes of its occurrence to ensure effective treatment and avoiding misdiagnosis.

CASE SUMMARY

Herein, we present the case of a 40-year-old female patient with intestinal obstruction who underwent laparoscopic appendectomy and developed herpes zoster after surgery. Combining the patient's clinical manifestations and relevant laboratory tests, it was suggested that the varicella zoster virus reactivated during the latent period after abdominal surgery, causing herpes zoster. Subsequently, the herpes virus invaded the visceral nerve fibers, causing gastrointestinal dysfunction and loss of intestinal peristalsis, which eventually led to intestinal obstruction. The patient was successfully treated through conservative treatment and antiviral therapy and subsequently discharged from the hospital.

CONCLUSION

Pseudo-intestinal obstruction secondary to herpes zoster infection is difficult to distinguish from mechanical intestinal obstruction owing to various causes. In cases of inexplicable intestinal obstructions, considering the possibility of a viral infection is essential to minimize misdiagnosis and missed diagnoses.

Characteristic Video Laryngeal Endoscopic "Pharyngeal Rotation" in Unilateral Pharyngeal Constrictor Muscle Paresis: A Case of Herpes Zoster Pharyngitis

Herpes zoster pharyngitis (HZP) is a rare condition that should be considered as a differential diagnosis of acute dysphagia secondary to unilateral glossopharyngeal and/or vagal nerve palsy. Although early treatment is important to avoid adverse sequelae, serological diagnosis of varicella zoster virus (VZV) takes over a few days. Therefore, it is important to actively suspect VZV infection based on physical findings. Mucocutaneous lesions, curtain signs, and laryngeal palsy are well-known characteristic physical findings. In addition to these findings, the video laryngeal endoscopic finding that the pharyngeal constrictor muscles contract on only one side during swallowing, showing an appearance of "pharyngeal rotation", is one of the characteristic findings of glossopharyngeal/vagal nerve palsy and can support the diagnosis. We report the case of an 82-year-old Asian female who presented with acute dysphagia, sore throat, left ear pain, and fever that persisted for several days. Initial video laryngeal endoscopy revealed a markedly decreased pharyngeal reflex and significant salivary retention without mucosal vesicular lesions. Repeat videoendoscopic evaluation of swallowing revealed characteristic pharyngeal rotation, which was helpful in diagnosing unilateral pharyngeal constrictor muscle paresis, thus suggesting unilateral glossopharyngeal/vagal nerve palsy. An increase in serum antibody titers (IgG and IgM) against VZV was observed. Bilateral differences and rotation of the pharynx during pharyngeal contraction can be detected endoscopically in pharyngeal constrictor muscle paresis caused by glossopharyngeal/vagal nerve palsy and should be evaluated during video laryngeal endoscopy in patients with dysphagia.

Cost-effectiveness of the recombinant zoster vaccine (RZV) against herpes zoster: An updated critical review

The objective of this study was to critically review the cost-effectiveness (CE) of the recombinant zoster vaccine (RZV) against herpes zoster (HZ). A literature review was conducted in PubMed, Embase, and Cochrane between January 1, 2017, and February 28, 2022, and on select public healthcare agency websites to identify and collect data from CE studies comparing RZV to zoster vaccine live (ZVL) or to no vaccination. Study characteristics, inputs, and outputs were collected. The overall CE of RZV was assessed. RZV vaccination against HZ is cost-effective in 15 out of 18 studies included in the present review. Varying incremental cost-effectiveness ratios (ICERs) observed may be associated with different assumptions on the duration of protection of RZV, as well as different combinations of structural and disease-related study (model) inputs driving the estimation of ICERs.

