Varicella vaccine meningoencephalitis in a child receiving autologous bone marrow transplantation

BACKGROUND

Varicella vaccine, a live-attenuated Oka-strain of varicella zoster virus (VZV), is a recommended childhood vaccine by many countries. As with wild varicella strain, after primary infection, the live-attenuated virus can establish latency in sensory ganglia and reactivate causing vaccine-strain illnesses: herpes zoster (HZ), visceral or peripheral and central nervous system dissemination. We report a case of early reactivation of live-attenuated virus-HZ and meningoencephalitis-in an immunocompromised child.

METHODS

This is a retrospective descriptive report of a case, in a tertiary pediatric hospital, CHU Sainte-Justine (Montréal, Canada).

RESULTS

An 18 month-year old girl diagnosed with a primitive neuro-ectodermal tumor (PNET) received the day prior to diagnosis, a first varicella vaccine (MMRV). She received chemotherapy 20 days post MMRV vaccine and autologous bone marrow transplantation 3 months post vaccination. She was considered not eligible, to acyclovir prophylaxis prior transplantation (positive for VZV IgG and negative for herpes simplex virus IgG by ELISA). At day 1 post transplantation, she developed dermatomal HZ and meningoencephalitis. Oka-strain varicella was isolated, she was treated with acyclovir and foscarnet. Neurologic status improved in 5 days. Control of VZV viral load in cerebrospinal fluid showed a slow decrease to from 5.24 log 10 copies/mL to 2.14 log 10 copies/mL in 6 weeks. No relapse was observed. She recovered without neurological sequelae.

CONCLUSIONS

Our experience highlights the importance of conducting a thorough medical history regarding vaccination and serological status of newly immunocompromised patients. Intensive chemotherapy succeeding live vaccine administration <4 weeks could have influenced early and severe viral reactivation. Early initiation of prophylactic antiviral treatment is questioned in such circumstances.

Low post-transplant measles and varicella titers among pediatric liver transplant recipients: A 10-year single-center study

BACKGROUND

Vaccine preventable illnesses are important sources of morbidity, mortality, and increased healthcare costs in pediatric LT recipients. Our aim was to measure the seroprevalence of antibodies to measles and VZV in this population.

METHODS

We conducted a retrospective chart review of 44 patients who received LT before age 18 at UCLA Mattel Children's Hospital from January 2008 to December 2017.

RESULTS

Median age at transplantation was 2.5 years (IQR 1.2-7.7). Post-transplant measles antibodies were present in 17 of 37 patients (46%); risk factors for seronegativity included younger age at transplant (p = .02) and greater time from transplant to testing (p = .04). Post-transplant VZV antibodies were present in 17 of 39 patients (44%); risk factors for seronegativity included greater time from transplant to testing (p = .04). 6 of 16 patients (38%) who tested positive for pre-transplant VZV antibodies tested negative after transplantation. Fourteen of 20 patients (70%) with at least 1 documented dose of the MMR vaccine tested positive for post-transplant measles antibodies. Ten of 20 of patients (50%) with at least 1 documented dose of the VZV vaccine tested positive for post-transplant VZV antibodies. We also describe 10 patients who received post-transplant measles and VZV vaccines without documented complications.

CONCLUSIONS

Our study suggests that pediatric LT patients are at greater risk of contracting measles and VZV despite vaccination status, and that prevalence of measles and VZV antibodies decreases as time from transplantation increases. This should weigh into the institutional risk-benefit assessment when deciding whether or not to administer LAVs to these patients.

Vaccine-derived varicella zoster infection in a kidney transplant recipient after zoster vaccine live administration

A 49-year-old kidney transplant recipient, presented with a skin rash, and interstitial infiltrates three weeks after receiving a live attenuated varicella-zoster vaccine. Varicella-zoster Oka-vaccine strain was detected in plasma by polymerase chain reaction and sequencing analysis targeting open reading frame 62 (ORF 62). She was treated successfully with intravenous acyclovir. Our case report supports the current contraindication of live attenuated varicella-zoster vaccine in the solid-organ transplant recipients. Recombinant subunit varicella-zoster vaccine may be the vaccine of choice in these patients; nevertheless, further information is required to establish its safety, efficacy, and optimal timing.

Association between the incidence of varicella and meteorological conditions in Jinan, Eastern China, 2012-2014

BACKGROUND

Varicella remains an important public health issue in China. In this study we explored the effect of weather conditions on the incidence of varicella in the temperate city of Jinan, Eastern China during 2012-2014 to inform public health prevention and control measures.

METHODS

Data on reported cases of varicella were obtained from National Notifiable Disease Report System. Meteorological data for the same time period were obtained from the Jinan Meteorological Bureau. A negative binomial regression model was used to assess the relationships between meteorological variables and the incidence of varicella. Given collinearity between average temperature and atmospheric pressure, separate models were constructed: one including average temperature without atmospheric pressure, the other including atmospheric pressure but without average temperature. Both models included relative humidity, wind velocity, rainfall, sunshine, and year as independent variables.

