Association of herpes zoster ophthalmicus with acquired immunodeficiency syndrome and acute retinal necrosis

We conducted a review to investigate the prevalence of human immunodeficiency virus (HIV), or acquired immunodeficiency syndrome (AIDS), in patients with herpes zoster ophthalmicus, as well as the incidence of acute retinal necrosis after herpes zoster ophthalmicus. All charts of patients seen at our institution between 1987 and 1992 with a primary diagnosis of herpes zoster ophthalmicus were reviewed. Of 112 patients with herpes zoster ophthalmicus, 29 (26%) had HIV or AIDS. All these patients were younger than 50 years at the time of diagnosis. Five of 29 (17%) immunocompromised patients had acute retinal necrosis after herpes zoster ophthalmicus. No acute retinal necrosis was identified in the nonimmunocompromised patients after herpes zoster ophthalmicus. We recommend that all patients younger than 50 years who have herpes zoster ophthalmicus at initial examination be tested for HIV. Additionally, HIV-infected patients should be monitored closely after herpes zoster ophthalmicus for development of acute retinal necrosis. Long-term oral prophylactic as well as initial high-dose intravenous acyclovir may be appropriate in HIV-infected individuals with herpes zoster.     

Rhabdomyosarcoma. Presentation of 67 cases

Two cases of herpes zoster ophthalmicus with dendritic keratitis are reported. Virological studies confirmed the double infection with herpes simplex type 1 virus in the corneal lesions and herpes zoster virus in the cutaneous lesions. We suggest the use of the immunoperoxidase test to identify the viral agent mainly because of its rapid and specific results. We are against the use of local steroids in dendritic keratitis unless the etiological agent is proved to be herpes zoster virus and not herpes simplex virus.     

Chronic varicella-zoster virus skin lesions in patients with human immunodeficiency virus are related to decreased expression of gE and gB

The pathogenesis of chronic, verrucous varicella-zoster virus (VZV) cutaneous lesions in human immunodeficiency virus (HIV)-infected persons is unknown. It has been hypothesized that these lesions are due to an altered pattern of virus gene expression. Immediate early and late (L) gene expression in five chronic verrucous VZV lesions, four full-blown herpes zoster vesicular lesions in HIV-infected persons, and eight vesicular herpes zoster lesions in immunocompetent individuals was semiquantitatively assessed immunohistochemically using specific antibodies to the IE63, gE (L), and gB (L) proteins. All patients had evidence of IE63 expression in keratinocytes; however, gE expression was either weak or absent in keratinocytes of three verrucous lesions, and gB was either weak or absent in two. These results suggest that chronic VZV skin lesions are associated with diminished gE and gB expression. It is inferred that the VZV behavior in keratinocytes may vary from a latency-like state to a fully developed, productive infection.     

Transdermal application of 10% lidocaine-gel for management of pain associated with herpes zoster

We have developed transdermally applicable 10% lidocaine aqueous gel containing an absorption promoter and applied it for 15 patients suffering from severe pain in acute or subacute phase of herpes zoster. The patients, consisting of 7 males and 8 females with a mean age 58.5 +/- 13.0 (SD) yrs, had skin eruptions of herpes zoster for the past 2 months. Lidocaine-gel was applied locally to the diseased skin with or without an occlusive dressing. In 14 of the 15 patients (93%), a remarkable reduction of pain (below 10% of pretreatment level) was obtained after 9.9 +/- 5.6 (SD) times of lidocaine-gel treatments. There was no adverse systemic reactions or local skin damages. None of them developed post-herpetic neuralgia. The lidocaine-gel treatment appears to be very useful for reduction of pain associated with acute or subacute phase of herpes zoster.     