Characteristics and economic burden of hospitalized patients with herpes zoster in China, before vaccination

Herpes zoster (HZ) brings a significant economic burden. The HZ vaccine was introduced in China for the first time in 2020, and there is a lack of up-to-date information on the hospitalization costs and characteristics prior to vaccination. This study aimed to describe the characteristics and economic burden of HZ inpatients in Hunan Province, China, and analyze the factors influencing the length of stay (LOS) and costs. This was a retrospective study and we extracted information from the Chinese National Health Statistics Network Reporting System on HZ inpatients in Hunan Province, China from 2017 to 2019. Spatial join tools and Global or Local Moran's Index were used for the geographic analysis of hospitalized HZ incidence. Multivariate linear regression models were used to analyze the factors influencing LOS and costs. There were 44,311 HZ inpatients included in this study, incurring a total of $31,857,734 medical costs. These patients had a median LOS of 8 days and a median expenditure of $573.47. Older age, more comorbidities, and the presence of complications with nervous system involved were all significantly associated with longer LOS and higher costs. HZ infection resulted in a large direct medical cost and heavy disease burden, especially in patients with advanced age or underlying medical conditions. The HZ vaccine has the potential to effectively reduce the disease burden and should be widely popularized especially among high-risk groups.

Emerging concerns of atypical hand foot and mouth disease caused by recombinant Coxsackievirus A6 variants in Henan, China

An increasing number of studies have reported that atypical hand, foot, and mouth disease (HFMD) is becoming a new concern for children's health. At present, there is no official definition for atypical HFMD, but some studies have defined that it occurs at anatomic sites not listed in the definition of HFMD issued by the World Health Organization. Several pathogens have been reported to cause atypical HFMD, such as Coxsackievirus (CV)A6. As one of the most prevalent enteroviruses in the world, CVA6 seems to affect a wider range of children and causes more severe and prolonged illness than other enteroviruses. The early lesions of atypical HFMD are very similar to the clinical presentations of other diseases, such as eczema, which poses a challenge for clinicians aiming to identify and diagnose HFMD in a timely manner. Here, we report on six atypical HFMD patients caused by recombinant CVA6 variants, and the atypical manifestations include eczema coxsackium, large herpes, rice-like red papules and herpes, purpuric rash, and onychomadesis, as well as and large red herpes on scalp, perianal, testicles, shoulders and neck, and other atypical eruption sites, hoping to draw the attention of other pediatricians. This study will provide scientific guidance for timely diagnosis of HFMD to prevent serious complications.

Bidirectional two-sample Mendelian randomization analysis reveals a causal effect of interleukin-18 levels on postherpetic neuralgia risk

Background

Postherpetic neuralgia (PHN) is a debilitating complication of herpes zoster, characterized by persistent neuropathic pain that significantly impairs patients' quality of life. Identifying factors that determine PHN susceptibility is crucial for its management. Interleukin-18 (IL-18), a pro-inflammatory cytokine implicated in chronic pain, may play a critical role in PHN development.

Methods

In this study, we conducted bidirectional two-sample Mendelian randomization (MR) analyses to assess genetic relationships and potential causal associations between IL-18 protein levels increasing and PHN risk, utilizing genome-wide association study (GWAS) datasets on these traits. Two IL-18 datasets obtained from the EMBL's European Bioinformatics Institute database which contained 21,758 individuals with 13,102,515 SNPs and Complete GWAS summary data on IL-18 protein levels which contained 3,394 individuals with 5,270,646 SNPs. The PHN dataset obtained from FinnGen biobank had 195,191 individuals with 16,380,406 SNPs.

Results

Our findings from two different datasets of IL-18 protein levels suggest a correlation between genetically predicted elevations in IL-18 protein levels and an increased susceptibility to PHN.(IVW, OR and 95% CI: 2.26, 1.07 to 4.78; p = 0.03 and 2.15, 1.10 to 4.19; p =0.03, respectively), potentially indicating a causal effect of IL-18 protein levels increasing on PHN risk. However, we did not detect any causal effect of genetic liability to PHN risk on IL-18 protein levels.

Conclusion

These findings suggest new insights into identifying IL-18 protein levels increasing at risk of developing PHN and may aid in the development of novel prevention and treatment approaches for PHN.

