Recurrent Herpes Zoster in an Immunocompetent Male: A Case Report

Herpes zoster is an infection caused by reactivation of varicella-zoster virus presenting as multiple grouped vesicular eruptions in a dermatomal pattern with associated pain. Recurrent herpes zoster is an uncommon event in an immunocompetent host. Here, we report a case of a young male presenting with herpes zoster over the T9 and T10 dermatome with the previous scarring of herpes zoster over the T6 dermatome over the right upper trunk. The patient improved on treatment with oral acyclovir and analgesics. In any patient with recurrenrt hepes zoster, work-up should be done to rule out immunosuppresion.

Antiviral Therapy for Varicella Zoster Virus (VZV) and Herpes Simplex Virus (HSV)-Induced Anterior Uveitis: A Systematic Review and Meta-Analysis

Topic: Herpes simplex virus (HSV) and varicella zoster virus (VZV) are the most common ocular pathogens associated with infectious anterior uveitis. Currently, there are a number of antiviral agents administered to treat viral anterior uveitis (VAU). However, there is no consensus or guidelines about the most appropriate approach leading for the best treatment outcomes with fewer ocular complications.Clinical Relevance: To perform a systematic review and meta-analysis of the efficacy of different antiviral therapies in the management of anterior uveitis secondary to HSV and VZV.Methods: We searched PubMed, Web of Science, CINAHL, OVID, and Embase up to January 2020. Randomized trials, non-randomized intervention studies, controlled before and after studies and observational studies assessing the effect of oral and or topical treatments for VAU were considered. Data extraction and analysis with evaluation of the risk of bias in the included trials were performed.Results: Oral acyclovir demonstrated a statistically significant good treatment outcome in the management of VZV anterior uveitis (vs. placebo) (OR 0.26, 95% CI 0.11–0.59), but did not have similar effect in HSV anterior uveitis (OR 0.47, 95% CI 0.15–1.50). In the treatment of VZV anterior uveitis, there was significant superiority of oral acyclovir−7 day course—over topical acyclovir (OR 4.17, 95% CI 1.28–13.52). Whereas, there was no significant superiority of one of the following treatment regimens over the others: topical acyclovir over topical corticosteroids (OR 1.86, 95% CI 0.67–5.17), and oral acyclovir−7 day course—over oral acyclovir−14 day course—(OR 0.21, 95% CI 0.01–4.50) or oral valaciclovir (OR 1.40, 95% CI 0.48–4.07).Conclusion: Treatment of HSV and VZV anterior uveitis is currently based on individual experiences and limited literature, largely due to weak clinical trial evidence in this regard. Our results highlight the existence of a substantial gap in our evidence base. This finding might contribute to future research studies to ascertain the role of different antiviral therapies in the treatment of VAU.Systematic Review Registration: PROSPERO registration number: CRD420202 00404.

#6: Varicella Outbreak Investigation in a Cancer Hospital

Background Primary varicella infection is usually self-limited in immunocompetent hosts, whereas it can be quite severe in immunocompromised hosts. Atypical presentations of varicella in immunocompromised hosts can be diagnostically challenging, without laboratory testing. Varicella is an occupational hazard for susceptible healthcare providers (HCP). It assumes importance in infection prevention and control, due to the possibility of spread to other susceptible coworkers and patients. Methods This outbreak investigation report is from a 300-bed cancer care hospital in South India. A 62-year-old male patient with lymphoplasmacytic non-Hodgkin’s lymphoma was admitted on October 1 with features of bronchopneumonia and extensive skin lesions, 2 months after his last chemotherapy cycle. The patient was received in the emergency department (ED) and later shifted to the intensive care unit (ICU) due to worsening clinical condition. The clinical picture was more in favor of Stevens–Johnson syndrome, but oral acyclovir therapy was given considering a differential diagnosis of varicella. His condition deteriorated further requiring ventilator support and on the 19th day of admission, the patient succumbed to his illness and passed away. From October 14 to 19, eight HCP presented with vesicular eruptions and fever, clinically diagnosed as having varicella. This aroused the suspicion of an outbreak. An emergency outbreak control group meeting was convened to assess and address the situation. Results All outbreak cases were confirmed as varicella, clinically. Contacts, including patients assigned to HCP involved in the outbreak were traced, and their varicella immune status was assessed. Nonimmune contacts were given oral acyclovir prophylaxis as per CDC recommendations. Other HCP in the hospital were offered first dose of varicella vaccine based on their varicella immune status. With these infection prevention and control measures in place, no additional cases were identified. Being a hospital in low- to middle-income country, it was not routine practice to vaccinate susceptible HCP, after screening of varicella immune status at the time of recruitment. In the wake of the outbreak, assessment of immunity against varicella, and vaccination of susceptible HCP, is being followed up meticulously. Conclusion Varicella can present with atypical symptoms, especially in the immunocompromised host. Suspected cases should be isolated until sensitive PCR studies are done. Varicella immune status of HCP should be assessed at recruitment and vaccination should be offered to susceptible individuals. Implementation and infection prevention and control measures can help prevent and mitigate varicella outbreaks within healthcare facilities.