Scanning and transmission electron microscopic studies of lesional epidermis in herpes zoster

The epidermal skin lesions of herpes zoster were studied by scanning (SEM) and transmission electron microscopy (TEM). When erythematous lesions were observed by TEM, many of the infected keratinocytes showed evidence of cell degeneration, being characterized by swollen nuclei, disappearance of desmosomes, and widening of intercellular spaces. Macrophages and/or lymphocytes migrated through the intercellular spaces between degenerated keratinocytes. In the vesicular lesions, SEM and TEM showed some infiltrating neutrophils, directly adhering to the virus-infected keratinocytes, with swollen nuclei and irregularly clumped chromatin. In some specimens, balloon-degenerated keratinocytes were observed in the cavity. In the pustular stage, ruptured keratinocytes and numerous neutrophils were observed in the reticular-degenerated epidermal tissue. These results suggest that, in herpes zoster, the epidermal damage may be due, at least in part, to cell-mediated host immunity as well as to the cytopathic effect of varicella-zoster virus.     

Immunohistochemical identification of varicella-zoster virus gene 63-encoded protein (IE63) and late (gE) protein on smears and cutaneous biopsies: implications for diagnostic use

Early and specific recognition of varicella zoster virus (VZV) infection is of vital concern in immunocompromised patients. The aim of this study was to compare the diagnostic accuracy of histochemical and immunohistochemical identification of the VZV ORF63 encoded protein (IE63) and of the VZV late protein gE on smears and formalin-fixed paraffin-embedded skin sections taken from lesions clinically diagnosed as varicella (n = 15) and herpes zoster (n = 51). Microscopic examinations of Tzanck smears and skin sections yielded a diagnostic accuracy of Herpesviridae infections in 66.7% (10/15) and 92.3% (12/13) of varicella, and 74.4% (29/39) and 87.8% (43/49) of herpes zoster, respectively. Immunohistochemistry applied to varicella provided a type-specific virus diagnostic accuracy of 86.7% (13/15; IE63) and 100% (15/15; gE) on smears, and of 92.3% for both VZV proteins on skin sections. In herpes zoster, the diagnostic accuracy of immunohistochemistry reached 92.3% (36/39; IE63) and 94.9% (37/39; gE) on smears, and 91.7% (44/48; IE63) and 91.8% (45/49; gE) on skin sections. These findings indicate that the immunohistochemical detection of IE63 and gE on both smears and skin sections yields a higher specificity and sensitivity than standard microscopic assessments.     

Subcutaneous implantation metastasis of a cholangiocarcinoma of the bile duct after percutaneous transhepatic biliary drainage (PTBD)

The differential diagnosis of herpes simplex and zoster may require virological confirmation, yet virus typing is not regarded as necessary in routine dermatological assessment. In an attempt to evaluate the clinical benefits of the routine detection of herpes simplex virus (HSV) and varicella zoster virus (VZV), we analysed skin swabs from 110 patients who were diagnosed at the first clinical visit as having herpes simplex (n = 45) or zoster (n = 65). Viruses were typed using the polymerase chain reaction (PCR) with the general primer pair GPHV-RU. PCR analysis showed that at the initial clinical presentation, herpes simplex in these patients was not mistaken for zoster but that zoster was incorrectly diagnosed as herpes simplex in nine cases. Thus these results suggest that initial zoster often mimics herpes simplex, hence routine PCR diagnosis of HSV and VZV or alternative rapid diagnostic approaches may be beneficial in these cases.     

Bilateral pneumothorax, pneumomediastinum and pneumoperitoneum following unilateral percutaneous lung biopsy

A case of atypical varicella zoster in a 33-year-old AIDS patient is reported. The patient had had two attacks of herpes zoster within a year and was given high-dose acyclovir several times. Thereafter he developed small keratotic pellucid papules on fingers, wrists and face, which were found to contain varicella-zoster antigen by the ELISA test. Skin biopsy showed acanthosis and lack of vesication, as is usually seen in herpes infections. The atypical varicella-like lesions persisted despite repeated doses of acyclovir but cleared temporarily when the patient was given foscarnet. We believe that the prolonged therapy may have allowed selection of acyclovir-resistant varicella-zoster strains, resulting in the atypical clinical course.     