Case report: Be alert to herpes zoster after total knee arthroplasty

An 88-year-old woman started complaining of severe pain at the right knee and above at three weeks after right total knee arthroplasty (TKA). The empirical treatment cannot effectively control the progress of pain. The lesion was eventually diagnosed to be due to herpes zoster (HZ). The finding of HZ was unexpected in this case, because HZ is extremely rare in patients after TKA.

CRISPR-based quantum dot nanobead lateral flow assay for facile detection of varicella-zoster virus

Varicella-zoster virus (VZV) infects more than 90% of the population worldwide and has a high incidence of postherpetic neuralgia in elderly patients, seriously affecting their quality of life. Combined with clustered regularly interspaced short palindromic repeats (CRISPR) system, we develop a quantum dot nanobeads (QDNBs) labeled lateral flow assay for VZV detection. Our assay allows the identification of more than 5 copies of VZV genomic DNA in each reaction. The entire process, from sample preparation to obtaining the results, takes less than an hour. In 86 clinical vesicles samples, the test shows 100% concordance with quantitative real-time PCR for VZV detection. Notably, when vesicles are present in specific areas, such as the genitals, our method outperforms clinical diagnosis. Compared to traditional detection methods, only a minute amount of blister fluid is required for accurate detection. Therefore, we anticipate that our method could be translated to clinical applications for specific and rapid VZV detection. KEY POINTS: • CRISPR/Cas12a and quantum dot nanobead-based lateral flow assay achieved 5 copies per reaction for VZV detection • Specific identification of VZV in atypical skin lesions • Results read by the naked eye within one hour.

Efficacy and Safety of Pulsed Radiofrequency in Herpes Zoster Related Trigeminal Neuralgia: A Systematic Review and Meta-Analysis

Purpose

Pulsed radiofrequency (PRF) is a neuromodulation technique for neuropathic pain. However, the effects of PRF on zoster-related trigeminal neuralgia (TN) remain unclear. The purpose of this meta-analysis is to investigate the efficacy and safety of PRF in the management of zoster-related TN.

Patients and Methods

We searched PubMed, Embase, Cochrane Library, Chinese Biomedical Database (CBM), Chinese National Knowledge Infrastructure (CNKI), and Wanfang for randomized controlled trials from their inception to August 2022. The primary clinical outcomes included pain intensity and adverse events. Secondary clinical outcomes included pain remission rate, trigeminal postherpetic neuralgia (TPHN) incidence, rescue analgesic dose, sleep quality, and quality of life (QoL).

Results

Eight studies with 788 participants were included for final analysis. PRF group exhibited lower pain scores (week 1: MD -2.10, 95% CI -3.28 to -0.93, P=0.0005; week 4: MD -1.56, 95% CI -2.60 to -0.51, P=0.003; week 12: MD -1.52, 95% CI -2.68 to -0.35, P=0.01), lower risk of TPHN incidence (RR 0.22, 95% CI 0.06 to 0.81, P=0.02) and better sleep quality (week 4: MD -2.52, 95% CI -3.28 to -1.77, P<0.01; week 12: MD -2.25, 95% CI -2.90 to -1.60, P<0.01) than control group. Besides, pain remission rate (RR 1.08, 95% CI 0.93 to 1.26, P=0.31) and adverse events (RR 0.95, 95% CI 0.71 to 1.27, P=0.74) were comparable in both groups.

Conclusion

PRF is an effective and safe treatment and it yields better effects in pain relief, improvement of sleep quality, and prevention of developing TPHN. Although PRF provides a comparable pain remission rate with the control, it is still a preferred and alternative treatment for relieving zoster-related facial pain.

Efficacy, effectiveness, and safety of herpes zoster vaccine in the immunocompetent and immunocompromised subjects: A systematic review and network meta-analysis

Objective

To investigate the efficacy, effectiveness and safety of recombinant zoster vaccine (RZV) and zoster vaccine live (ZVL) in immunocompetent and immunocompromised subjects.