RESULTS

Annual incidence rates of varicella were 44.47, 53.69, and 46.81 per 100,000 for 2012, 2013, and 2014, respectively. Each increase of 100 Pa (hPa) in atmospheric pressure was estimated to be associated with an increase in weekly incidence of 3.35 % (95 % CI = 2.94-3.67 %), while a 1 °C rise in temperature was associated with a decrease of 3.44 % (95 % CI = -3.73-3.15 %) in the weekly incidence of varicella. Similarly, a 1 % rise in relative humidity corresponded to a decrease of 0.50 % or 1.00 %, a 1 h rise in sunshine corresponded to an increase of 1.10 % or 0.50 %, and a 1 mm rise in rainfall corresponded to an increase of 0.20 % or 0.30 %, in the weekly incidence of varicella cases, depending on the variable considered in the model.

CONCLUSION

Our findings show that weather factors have a significant influence on the incidence of varicella. Meteorological conditions should be considered as important predictors of varicella incidence in Jinan, Eastern China.

Prevalence and Outcome of Disseminated Varicella Zoster Infection Post Kidney Transplantation

OBJECTIVE

Varicella zoster (VZV) is a potentially life-threatening infection after kidney transplantation (KT) but data on the incidence and outcome of late KT VZV infection is limited.

MATERIAL AND METHOD

A retrospective study of disseminated VZV infection (D-VZV) in post KT patients was conducted between 2003 and 2013. Acyclovir prophylaxis was given routinely for six months after KT Statistical analyses were performed by SPSS software version 17.0.

RESULTS

Prevalence of D-VZV was 2% [22/1,032 patients]. Patients median age were 40 (21-67) years old and 12 (55%) were male. Timing of the infection was mostly (68.2%) late (> 1 year) post KT The majority of maintenance immunosuppressive drug included prednisolone (95.5%), cyclosporine (77.3%), mycophenolate (68.2%). Two (9.1%) had a recent VZV exposure and four (18%) received intensified immunosuppression before the diagnosis. Common clinical presentations were lymphopenia (54.5%), generalized vesicular rash (50%), and multi-dermatomal distribution (50%) while liver involvement was infrequent (9.1%). None had pneumonitis or neurological involvement. All cases received systemic acyclovir with the median duration of 14 (3-31) days. One had received IVIG for fulminant hepatitis. Immunosuppressive drug/s was reduced in 59%. Median duration of hospitalization was seven (3-37) days. None of patients died. The median follow-up duration was 1939 (IQR 804-2440) days. Recurrent infection was uncommon (4.5%). Secondary prophylaxis was given only in one patient with fulminant VZV hepatitis.

CONCLUSION

Incidence of D-VZV post KT was low. Treatments with intravenous acyclovir and reduction of immunosuppression without the use of VZV IgG provided favorable outcome in resource-limited settings.

Vaccine-associated varicella and rubella infections in severe combined immunodeficiency with isolated CD4 lymphocytopenia and mutations in IL7R detected by tandem whole exome sequencing and chromosomal microarray

In areas without newborn screening for severe combined immunodeficiency (SCID), disease-defining infections may lead to diagnosis, and in some cases, may not be identified prior to the first year of life. We describe a female infant who presented with disseminated vaccine-acquired varicella (VZV) and vaccine-acquired rubella infections at 13 months of age. Immunological evaluations demonstrated neutropenia, isolated CD4 lymphocytopenia, the presence of CD8(+) T cells, poor lymphocyte proliferation, hypergammaglobulinaemia and poor specific antibody production to VZV infection and routine immunizations. A combination of whole exome sequencing and custom-designed chromosomal microarray with exon coverage of primary immunodeficiency genes detected compound heterozygous mutations (one single nucleotide variant and one intragenic copy number variant involving one exon) within the IL7R gene. Mosaicism for wild-type allele (20-30%) was detected in pretransplant blood and buccal DNA and maternal engraftment (5-10%) demonstrated in pretransplant blood DNA. This may be responsible for the patient's unusual immunological phenotype compared to classical interleukin (IL)-7Rα deficiency. Disseminated VZV was controlled with anti-viral and immune-based therapy, and umbilical cord blood stem cell transplantation was successful. Retrospectively performed T cell receptor excision circle (TREC) analyses completed on neonatal Guthrie cards identified absent TREC. This case emphasizes the danger of live viral vaccination in severe combined immunodeficiency (SCID) patients and the importance of newborn screening to identify patients prior to high-risk exposures. It also illustrates the value of aggressive pathogen identification and treatment, the influence newborn screening can have on morbidity and mortality and the significant impact of newer genomic diagnostic tools in identifying the underlying genetic aetiology for SCID patients.

Safety and efficacy of etanercept in a cohort of patients with juvenile idiopathic arthritis under 4 years of age

OBJECTIVE

To evaluate safety, tolerability, and efficacy of etanercept in a cohort of patients with juvenile idiopathic arthritis (JIA) under 4 years of age.

METHODS

Data were collected at every visit during treatment with etanercept in 25 children who began treatment at a mean age of 3 years (range 18-48 months). Safety endpoints included the incidence of any adverse events. Efficacy endpoints included the American College of Rheumatology (ACR) Pediatric 30, 50, and 70 criteria for improvement.