A retrospective study of the clinical presentation and outcome of herpes zoster in a tertiary dermatology outpatient referral clinic

BACKGROUND: This is a retrospective study of the epidemiology and morbidity of herpes zoster and the risk factors for herpes zoster morbidity in Singapore. RESULTS: The mean age of 164 patients with herpes zoster seen at our dermatology clinic between January 1994 and December 1995 was 48.8 years, with a sex ratio of 1:1. The common presenting symptoms were pain (90%), feelings of helplessness and depression (20%), and flu-like symptoms (12%). The commonest prodromes were pain (41%), itching (27%), and paresthesia (12%). Prodromal pain was more frequently experienced by patients aged more than 50 years (42%) than by patients aged less than 30 years (25%). The thoracic (45%) and cervical (23%) dermatomes were the most commonly affected in all age groups. There was no statistically significant difference in the frequency of dermatomal distribution among the different age groups and between the sexes. Pain was experienced by almost all (95%) patients during the course of their disease. It tended to be more severe in older patients. Burning (26%), stabbing (15%), and shooting (15%) pain were the most common types experienced. Post-herpetic neuralgia was significantly more common in older patients. The prevalence of post-herpetic neuralgia decreased over time in all age groups. A higher proportion of older patients (more than 50 years of age) (20%) suffered from post-herpetic neuralgia compared with younger patients (less than 30 years of age) (7%) (not significant). Patients in all age groups considered acute pain (46%) and persistent pain (25%) to be their most unbearable symptoms during the course of herpes zoster. The most significant problems caused by herpes zoster pain were insomnia (25%), misery (feeling helpless and depressed) (20%), limitation of movement (9%), and inability to continue work (8%). Insomnia was significantly more commonly experienced by patients more than 50 years of age (36%) than those less than 30 years of age (P = 0.026). Few patients (9%) consulted their general practitioner (GP) during the prodrome or on the day of appearance of skin eruptions. Most patients (45%) consulted their GP within the first 3 days of the onset of skin eruptions; 33% sought treatment more than 3 days after the appearance of zoster symptoms. Only 30% of patients were willing to pay more than S$200 for antiviral therapy. Most (43%) were only prepared to pay for antiviral treatment if it cost less than S$200. The most important features the patients wished to derive from antiviral therapy were a shortening of the duration of skin lesions (55%) and a reduction in the severity of pain (acute and chronic) (30%). CONCLUSIONS: Our study indicated that older patients (aged more than 50 years) were at a higher risk of developing post-herpetic neuralgia. They were also more likely to suffer morbidity, e.g. insomnia. There is a need to educate patients at risk to identify the prodrome and skin eruptions of herpes zoster so that early antiviral therapy can be considered.     

Lactation associated with herpes zoster pectoralis

The phenomenon of lactation associated with herpes zoster is unexpected. To our knowledge such an association has been reported only once. A case is reported in whom spontaneous lactation occurred in the ipsilateral breast following herpes zoster. It is believed to have resulted from stimulation of the intercostal nerve endings supplying the overlying skin of the breast.     

Urinary retention due to herpes virus infections

Urinary retention is uncommon in patients with herpes zoster and anogenital herpes simplex. Seven patients (four men, three women) with a mean age of 68.1 years (range, 35-84) with urinary retention due to herpes zoster (n = 6) or anogenital herpes simplex (n = 1) were studied. Six patients had unilateral skin eruption in the saddle area (S2-4 dermatome) and one patient with herpes zoster had a skin lesion in the L4-5 dermatome. All patients had detrusor areflexia without bladder sensation, and two of them had inactive external sphincter on electromyography at presentation. Clean intermittent catheterization was performed, and voiding function was recovered in 4-6 weeks (average, 5.4) in all patients. Urodynamic study was repeated after recovery of micturition in three patients, and they returned to normal on cystometrography and external sphincter electromyography. Acute urinary retention associated with anogenital herpes infection has been thought to occur when the meninges or sacral spinal ganglia were involved, and, in conclusion, this condition may be considered to be reversible.     