Methods

Data sources: PubMed, EMBASE, Cochrane Library, and Web of Science databases (up to Jan 2022) were searched to identify English articles. Search terms included randomized controlled trials (RCTs), observational studies, herpes zoster, RZV, ZVL. Study Selection: Only randomized controlled trials (RCTs) evaluating vaccine efficacy and safety and observational studies assessing vaccine effectiveness (after a vaccine was approved for marketing) were included. Data Extraction: Two researchers independently screened the literature, extracted the data, and checked the each other results.

Results

Seventeen RCTs and 19 cohort studies were included. Among immunocompetent subjects, RZV was superior to ZVL at wide intervals (relative vaccine efficacy: 84%, 95% CI: 53%–95%; relative vaccine effectiveness: 49%, 95% CI: 21%–67%), across genders and subjects aged ≥ 60 years. Among immunocompromised subjects, RZV was superior to placebo in terms of vaccine efficacy (60%, 95% CI: 49%–69%). There was no difference between ZVL and placebo in those with selected immunosuppressive conditions. RZV was 45% (95% CI: 30%–59%) superior to ZVL in real-world practice. Compared with placebo, adverse events related to RZV were primarily related to injection-site and systemic, and RZV did not increase the risk of serious adverse events (SAEs) or death. There was no difference in the incidence of adverse events between groups with and without immunosuppression.

Conclusions

Both RZV and ZVL can reduce the risk of herpes zoster in both immunocompetent and immunocompromised subjects. RZV was well-tolerated in the study population and demonstrated stronger protection than ZVL.

Systematic review registration

Prospero CRD42022310495.

Disseminated Zoster Involving the Whole Body in an Immunocompetent Patient Complaining of Left Leg Radiating Pain and Weakness: A Case Report and Literature Review

Introduction

Disseminated herpes zoster is defined as at least 20 skin lesions in multiple dermatomes. In particular, it has been reported mainly in patients with immunological defects. To our knowledge, there is no reported case of disseminated zoster in a non-immunocompromised patient with leg radiating pain and weakness.

Case presentation

A 74-year-old man visited our hospital with left leg radiating pain and left hip pain. He had no underlying disease other than hypertension. Neurologic examination revealed radiating pain on the L4 dermatome of the left leg. The muscle power was grade 3 for the hip flexor and knee extensor, and grade 4 for the ankle dorsiflexor and big toe dorsiflexor of the left leg. There were no sensory changes or skin lesions on his left leg. Herniation of the nucleus pulposus of the lumbar spine was suspected and lumbar magnetic resonance imaging (MRI) was performed. However, no pathologic lesions were seen on lumbar MRI. On the third day of hospitalization, erythematous patches and vesicles were observed on the head, face, ear, neck, trunk, back, and both lower extremities. Herpes zoster infection was confirmed by polymerase chain reaction analysis. Treatment was performed with 250 mg of intravenous acyclovir every 8 hours for 6 days and 62.5 mg of intravenous methylprednisolone for 4 days. On the 13th day of hospitalization, the skin lesions and left leg radiating pain and weakness improved.

Conclusion

We report the first case of disseminated herpes zoster involving the whole body in a non-immunocompromised patient complaining of left leg radiating pain and weakness. After treatment, both the patient's radiating pain and weakness improved.

Dynamic Immune Landscape and VZV-Specific T Cell Responses in Patients With Herpes Zoster and Postherpetic Neuralgia

Objectives

Varicella-zoster virus (VZV) can induce herpes zoster (HZ) and postherpetic neuralgia (PHN). Immune cells play an important role in regulating HZ and PHN pathogenesis, but the dynamic immune profiles and molecular mechanisms remain unclear. This study aimed to screen dynamic immune signatures during HZ progression and elucidate the mechanism of VZV-specific T cells in PHN.