RESULTS

Data from 25 patients with JIA treated with etanercept for a mean period of 23 months were analyzed. All patients received concomitant medications: 24 methotrexate, 3 cyclosporin A, and 10 corticosteroids. After the first 6 months of treatment, 15 (71.4%) patients achieved an ACR Pedi30 response and at the last observation 20 (80%) achieved ACR Pedi30. ACR Pedi50 and 70 responses were, respectively, 62% and 43% at 6 months and 72% and 64% at the last followup. Five patients (20%) discontinued etanercept for lack of efficacy. Two (8%) developed adverse events, both primary varicella zoster virus (VZV) infections (both not vaccinated). One was hospitalized because of a necrotizing fasciitis secondary to VZV infection. No cases of tuberculosis, opportunistic infections, or malignancies were reported.

CONCLUSION

In our cohort of patients etanercept proved to be safe and efficacious in the majority of children. The response in toddlers was similar to that in older children. We observed only 1 case of severe infection that required hospitalization and stopped treatment temporarily.

Public health significance of chickenpox on ships - conclusions drawn from a case series in the port of Hamburg

BACKGROUND

Despite international notification requirements, the magnitude of disease transmission on board ships remains undetermined. This case series aims to exemplify that varicella aboard ships is a topic of interest for maritime medicine and of public health significance.

MATERIAL AND METHODS

Systematic presentation of cases of chickenpox reported to the Hamburg Port Health Authority between November 2007 and April 2008. A systematic literature search on 'ships and chickenpox' was performed.

RESULTS

Five crew cases of chickenpox were reported from two passenger ships and two cargo ships. The cases originated from Indonesia (2), the Philippines (1), and Sri Lanka (2). Three cases were notified by the shipmaster, one by a general practitioner, and one by the immigration service. Sources of infection were other crewmembers, passengers, and persons in the home countries.

CONCLUSIONS

This description of five varicella cases aboard ships points to the significance of the disease among seafarers. Many seafarers originate from tropical countries where seroconversion to varicella zoster virus generally occurs in late adolescents and adults. Thus, a substantial portion of the crew may be non-immune and have the potential to introduce the disease from their home country to the ship, or are at risk for infection on the ship. Port health authorities, shipmasters, and doctors need to be well informed about the relevance of chickenpox on ships and the recommended control measures. Travellers should be advised to report to the ship doctor with any signs of infectious disease.

[Herpes zoster-associated morbidity in children undergoing chemotherapy for acute lymphoblastic leukaemia]

INTRODUCTION

Herpes zoster rarely occurs in healthy children, but may occur frequently and may take a complicated course in children receiving chemotherapy. We aimed to assess morbidity from herpes zoster in children with acute lymphoblastic leukemia (ALL).

MATERIAL AND METHODS

Reviewing records, treatment and course of zoster eruptions were registered in a cohort of 67 children with newly diagnosed ALL. Of these, 45 had had varicella at the time of diagnosis and 15 contracted varicella or were vaccinated during the course of therapy.

RESULTS

Eleven children had a total of 17 eruptions while receiving chemotherapy. All eruptions were treated with acyclovir, in eight cases intravenously, and in six cases chemotherapy was interrupted. Cutaneous dissemination occurred in two cases, visceral dissemination in none. One child had postherpetic trigeminal neuralgia for two months. The eruption rate was higher among small children than among school-aged children (0.22 vs. 0.13 per year of chemotherapy) and was related to the intensity of chemotherapy (0.30 per year of consolidation treatment vs. 0.13 for maintenance therapy). Three children on prolonged intensive chemotherapy had recurrent zoster episodes.

CONCLUSION

Chemotherapy causes zoster eruptions in approximately one quarter of children with ALL, and with intensive protocols recurrent zoster can cause significant morbidity. Attempts to improve immunity by vaccine boosting after attaining remission seems warranted.

[Varicella-associated morbidity in children undergoing chemotherapy for acute lymphoblastic leukaemia]

INTRODUCTION

In children with cancer, varicella can be complicated by visceral dissemination with a risk of fatal outcome, especially in children with acute lymphoblastic leukaemia (ALL). Immunoprophylaxis and antiviral therapy have reduced the mortality, but the morbidity remains significant and is explored here in a cohort of children with ALL.

MATERIAL AND METHODS

Among 67 children diagnosed with ALL during 1992-2007, 22 were seronegative for varicella-zoster virus (VZV) at the time of diagnosis. Patient records were reviewed to describe varicella exposures, eruptions and vaccinations during chemotherapy (24-30 months) and the following six months of immune recovery.

RESULTS

Fifteen exposures were recognised in eight children and were managed with oral acyclovir prophylaxis; three resulted in clinical infection. Adoption of brief prophylaxis in the second week of incubation has not - so far - increased the infection rate (one in six versus two in nine). A further six varicella cases occurred without recognised exposure. All nine eruptions (in eight children) were uncomplicated but entailed hospitalisation days for intravenous therapy with acyclovir and loss of chemotherapy days. Seven children were VZV-vaccinated during maintenance chemotherapy; none developed varicella or zoster later in the course.