三氧化二砷治疗血液病后合并带状疱疹的临床研究

目的 分析三氧化二砷(ATO)治疗血液病后合并带状疱疹感染患者的临床特征及其可能的发生机制.方法 将研究对象分为研究组(应用ATO)和对照组(未应用ATO),观察两组带状疱疹发病率,以及研究组中发生带状疱疹和未发生带状疱疹患者的平均化疗次数.结果 研究组带状疱疹发病率为23.95%(23/96),发生带状疱疹者平均化疗7.60次,未发生带状疱疹者平均化疗7.72次(Z=0.976,P=0.296);对照组带状疱疹发病率7.89%(3/38),两组间带状疱疹发病率差异有统计学意义(χ2=4.492,P=0.034).结论 ATO治疗血液疾病可以增加带状疱疹的发病率,可能与其激活水痘-带状疱疹病毒有关.     

The occurrence of Biomphalaria straminea (Pulmonata: Planorbidae) on an aquaculture farm of IBAMA in Uberlandia, MG. Instituto Brasileiro do Meio Ambiente a dos Recursos Naturais Renováveis]

INTRODUCTION: Only few studies focus on ocular motor paralyses in herpes zoster ophtalmicus. We report 2 cases of complete ptosis resulting from paralysis of the superior lid levator, appearing at day 6 and 7 of an ophtalmic herpes zoster under treatment with acyclovir. CASE REPORTS: Case 1: A 68 year old woman presented an history of ophtalmic herpes zoster with kerato-conjunctivitis and uveitis treated with acyclovir. At the third day of the treatment and 7th day of the ophtalmic zoster, an incomplete paralysis of the oculomotor nerve appeared resulting in a complete ptosis. The treatment was carried on until the 21st day without improvement. Four months later, all symptoms had completely cleared. CASE 2: A 66 year old woman was treated with acyclovir for an ophtalmic herpes zoster without ocular involvement. At the 4th day of the treatment and 6th day of the onset of the ophtalmic zoster, a paralytic ptosis and a acute epithelial keratitis appeared. Acyclovir treatment was continued for 10 days. The ptosis resolved gradually during 2 months. DISCUSSION: The manifestation of a complete ptosis with paralysis of the oculomotor nerve or of one of its branch is rarely seen in ophtalmic herpes zoster. However minor symptoms are often detected when patients were carefully examined with regard to external ocular movements. The physiopathological mechanism are discussed about. The possible action of an early antiviral treatment on the prevention of these complications is not known. In our two cases, a paralytic ptosis broke out suddenly, even under treatment with acyclovir for respectively 3 and 4 days. For future prospective studies about antiviral drugs for ophtalmic herpes zoster, a systematic evaluation of these neurological symptoms would be interesting.     

Conjunctival flaps

PURPOSE: The authors reviewed their experience with total conjunctival flaps (TCF) and partial conjunctival flaps (PCF) for the past 5 years in 61 patients. METHODS: Forty-eight patients had TCF and 13 had PCF. Diagnoses for surgery included severe bullous keratopathy for chronic graft failure (not candidates for keratoplasty) (19), herpes zoster ophthalmicus (7), chronic ulcerative keratitis (14), neurotrophic keratitis (2), and herpes simplex keratitis (9). RESULTS: There were seven complications. Four flap retractions occurred in the TCF group, requiring resuturing in two. Three complications occurred in the PCF group. One patient had two flap retractions and recurrent ulceration, requiring tarsorrhaphy. One patient with PCF suffered a perforation after flap retraction, necessitating penetrating keratoplasty. CONCLUSION: The authors believe conjunctival flaps are underused and should be considered seriously for bullous keratopathy, neurotrophic keratitis, recalcitrant keratitis, and persistent nonhealing epithelial defects.     