Methods

We used cytometry by time-of-flight (CyTOF) to analyze peripheral blood mononuclear cells (PBMC) samples from 45 patients with HZ and eight age-sex-matched healthy controls, eight PHN samples and seven non-PHN samples. Correlations between the immune subsets and clinical pain-related scores were performed. Further, the characteristics of VZV-specific T cells between PHN and non-PHN patients were evaluated by VZV peptide pools stimulation. The expression level of cytokines, including granzyme B, interleukin (IL)-2, interferon (IFN)-γ, and tumor necrosis factor (TNF)-α was performed via cytometric bead array. Finally, we analyzed the alteration of Ca²⁺ signals in dorsal root ganglion (DRG)-derived cells after TNF-α stimulation.

Results

We investigated the dynamic characteristics of the immune landscape of peripheral blood samples of patients with HZ and PHN, and depicted two major dynamic signatures in NK, CD4⁺ and CD8⁺ T subsets in patients with HZ, which closely correlated with clinical pain-related scores. The frequency of PD-1⁺CD4⁺ T cells, VZV-specific PD-1⁺CD4⁺ T cells, and the amount of TNF-α produced by VZV-specific T cells were higher in patients with PHN than without PHN. Furthermore, we showed that TNF-α could induce calcium influx in DRG-derived cells in a dose-dependent manner.

Conclusions

Our results profiled the dynamic signatures of immune cells in patients with HZ and highlighted the important role of VZV-specific T cells in the pathogenesis of PHN.

Trigeminal extracranial thermocoagulation along with patient-controlled analgesia with esketamine for refractory postherpetic neuralgia after herpes zoster ophthalmicus: A case report

BACKGROUND

Primary trigeminal neuralgia can achieve satisfactory results through clinical treatment and intervention. The pathogenesis of neuralgia caused by varicella-zoster virus infection of the trigeminal nerve is more complex, and it is still difficult to relieve the pain in some patients simply by drug treatment or surgical intervention.

CASE SUMMARY

A 66-year-old woman was hospitalized with herpetic neuralgia after herpes zoster ophthalmicus (varicella-zoster virus infects the ophthalmic branch of the trigeminal nerve). On admission, the patient showed spontaneous, electric shock-like and acupuncture-like severe pain in the left frontal parietal region, and pain could be induced by touching the herpes area. The numerical rating scale (NRS) was 9. There was no significant pain relief after pulsed radiofrequency and thermocoagulation of the ophthalmic branch of the trigeminal nerve. Combined with patient-controlled intravenous analgesia (PCIA) with esketamine, neuralgia was significantly improved. The patient had no spontaneous pain or allodynia at discharge, and the NRS score decreased to 2 points. The results of follow-up 2 mo after discharge showed that the NRS score was ≤ 3, and the Pittsburgh Sleep Quality Index score was 5 points. There were no adverse reactions.

CONCLUSION

Trigeminal extracranial thermocoagulation combined with esketamine PCIA may be a feasible method for the treatment of refractory herpetic neuralgia after herpes zoster ophthalmicus.

The Interplay Between Stress and Immunity Triggers Herpes Zoster Infection in COVID-19 Patients: A Review

Coronavirus disease 2019 (COVID-19) is a potential health threat in the highly mobile society of the world. Also, there are concerns regarding the co-infections occurring in COVID-19 patients. Herpes zoster (HZ) is now being reported as a co-infection in COVID-19 patients. It is a varicella-zoster virus induced viral infection affecting older people and immunocompromised individuals. Reactivation of HZ infection in COVID-19 patients are emerging and the mechanism of reactivation is still unknown. A most convincing argument would be, increased psychological and immunological stress leading to HZ in COVID-19 patients, and this review justifies this argument.