CONCLUSION

Despite protective isolation and prophylactic treatment, seronegative children with ALL have a high risk of varicella during or shortly after chemotherapy. We recommend that susceptible siblings should be vaccinated at the time of diagnosis and the child should receive vaccination once oral maintenance chemotherapy has been initiated.

[Adenosine deaminase deficiency associated severe combined immunodeficiency with disseminated varicella infection after vaccination: a case report]

OBJECTIVE

To enhance the knowledge of adenosine deaminase (ADA) deficiency associated severe combined immunodeficiency (SCID) with disseminated varicella infection after vaccination.

METHODS

With case report and review of literature, the background knowledge, clinical and laboratory findings, diagnosis and treatment of ADA-deficient SCID were discussed.

RESULTS

The patient had the condition with failure to thrive. The main complaint was more than three weeks of fever and rash. He had received the live attenuated Oka strain varicella vaccination approximately two weeks before the onset of rash. Varicella infection was confirmed with direct immunofluorescence assay. The patient had mild leukopenia, with 3% lymphocytes. The initial immunologic workup included decreased IgG, IgM and IgA, abnormal expanded lymphocyte enumeration which confirmed the reduction of CD3, CD4, CD8, CD19 and CD56. Enzyme testing for ADA activity showed remarkably low level in the hemolysate, as well as increased levels of deoxyadenosine nucleotides.

CONCLUSION

ADA-deficient SCID has some characteristic clinical and laboratory findings. Management options for ADA-deficient SCID include hematopoietic stem cell transplantation, enzyme replacement therapy and gene therapy. Immunodeficiency should be considered in children with severe failure-to-thrive. Live vaccine administration should be avoided in patients with immunodeficiency.

Persistent varicella as the initial manifestation of systemic lymphoma

Varicella is a common benign childhood disease that often presents in adolescents and adults in a more severe form. We report a previously healthy 50-year-old man who developed multiple necrotic cutaneous ulcers associated with fever, asthenia and anorexia. Physical examination revealed few tense hemorrhagic vesicles on the trunk and necrotic cutaneous ulcers scattered over the entire cutaneous surface. After the diagnosis of varicella with varicella pneumonia was established, treatment with acyclovir was instituted. His poor response to treatment was indicative of immune compromise; an underlying peripheral T-cell lymphoma was discovered.

Different genotype pattern of varicella-zoster virus obtained from patients with varicella and zoster in Germany

The general use of the varicella vaccine requires the surveillance of varicella-zoster virus (VZV) strains in patients infected with VZV. This paper reports the data achieved from a prospective study of genotyping VZV in Germany, analyzing the restriction fragment length polymorphism (RFLP) of the open reading frames (ORF) 38, 54, and 62 as well as the polymorphism of the R5 repeat region. The study included 177 patients with varicella. Seventy-eight patients with zoster served as controls. Results revealed that 78% of VZV strains in patients with varicella had the genetic profile of the dominant wild-genotype occurring in Europe and 22% had the markers of African or Asian strains. Varicella patients with the profile of African or Asian strains were significantly younger than patients with varicella caused by the dominant genotype. By contrast, all zoster patients exhibited strains representing the majority of wild-type strains in Europe. In conclusion, VZV strains from patients with varicella have a significantly higher genetic variability than viral strains from zoster patients. Since variants with the markers of African or Asian strains could only be found in young children with chickenpox, the results suggest a changing scene of VZV genotypes in Germany. As reasons, the spread of viruses, which may be imported originally by persons immigrating from warmer climates, or the recombination between wild-and vaccine-type viruses have to be considered.

Risk factors for chickenpox incidence in Taiwan from a large-scale computerized database

OBJECTIVE

We analyzed data from the National Health Insurance Research (NHIR) database in the year 2000 to estimate the seasonal variation in the chickenpox rate in Taiwan.

PATIENTS AND METHODS

All chickenpox cases listed in the NHIR database were included (n = 165,719). A Lorenz curve was plotted and a chi-square test for equal proportions calculated for seasonal variation. To determine the effects of temperature and season on outcome values, generalized estimating equation methods were utilized to adjust the effects of other possible influencing factors and take into account the within-subject dependence over repeated assessments.

RESULTS

All four regions of the country had highest incidence rates in January, and three of them had lowest rates in September. Incidence was significantly higher in females aged 15-24 years than in males. An increment of 1 degrees C resulted in an incidence ratio of approximately 0.98 or, equivalently, a 10 degrees C increment gives an incidence ratio of approximately 0.78.

CONCLUSION

The results suggest that season and temperature are significantly related to the incidence of chickenpox. Infectious diseases can be monitored. Prevention procedures can be taken by understanding its pattern and activity in order to decide the best policy for vaccination. Further studies are warranted, particularly for long-term trends, and in other nations with different seasonal temperatures from Taiwan.

An outbreak of chickenpox in adult renal transplant recipients

Infection with the varicella-zoster virus, the etiologic agent of chickenpox and herpes zoster, is more serious in immunosuppressed renal transplant recipients than it is in the general population. Chickenpox is a rare infection in adult renal transplant recipients; however, it is significant owing to the severity of its clinical features and its associated high mortality rate. To date, there are no reported outbreaks of primary varicella-zoster virus infection in adult renal transplant recipients. Here, we report 3 patients with chickenpox who presented to our center between May 2006 and June 2006.