Early postoperative feeding after elective colorectal surgery is not a benefit unique to laparoscopy-assisted procedures

Fungal infection of the face is frequently misdiagnosed, since the typical ringworm, erythematous, slightly scaling, indistinct borders are only uncommonly seen on the face. Herpes zoster is a common infection caused by the varicella-zoster virus that transmits varicella (chickenpox). Granulomatous reactions such as granuloma annulare, pseudolymphoma, sarcoidal reaction, and eruptive keratoacanthoma have been described in herpes zoster scars. We describe here the first reported case of dermatophytosis occurring in healing herpes zoster lesions. This condition has not been previously reported.     

Cerebral infarction associated with vasculitis due to varicella zoster virus in patients infected with the human immunodeficiency virus

Cases of herpes zoster ophtalmicus (HZO) with delayed contralateral hemiparesis caused by hemispheric stroke secondary to granulomatous angiitis have been reported and are a well-recognized complication of herpes zoster. Similar cases have been reported more recently during infection with human immunodeficiency virus (HIV). We describe two HIV+ patients without any clinical history of zoster dermatitis who developed a sudden hemiparesis followed 2 weeks later for one by an acute retinal necrosis. Computerized tomography (CT) scan, magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and digital subtraction angiography (DSA) were performed and showed a hemispheric stroke with evidence of a segmental arteritis of the carotid syphon. Varicella zoster virus (VZV) was found in the cerebro spinal fluid (CSF) in the two patients and after puncture of the vitreous fluid of the patient with the acute retinal necrosis. These two cases exemplify the difficulty of diagnosis of stroke in HIV+ patients, which seems to be more frequent than in similarly aged non-infected patients and demonstrates that VZV needs to be taken in consideration and identified even without any past history of zoster dermatitis.     

Electron microscopic study of proteoglycan aggregates synthesized by embryonic chick sternal chondrocytes in vitro

Treatment with moroxidine, Romanian preparation with virustatic effects, was applied in 350 patients with different localisation herpes zoster lesions. Treatment had good effects, especially when it was applied early.     

Detection of viral DNA to evaluate outcome of antiviral treatment of patients with recurrent genital herpes

Culture of infectious virus, PCR amplification of viral DNA, and the appearance of genital skin lesions were used as markers to study the course of a recurrence of genital herpes in 40 patients treated with famciclovir or placebo. The highest frequency of patients with skin lesions occurred within the first 36 h following the onset of a recurrence, which also corresponded to the peak in the production of virus. While the timing of the peak in skin lesions was independent of the type of treatment, the frequency of lesions and the release of virus at the lesion site were both reduced by famciclovir treatment. Furthermore, patients receiving this antiviral agent showed a more rapid recovery time and a shorter period during which viral DNA could be detected at the lesion. PCR and then Southern blot hybridization greatly enhanced our ability to detect herpes simplex virus at the lesion site. This procedure proved to be of greater diagnostic value in assessing genital herpes than the standard culture method currently used. In addition, PCR was more sensitive in evaluating treatment effectiveness.     

Hyponatraemia associated with the use of selective serotonin re-uptake inhibitors

A man with a 15-year history of non-Hodgkin's lymphoma presented with disseminated herpes zoster which initially responded to aciclovir. This was shortly followed by an acute exacerbation in the sites previously affected which was apparently resistant to antiviral therapy. Biopsy revealed a dense monomorphic lymphocytic infiltrate below active herpes zoster which had the same morphology and immunoreactivity as the underlying lymphoma. His clinical condition resolved with further chemotherapy for his lymphoma and continued treatment with aciclovir.     

Granuloma annulare after herpes zoster: isotopic response

A 33 year-old woman was seen with a localized zosteriform papular eruption in a Th7 dermatomal distribution. The patient experienced neuralgic pain. A skin biopsy demonstrated palisading granulomatous dermatitis and a diagnosis of granuloma annulare after a subclinical herpes zoster infection was made. "Isotopic response" describes the occurrence of a new disorder at the site of another, unrelated, and already healed skin disease.