Herpes Zoster in Four HIV Seropositive Patients and One Patient With Recurrent Carcinoma After Radiotherapy

Herpes zoster is a ubiquitous ultramicroscopic neurotropic virus that causes pruritic acute grouped vesicular eruptions and rashes, these vesicles rupture spontaneously resulting in pustules, crustations, which are pruritic in nature on the affected skin along the course of the dermatome resulting in scab. The scab withers off later leaving a permanent scar and pigmentation. The characteristic clinical finding was that vesicles or ulcers resulting from herpes zoster lesions never cross the midline. Two such reported cases of herpes zoster in seropositive HIV patients that resulted in extensive crustations and periorbital edema, left unilateral facial pain of burning quality in 25-year-old female patient and spontaneous exfoliation of a tooth in another 35-year-old patient, treated with drug therapy comprising acyclovir, gabapentin, amitriptyline are discussed here.

Perceived psychological stress and risk of herpes zoster: a nationwide population-based cohort study

BACKGROUND

Psychological stress may reduce cellular immunity, but its role in triggering latent infections, including herpes zoster (HZ), is controversial.

OBJECTIVES

To examine the association between perceived psychological stress and risk of HZ.

METHODS

In a linked registry-based cohort study, we followed 77 310 persons aged 40 years or older who participated in the 2010 Danish National Health Survey from 1 May 2010 until HZ diagnosis, death, emigration or 1 July 2014, whichever occurred first. We computed hazard ratios (HRs) of HZ associated with Cohen's Perceived Stress Scale (PSS) score (range 0-40) using Cox regression with age as the timescale, adjusted for sex, immunosuppressive and selected chronic conditions, immunosuppressive drugs, and sociodemographic, lifestyle and anthropometric factors. The PSS measures chronic stress perceived by an individual in response to various demands of daily life. We modelled the PSS score using quintiles and a restricted cubic spline function.

RESULTS

The unadjusted rate of HZ varied from 5·53 to 7·20 per 1000 person-years from the lowest to the highest PSS score quintile. Compared with the lowest PSS score quintile, the adjusted HR for HZ was 1·00 [95% confidence interval (CI) 0·86-1·16], 1·08 (95% CI 0·92-1·26), 1·05 (95% CI 0·90-1·23) and 1·14 (95% CI 0·97-1·34) for the second to the fifth quintile, respectively. In cubic spline analyses, PSS scores < 20 were not associated with increased HR of HZ, but thereafter the HR increased linearly from 1·10 (95% CI 0·85-1·41) to 2·22 (95% CI 1·32-3·75).

CONCLUSIONS

Our study indicated that high levels of psychological stress are associated with increased risk of HZ.

Associations of Lifestyle and Anthropometric Factors With the Risk of Herpes Zoster: A Nationwide Population-Based Cohort Study

The role of lifestyle in development of herpes zoster remains unclear. We examined whether smoking status, alcohol consumption, body mass index, or physical activity were associated with zoster risk. We followed a population-based cohort of 101,894 respondents to the 2010 Danish National Health Survey (baseline, May 1, 2010) until zoster diagnosis, death, emigration, or July 1, 2014, whichever occurred first. We computed hazard ratios for zoster associated with each exposure, using Cox regression with age as the time scale and adjusting for potential confounders. Compared with never smokers, hazards for zoster were increased in former smokers (1.17, 95% confidence interval (CI): 1.06, 1.30), but not in current smokers (1.00, 95% CI: 0.89, 1.13). Compared with low-risk alcohol consumption, neither intermediate-risk (0.95, 95% CI: 0.84, 1.07) nor high-risk alcohol consumption (0.99, 95% CI: 0.85, 1.15) was associated with zoster. We also found no increased hazard associated with weekly binge drinking versus not (0.93, 95% CI: 0.77, 1.11). Risk of zoster varied little by body mass index (referent = normal weight) and physical activity levels (referent = light level), with hazard ratios between 0.96 and 1.08. We observed no dose-response association between the exposures and zoster. The examined lifestyle and anthropometric factors thus were not risk factors for zoster.