The high incidence of varicella herpes zoster with the use of bortezomib in 10 patients

Bortezomib, a proteasome inhibitor, has been used for patients with refractory and relapsed multiple myeloma, lymphoma and leukemia. We used bortezomib in ten refractory or relapsed patients (seven of multiple myeloma, two of lymphoma and one of acute myeloblastic leukemia). Six out of ten (60%) patients developed varicella herpes zoster after the complete of one cycle of bortezomib. The incidence of varicella herpes zoster was higher than reported in the literature. It may be due to immunosuppression caused by the combination of high-dose dexamethasone or other drugs. We considered that prophylactic antiviral medication could be used in predisposed patients to reduce the incidence of varicella herpes zoster.

Development of Mixed-Type Autoimmune Hemolytic Anemia and Evans' Syndrome following Chicken Pox Infection in a Case of Low-Titer Cold Agglutinin Disease

We describe a patient with low-titer cold agglutinin disease (CAD) who developed mixed-type autoimmune hemolytic anemia (AIHA) and idiopathic thrombocytopenia following chicken pox infection. At least 1 year before admission to hospital, the patient had mild hemolytic anemia associated with low-titer cold agglutinins. A severe hemolytic crisis and thrombocytopenia (Evans' syndrome) occurred several days after infection with chicken pox, and the patient was referred to our hospital. Serological findings revealed the presence of both cold agglutinins and warm-reactive autoantibodies against erythrocytes, and the diagnosis was mixed-type AIHA. Following steroid therapy, the hemoglobin (Hb) level and platelet count improved. The patient was closely followed over a 10-year period with recurrent documented hemolysis after viral or bacterial infections. Warm-reactive autoantibodies have not been detected in the last 2 years, and only the immunoglobulin M anti-I cold agglutinins with a low titer and wide thermal amplitude have remained unchanged. Therefore, the patient has received at least 10 mg prednisolone daily to maintain a Hb level of 10 g/dL. To the best of our knowledge, no adult case of low-titer CAD that has evolved into mixed-type AIHA and Evans' syndrome after chicken pox infection has been previously reported in the literature.

Chicken pox after pediatric liver transplantation

Previous case series have reported serious complications of chicken pox (CP) after pediatric liver transplantation (PLT), mainly due to visceral dissemination. The goal of our study was to determine the incidence, risk factors, and outcomes of CP after PLT. A case-control study of all CP infections in pediatric transplant recipients followed at our center from September 1993 to April 2004 was performed. Data were collected before and after infection and at the same time points in age-, gender-, and transplant year-matched controls. Potential risk factors prior to CP and adverse outcomes after infection were compared between cases and controls. Twenty (6.2%) developed CP at a median of 1.8 yr (0.6-4.8) after PLT. All CP infections were cutaneous, with no evidence of organ involvement. Twelve were hospitalized: 9 only to receive intravenous acyclovir and 3 stayed > or =2 weeks for other complications. Risk factors were not statistically different among cases and controls. Of the outcomes analyzed, cases were significantly more likely to develop non-CP infections within one year of CP than controls (Hazard Ratio = 12.6, 95% confidence interval = 3.1-51.7; P < 0.001). These infections were often bacterial and occurred long after CP infection. In conclusion, CP is uncommon after PLT and has a low likelihood of organ dissemination. No risk factors were identified. Some cases required prolonged hospitalizations. Close monitoring for the development of late bacterial infections is warranted.

Varicella-zoster virus ORF4 latency-associated protein is important for establishment of latency

Varicella-zoster virus (VZV) encodes at least six genes that are expressed during latency. One of the genes, ORF4, encodes an immediate-early protein that is present in the virion tegument. ORF4 RNA and protein have been detected in latently infected human ganglia. We have constructed a VZV mutant deleted for ORF4 and have shown that the gene is essential for replication in vitro. The ORF4 mutant virus could be propagated when grown in cells infected with baculovirus expressing the ORF4 protein under the human cytomegalovirus immediate-early promoter. In contrast, the VZV ORF4 deletion mutant could not be complemented in cells expressing herpes simplex virus type 1 (HSV-1) ICP27, the homolog of ORF4. Cells infected with baculovirus expressing ORF4 did not complement an HSV-1 ICP27 deletion mutant. VZV-infected cotton rats have been used as a model for latency; viral DNA and latency-associated transcripts are expressed in dorsal root ganglia 1 month or more after experimental infection. Cotton rats inoculated with VZV lacking ORF4 showed reduced frequency of latency compared to animals infected with the parental or ORF4-rescued virus. Thus, in addition to VZV ORF63, which was previously shown to be critical for efficient establishment of latency, ORF4 is also important for latent infection.