Clinical Study on Outcome of Treatment for Herpes Zoster

Introduction: Herpes Zoster (HZ) is caused by reactivation of Varicella Zoster Virus (VZV). It is characterised by occurrence of grouped vesicles on erythematous base which involves the entire dermatome innervated by a single spinal or cranial sensory ganglion and is associated with radicular pain. Antivirals (Acyclovir, Famciclovir and Valacyclovir) started within 72 hours of onset of lesions are the agents of choice. Aim: To study the clinical manifestations, comorbidities, efficacy and safety of Acyclovir, complications and sequelae associated with HZ. Materials and Methods: A 3-year longitudinal cohort study was conducted in 212 adult patients (>18 years of age) suffering with HZ in the Department of Dermatology, Dhiraj General Hospital, Pipariya, Gujarat, India. In this study 212 patients with HZ were prescribed oral Acyclovir in a dose of 800 mg 5 times a day for 7 days. All patients were analysed in terms of clinical manifestations, pre-existing co-morbidities and incidence of complications. The clinical history and findings were recorded in a prestructured proforma. All patients were subjected to cytological examination (Tzanck smear) and Human immunodeficiency viruses (HIV) testing Enzyme-Linked Immunosorbent Assay (ELISA). Diagnosis was made primarily on the basis of clinical findings and presence of multinucleated giant cells in Tzanck smear. All the patients were treated with Oral Acyclovir. Cases were followed-up fortnightly for six weeks and evaluated for relief of symptoms, treatment outcome and complications/sequelae. Results: Two hundred and twelve cases were studied. One hundred and forty-two cases were in the 4th and 5th decades of life. Sixty-three cases had comorbidities like diabetes mellitus in 31, autoimmune diseases like pemphigus vulgaris, systemic lupus erythematosus, rheumatoid arthritis and inflammatory bowel disease in 19 and AIDS in 8 cases. Five cases had malignancy/lymphomas and were receiving chemotherapy for the same. In the majority, HZ occurred de novo without any comorbidities. The most common dermatomes involved were cervical and thoracic. Out of 212 cases Oral Acyclovir 800 mg was well tolerated by 74. Most common complication was Postherpetic Neuralgia (PHN), seen in 80 cases. Conclusion: The treatment of HZ with Oral Acyclovir 800 mg 5 times a day for 7 days is efficacious for healing of skin lesions and also reduces the chances of PHN if instituted within 72 hours.

Population Pharmacokinetics of Intravenous and Oral Acyclovir and Oral Valacyclovir in Pediatric Population To Optimize Dosing Regimens

ABSTRACT Acyclovir is an antiviral currently used for the prevention and treatment of herpes simplex virus (HSV) and varicella-zoster virus (VZV) infections. This study aimed to characterize the pharmacokinetics (PK) of acyclovir and its oral prodrug valacyclovir to optimize dosing in children. Children receiving acyclovir or valacyclovir were included in this study. PK were described using nonlinear mixed-effect modeling. Dosing simulations were used to obtain trough concentrations above a 50% inhibitory concentration for HSV or VZV (0.56 mg/liter and 1.125 mg/liter, respectively) and maximal peak concentrations below 25 mg/liter. A total of 79 children (212 concentration-time observations) were included: 50 were taking intravenous (i.v.) acyclovir, 22 were taking oral acyclovir, and 7 were taking both i.v. and oral acyclovir, 57 for preventive and 22 for curative purposes. A one-compartment model with first-order elimination best described the data. An allometric model was used to describe body weight effect, and the estimated glomerular filtration rate (eGFR) was significantly associated with acyclovir elimination. To obtain target maximal and trough concentrations, the more suitable initial acyclovir i.v. dose was 10 mg/kg of body weight/6 h for children with normal renal function (eGFR ≤ 250 ml/min/1.73 m2) and 15 to 20 mg/kg/6 h for children with augmented renal clearance (ARC) (eGFR > 250 ml/min/1.73 m2). The 20-mg/kg/8 h dose for oral acyclovir and valacyclovir produced effective concentrations in more than 75% of children; however, a 15-mg/kg/6 h dose, if possible, is preferred. These doses should be prospectively confirmed, and therapeutic drug monitoring could be used to refine them individually. (This study has been registered at ClinicalTrials.gov under identifier NCT02539407.)

A case of successful acyclovir desensitization in a bone marrow transplant patient

Introduction The incidence of acyclovir-induced hypersensitivity is rare. To our knowledge, there are four published case reports of oral acyclovir desensitization in adults. Evidence-based guidelines prompt the use of acyclovir for herpes simplex virus (HSV) prophylaxis and treatment. Literature on the cross-reactivity of structurally similar antiviral agents is conflicting, presenting a clinical challenge when choosing an alternative agent. This is a case of successful acyclovir desensitization in an allogeneic stem cell transplant patient. Case Report A 69-year-old female patient, diagnosed with myelodysplastic/myeloproliferative neoplasm, presented to the hospital for donor mismatch allogeneic bone marrow transplant. The patient reported acyclovir-induced angioedema while receiving treatment for non-complicated herpes zoster (shingles) infection. Management & Outcome: After the acyclovir oral desensitization was conducted in an ICU setting with 1:1 patient-nurse ratio, the patient was successfully started on acyclovir therapy, 800mg by mouth twice daily for HSV prophylaxis with no further complications. Discussion: Oral acyclovir desensitization can provide an option for HSV therapy in patients reporting severe allergy.