Intravenous Administration of Vitamin C in the Treatment of Herpes Zoster-Associated Pain: Two Case Reports and Literature Review

Background

Herpes zoster (HZ) is an acute inflammatory neurocutaneous disease caused by the reactivation of varicella-zoster virus. It is estimated that the incidence of postherpetic neuralgia following HZ is 10–20%. The leading risk factors of the prognosis are aging and immunity dysfunction. Vitamin C plays a pivoted role in enhancing white blood cell function. Epidemiological evidence and clinical studies have indicated an association between pain and suboptimal vitamin C status. At present, vitamin C has been used as an additional option in the treatment of HZ-associated pain. Despite the current controversy, case reports and randomized controlled studies have indicated that both acute- and postherpetic neuralgia can be dramatically alleviated following intravenous vitamin C infusions. Case Presentation. Two patients (male aged 72 and female 78 years) with HZ did not respond well to antiviral therapy and analgesics. Skin lesions in the right groin and front thigh healed after early antiviral therapy, but the outbreak of pain persisted in the male patient. The female patient presented to our clinic with clusters of rashes in the right forehead with severe edema of her right upper eyelid. Because nerve blockade could not be conducted for both patients, intravenous infusion of vitamin C was applied and resulted in an immediate remission of the breakthrough pain in the male patient and cutaneous lesions in the female patient.

Conclusions

The use of vitamin C appears to be an emerging treatment alternative for attenuating HZ and PHN pain. Hence, we recommend the addition of concomitant use of intravenously administered vitamin C into therapeutic strategies in the treatment of HZ-associated pain, especially for therapy-resistant cases. Furthermore, animal studies are required to determine analgesic mechanisms of vitamin C, and more randomized clinical trials are essential to further determine the optimal dose and timing of administration of vitamin C.

Supraorbital Nerve Radiofrequency for Severe Neuralgia Caused by Herpes Zoster Ophthalmicus

Background

Radiofrequency of the Gasserian ganglion can be used for ophthalmic herpetic neuralgia (OHN), but it is associated with complications. This study aimed to use the supraorbital nerve for computed tomography- (CT-) guided radiofrequency thermocoagulation to treat refractory OHN.

Methods

This was a retrospective case series study of patients with simple or combined OHN treated at our hospital between 06/2012 and 06/2018. The numerical rating score (NRS), spontaneous pain, allodynia, gabapentin dosage, paracetamol/oxycodone dosage, patient global impression of change (PGIC) score, Barrow numbness score, postoperative 360-day recurrence rate, and complications were recorded before the operation and at 1, 30, 90, 180, and 360 days after the operation.

Results

Compared with baseline, the NRS was decreased, and PGIC was increased at postoperative 1, 30, 90, 180, and 360 days, and the gabapentin and paracetamol oxycodone doses at postoperative 30, 90, 180, and 360 days were decreased (all P < 0.001). Compared with 1 day after the operation, numbness was decreased at 30, 90, 180, and 360 days after the operation (P < 0.001). Compared with baseline, the number of patients with allodynia at each time point after the operation was decreased (P < 0.001), but without a difference for spontaneous pain (P=0.407). No subjects showed drooping eyelid, corneal ulcers, eyeball damage, decreased vision, and other severe complications.

Conclusion

CT-guided supraorbital nerve radiofrequency thermocoagulation for the treatment of OHN can effectively relieve pain and reduce the dose of analgesics, without any serious complication. This study suggests that this technique is feasible and applicable to clinical practice.

Pediatric Herpes Zoster

A 10-year-old male vaccinated against varicella had developed left-sided rashes on his thoracic region in single dermatomal distribution, which is consistent with herpes zoster. Although herpes zoster is uncommon in children, especially with the current vaccination regimen, this case report serves as a reminder to consider it in one’s differential diagnoses, even in the immunocompetent, fully immunized pediatric patient. This is a case report of a previously healthy, fully vaccinated child who developed herpes zoster.