The effect of low-dose aciclovir on reactivation of varicella zoster virus after allogeneic haemopoietic stem cell transplantation

Patients undergoing haemopoietic stem cell transplants (HSCT) are at high risk of varicella zoster virus (VZV) reactivation, with a significant incidence of dissemination. This study reports a retrospective analysis of 247 allogeneic HSCT recipients receiving anti-viral prophylaxis with low-dose oral aciclovir 400 mg/day, administered until immunosuppression was discontinued and the CD4(+) cell count exceeded 200/mm(3). Viral reactivation was successfully suppressed by aciclovir prophylaxis, with only one case of breakthrough infection. The cumulative incidence of zoster infection at 1 year post transplant was 2% and at 5 years 34%. In all, 64 patients discontinued prophylaxis. Zoster developed in 26 of these, giving a cumulative incidence of infection at 1 year after stopping aciclovir of 39% and at 3 years 44%. Infection occurred in a localised dermatomal distribution in 93% of cases. This supports previous findings that aciclovir prophylaxis prevents early VZV reactivation, although the long-term incidence is not affected as infection occurs once prophylaxis is discontinued. Such infection, however, is mild and localised. This study does not support the idea that use of such low-dose aciclovir regimens reduces the zoster incidence by permitting subclinical reactivation during prophylaxis, and therefore the re-establishment of protective anti-viral immunity.

Tuberculosis, chickenpox and scabies outbreaks in an orphanage for children with HIV/AIDS in Jamaica

OBJECTIVES

The aim of this study is to describe the investigation and management of outbreaks of acute tuberculosis, varicella zoster virus and scabies in a residential facility for children with HIV/AIDS.

METHOD

A review of the results and management for diagnosed cases of acute TB (four between 2001 and 2002) as well as varicella zoster virus (15) and scabies (14) (concurrent in March--June 2003), in a residential facility housing 24 abandoned children with HIV/AIDS was conducted. Outbreak control methods and challenges are described The modified WHO criteria were used for TB diagnosis. The diagnoses of varicella and scabies were entirely clinical.

RESULTS

Of the surviving 22 children, 12 (mean age 8 years 2 months) were female, and 10 (mean age 5 years 6 months) were male. Full immunization (primary series) was documented for 16 children, partial in one child, unknown status was documented in five children. One child had received varicella vaccine previously. Eleven (50%) children had been receiving antiretroviral triple therapy since 2002 (all in Centers for Diseases Control immunological categories 2-3). Two of the four children with tuberculosis died between 2001 and 2002; these were not on antiretroviral therapy--the 2 survivors are still on antiretroviral therapy. All staff mantoux test results were negative. Fifteen (68%) children developed chickenpox as well as three caregivers. The index case was a 13-year-old resident attending a nearby school with HIV negative children. This varicella outbreak went on to affect household members for the caregivers as well as other residential facilities nearby. Scabies affected 14 children (no caregivers); the index cases were most likely three new child residents who entered the institution in 2002 (from other homes) with histories of scabies infestation. Chickenpox and scabies dual infection occurred in seven (31%) of residents. No cases of herpes zoster, disseminated varicella infection or death because of varicella occurred Diagnosed cases of chickenpox were treated with oral acyclovir Knowledge about these disease outbreaks and their control was generally lacking.

CONCLUSIONS

Improvement in immunization coverage for children and staff as well as educating staff about infectious disease outbreaks, is necessary for effective control. Appropriate screening for infection/disease for all susceptible persons is essential along with timely reporting of outbreaks/reportable diseases. There is need for increased awareness of acute opportunistic infections in children with HIV/AIDS living in close proximity.

Involvement of the esophagus and stomach as a first manifestation of varicella zoster virus infection after allogeneic bone marrow transplantation

A 46-year-old man with myeloproliferative disorder received a stem cell transplant from an HLA-identical unrelated donor. Eight months status post transplantation, during the course of tacrolimus therapy, the patient developed severe epigastric pain and fever. FGS findings showed eruptions with blisters in the esophagus and ulcers in the stomach. Biopsy specimens revealed acidophilic inclusion bodies in the nuclei. Varicella zoster virus (VZV) DNA copies were detected in the serum. No skin lesions were observed prior to hospital admission. The diagnosis of visceral VZV infection was made and the gastric and esophageal lesions were successfully healed with acyclovir (ACV). Severe abdominal pain is one of the most important signs of VZV infection for recipients of stem cell transplantation.

Rashes occurring after immunization with a mixture of viruses in the Oka vaccine are derived from single clones of virus

Vaccination against chickenpox causes a varicella-like rash in up to 5% of healthy children and 50% of children with leukemia. The vaccine may establish latency and reactivate to cause herpes zoster, albeit more rarely than wild-type virus. All vaccine preparations are composed of a mixture of varicella-zoster virus strains that show genotypic variation at several loci. We have shown, by DNA sequencing of 40 polymorphic loci, that viruses sampled from vesicles in varicella-like and herpes zoster rashes are single clones. This finding suggests that, between the time of inoculation of the vaccine and development of rash, selection of single strains occurs. The results have general implications for the pathogenesis of varicella-zoster virus.

Immunogenicity of a two-dose regime of varicella vaccine in children with cancers

OBJECTIVE

Live-attenuated varicella vaccine is effective and safe in immunocompetent children. In this study, we assess the immunogenicity and adverse events following varicella vaccination in immunosuppressed cancer children.

METHODS

Varicella-zoster virus (VZV)-seronegative cancer children received two doses of live-attenuated VZV vaccine (Varilrix) in a span of 3 months. Patients with acute lymphoblastic leukaemia (ALL) were in the maintenance phase of chemotherapy, whereas those with solid tumours joined the study around 3-6 months from treatment discontinuation. VZV-specific cellular and humoral immune responses were measured before and after VZV vaccination.

RESULTS

The median (range) age of the 17 patients was 4.4 yr (2.0-14.5). Thirteen had ALL, one had myelodysplastic syndrome and three had solid tumours. Following vaccination, the VZV-specific stimulation index (SI) increased from 1.7 (0.9-2.9) to 17.9 (5.9-36.0) (P < 0.001). Similarly, SI to phytohaemagglutinin mitogen increased from 1136 (499-1930) to 1714 (848-2518) (P = 0.028). There were also significant increases in CD4+ cells and CD4:CD8 ratio as well as a reduction in CD16/56+ cells in peripheral blood lymphocytes. Seroconversion rate to VZV was 19% after one dose and increased to 94% after the second dose of VZV vaccine. Serum VZV-specific IgG concentrations also increased significantly following two doses when compared with one dose of VZV vaccine (P = 0.0004). One subject developed possibly vaccine-related chickenpox with self-limiting hepatitis at 5 wk following vaccination. None of the patients developed herpes-zoster at a median (range) follow-up of 27.5 months (24.0-30.0).

CONCLUSIONS

Non-immune cancer children can be effectively vaccinated against chickenpox at the defined period. However, the safety of chickenpox vaccine in these immunosuppressed children needs to be further studied.

Clinical and molecular pathogenesis of varicella virus infection

Varicella zoster virus (VZV) is a neurotropic human herpesvirus that infects nearly all humans and causes chickenpox (varicella). After chickenpox, VZV becomes latent in cranial nerve, dorsal root, and autonomic nervous system ganglia along the entire neuraxis. Virus reactivation produces shingles (zoster), characterized by pain and rash usually restricted to 1-3 dermatomes. Zoster is often complicated by postherpetic neuralgia (PHN), pain that persists for months to years after rash resolves. Virus may also spread to the spinal cord and blood vessels of the brain, producing a unifocal or multifocal vasculopathy, particularly in immunocompromised individuals. The increased incidence of zoster in elderly and immunocompromised individuals appears to be due to a VZV-specific host immunodeficiency. PHN may reflect a chronic VZV ganglionitis, and VZV vasculopathy is due to productive virus infection in cerebral arteries. Strategies that might boost host cell-mediated immunity to VZV are discussed, as well as the physical state of viral nucleic acid during latency and the possible mechanisms by which herpesvirus latency is maintained and virus is reactivated. A current summary of varicella latency and pathogenesis produced by simian varicella virus (SVV), the counterpart of human VZV, points to the usefulness of a primate model of natural infection to study varicella latency, as well as the experimental model of intratracheal inoculation to study the effectiveness of antiviral agents in driving persistent varicella virus into a latent state.

A cluster of primary varicella cases among healthcare workers with false-positive varicella zoster virus titers

BACKGROUND

Five cases of primary varicella zoster virus (VZV) we re diagnosed among hospital healthcare workers (HCWs). All had complied with a pre-employment VZV screening program and had been considered immune.

OBJECTIVES

To summarize the investigation of VZV among un-immunized HCWs and to provide recommendations for avoiding false-positive serologic tests.

DESIGN

Risk of transmission of VZV to susceptible HCWs is minimized through serologic screening. Varicella vaccine is recommended for susceptible HCWs. A commercially available latex bead agglutination assay (LA) is widely used because it is rapid and easy to perform. LA was compared with the whole-cell varicella ELISA standardized in the Centers for Disease Control and Prevention (CDC) National Herpes Laboratory.

SETTING/POPULATION

Large inner-city, tertiary-employee population.

RESULTS

In a year, 5 HCWs presented with laboratory-confirmed primary varicella infection. Four had VZV exposures 2 weeks prior to presentation. All had documented positive VZV titers by LA performed at hire. None were offered VZV vaccination. The original LAs were judged false-positives. INTERVENTION/FOLLOW-UP INVESTIGATION: Fifty-three consecutive VZV LA samples from the hospital laboratory were retested at the CDC. Forty-four samples concurred. Of the remaining 9, 4 were positive by hospital LA but negative by CDC IgG ELISA. Four were equivocal by hospital LA but negative by CDC IgG ELISA and LA. One was positive by hospital LA but negative by LA and equivocal by ELISA at the CDC.

CONCLUSION

LA may be prone to false-positive results and inappropriate for screening hospital HCWs.

Development of Varicella-Zoster virus infection in patients with chronic myelogenous leukemia treated with imatinib mesylate

PURPOSE

Infection with Varicella-Zoster virus (VZV) is an exceptionally rare complication of chronic myelogenous leukemia (CML) without stem cell transplantation. We report 16 patients with CML who developed VZV infection during imatinib mesylate therapy.

PATIENTS AND METHODS

From July 1998 until February 2002, 771 patients were included in 11 imatinib mesylate studies for all CML phases in the Departments of Leukemia and Bioimmunotherapy at The University of Texas M. D. Anderson Cancer Center. Sixteen patients developed VZV infection. Charts and follow-up information of were reviewed and analyzed.

RESULTS

Sixteen patients (2%) developed a VZV infection [15 episodes of herpes zoster (HZ), 1 varicella]. The baseline characteristics of the 16 patients with infection do not differ significantly from those who did not develop VZV infection, except for time from diagnosis of CML to imatinib (median: 55 versus 25 months, P = 0.0056) and the number of prior therapies (3 versus 1, P < 0.001). All patients received therapy with antiviral agents with good response. Six patients developed postherpetic neuralgia.

CONCLUSIONS

Our results suggest that imatinib therapy in CML is associated with low incidence of HZ infection. VZV infection is more frequent with longer duration of CML disease and with prior therapy, does not disseminate, responds well to therapy, and does not mandate a recommendation for HZ prophylaxis in such patients.

[Opportunistic infections in patients with inflammatory bowel disease undergoing immunosuppressive therapy]

Immunosuppressive agents (azathioprine, methotrexate) are increasingly being used in the treatment of inflammatory bowel disease. The use of immunosuppressive agents is associated with a greater risk of opportunistic infections, the most frequent of which are those caused by cytomegalovirus and varicella zoster virus. We present four cases of opportunistic infections due to Herpesviruses in patients undergoing immunosuppressive treatment with azathioprine for Crohn's disease. We also review the literature published on this topic. Two patients presented cutaneous varicella complicated by pneumonia and esophagitis respectively, one patient had cutaneous herpes zoster and the other had fatal pneumonia possibly caused by the Herpesvirus. In the first three the clinical course of the infection was favorable after withdrawing immunosuppressant treatment and initiating treatment with aziclovir. In patients Crohn's disease azathioprine treatment increases the risk of opportunistic infection by Herpesvirus. However, in the absence of other factors that increase immunosuppression, these infections usually have a benign course with specific antiviral therapy.

The role of solar ultraviolet irradiation in zoster

Ultraviolet radiation (UVR) suppresses many aspects of cell-mediated immunity but it is uncertain whether solar UV exposure alters resistance to human infectious diseases. Varicella-zoster virus (VZV) causes varicella (chickenpox) and can reactivate from latency to cause zoster (shingles). The monthly incidence of chickenpox and zoster in a defined Polish population over 2 years was recorded and ground level solar UV was measured daily. There was a significant seasonality of UVR. Evidence of seasonal variation was found for all zoster cases and for zoster in males, with the lowest number of cases in the winter. The number of zoster cases with lesions occurring on exposed body sites (the face) demonstrated highly significant seasonality with a peak in July/August. Seasonal models for UVR and zoster cases showed similar temporal patterns. By contrast, for varicella, the maximum number of cases was found in March and the minimum in August/September, probably explained by the respiratory spread of VZV. It is tempting to speculate that the increase in solar UVR in the summer could induce suppression of cellular immunity, thus contributing to the corresponding rise in the incidence of zoster.

Risk factors and outcome of varicella-zoster virus pneumonia in pregnant women

To determine the factors associated with an increased risk of developing varicella-zoster virus (VZV) pneumonia during pregnancy, a case-control analysis was done in which 18 pregnant women with VZV pneumonia were compared with 72 matched control subjects. VZV infection was identified clinically, and VZV pneumonia was diagnosed by dyspnea and findings on chest radiographs. Of 347 pregnant women with VZV infection, 18 (5.2%) had pneumonia treated with acyclovir, and none died. Mean gestational age at rash onset was 25.8 plus minus 8.8 weeks for patients with pneumonia and 17.7 +/- 10.3 weeks for control subjects, which was not significant in the multivariable model. Women with VZV pneumonia were significantly more likely to be current smokers (odds ratio [OR], 5.1; 95% confidence interval [CI], 1.6-16.7) and to have > or = 100 skin lesions (OR, 15.9; 95% CI, 1.9-130.2). Pregnant women with VZV infection may be more likely to develop varicella pneumonia if they are smokers or manifest > or = 100 skin lesions.

Gianotti-Crosti syndrome preceded by oral polio vaccine and followed by varicella infection

Gianotti-Crosti syndrome (papular acrodermatitis of childhood) is considered a nonspecific cutaneous host response to a variety of infectious agents, particularly viruses. Herein we report a case of Gianotti- Crosti syndrome preceded by oral polio vaccine and followed by varicella infection. The present case may support the hypothesis of initial immunization and following viral infection as a possible mechanism for Gianotti-Crosti syndrome.

Disseminated vaccine strain varicella as the acquired immunodeficiency syndrome-defining illness in a previously undiagnosed child

The Food and Drug Administration licensed a live-virus varicella vaccine (Varivax; Merck & Co Inc, West Point, PA) in March 1995. Prelicensure adverse events were minimal; however, since licensure and increased vaccine use, rare previously undetected risks have arisen. Presented here is the clinical course of a previously undiagnosed, human immunodeficiency virus-infected boy who developed dissemination of the vaccine strain of varicella zoster after immunization. chickenpox, human immunodeficiency virus, pneumonia, encephalopathy, varicella vaccine, adverse events, dissemination.