Acyclovir-resistant herpes zoster encephalitis successfully treated with vidarabine: a case report

A 78-year-old man developed herpes zoster virus (HZV) encephalitis. Initially, treatment with aciclovir (750 mg per day) improved CSF cell count and protein level. During the treatment, however, encephalitis in the patient deteriorated in spite of the treatment with aciclovir, suggesting that HZV in the patient had become resistant to aciclovir. Subsequent treatment with vidarabine (600 mg per day, for 15 days) resulted in dramatic improvement in CSF pleocytosis. About two months after the discontinuation of vidarabine, the CSF cell count was normal. The patient became alert gradually, but his amnestic syndrome remained unchanged. Vidarabine may be recommended in the treatment of HZV encephalitis when aciclovir is not effective.     

Clinical course and treatment of herpetic trigeminal ganglionic neuropathy

45 patients were observed in the periods of both acute herpes zoster and postherpetic neuralgia (PHN). In most of the patients herpetic eruptions were located in the areas of innervation of the first branch of the trigeminal nerve. In acute period of the disease there were used aciclovir, helepin or alpisarinum, antiherpetic immunoglobulin, deoxyribonuclease, non-narcotic analgetics were used. Of 28 patients residual PHN was observed in 6 cases, delayed PHN (during 3 months)--in 2 patients. The PHN development was characteristic for elderly patients, delayed request for medical care, concomitant diseases, eruptions with hemorrhagic component and secondary pyodermia and considerable residual sensory deficit. In therapy of PHN the most effective drugs were amitriptylin, non-narcotic analgetics, anticonvulsants as well as acupuncture and electroacupuncture. Relief of a typical deafferentation of pain syndrome was achieved by means of ultrasonic destruction of the trigeminal nucleus (one case). Early therapy of acute herpes zoster does not prevent completely PHN development, but it decreased considerably probability of its forming as well as the severity of its course.     

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.     

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.     

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.     

Hong Kong reverts to Chinese rule but won''t introduce China''s strict birth-control policies

A previously healthy, 37-year-old immunocompetent man presented with disseminated cutaneous zoster and aseptic meningitis. Varicella zoster virus DNA was recovered from the cerebrospinal fluid (CSF) by the polymerase chain reaction. Cytological evaluation of the CSF revealed 'reactive, highly atypical lymphocytosis'. The patient fully recovered after treatment with aciclovir.     

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.     

Chickenpox: varicella pneumonia in adults

Two patients, a man aged 33 years and a woman aged 30, suffered from a varicella zoster induced pneumonia. In adults a varicella zoster infection may be accompanied by a very severe pneumonia. In one patient mechanical ventilation was necessary. A chest X-ray and blood gas analysis must be made in adults suffering from a varicella zoster virus infection who have pulmonary complaints. In case of abnormalities in one of these two examinations the patient must be observed in a clinical setting. The pneumonia can be treated with aciclovir.     

Herpes zoster polyradiculopathy

Herpes zoster infection, resulting from reactivation of the dormant varicella zoster virus in the dorsal root ganglia, usually causes a painful dermatomal vesicular rash. Rarely, associated peripheral motor weakness is present, the mechanism of which is unclear. Three patients are reported who had focal limb muscle weakness associated with zoster infection. Physical and occupational therapy played a key role in motor function recovery of the patients, yet emphasis on the rehabilitation of postherpetic motor weakness is lacking in the literature. Physiatrists evaluating patients with limb muscle weakness following herpes zoster infection should be alert to this condition. The clinical syndrome of herpes zoster radiculopathy and the rehabilitation of these patients are discussed.     

Herpes zoster, immunological deterioration and disease progression in HIV-1 infection

OBJECTIVE: To study the incidence of herpes zoster, the relationship between herpes zoster and immunological markers, and the prognostic value of herpes zoster for progression of HIV disease. DESIGN AND METHODS: A total of 966 homosexual participants in The Amsterdam Cohort Study were studied. Herpes zoster was defined by its characteristic clinical presentation. Incidence was calculated using Poisson regression, cumulative incidence by the Kaplan-Meier product-limit method and the prognostic value was evaluated using Cox proportional hazards model. RESULTS: The incidence of first episodes of herpes zoster was 3.31 per 1000 person-years (PY) in HIV-seronegatives and 51.51 per 1000 PY in HIV-1-seropositive individuals. Recurrences only occurred in HIV-1-positive patients (25.6%). Cumulative incidences of first episodes increased linearly with the duration of follow-up. In HIV-1-seropositives the incidence was 31.2 per 1000 PY at CD4+ cells > or = 500 x 10(6)/l, 47.2 per 1000 PY [relative risk (RR), 1.51; 95% confidence interval (CI), 0.78-2.94] at CD4+ cells 200-499 x 10(6)/l and 97.5 per 1000 PY (RR, 3.13; 95% CI, 1.54-6.32) at CD4+ cells < 200 x 10(6)/l. Besides CD4+ cell counts, CD3 monoclonal antibodies and phytohaemagglutinin-induced T-cell reactivity were independent predictors for herpes zoster. The hazard ratio for AIDS after herpes zoster was 1.6 (95% CI, 1.1-2.4) and for death 1.7 (95% CI, 1.1-2.5), but these were not independent from CD4+ cell counts. CONCLUSION: In HIV-1 infection the incidence of herpes zoster increases with the decrease of CD4+ cell counts and T-cell reactivity, but herpes zoster is not an independent predictor for disease progression.     

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.     

Antihypertensive effects of CS-045 treatment in obese Zucker rats

A case of herpes zoster involving the ophthalmic and maxillary divisions of the trigeminal nerve is reported. It presented as a oral herpes zoster infection with prodromal odontalgia and progressed to spontaneous exfoliation and devitalization of teeth and osteonecrosis of the maxilla. The literature is reviewed and the pathophysiology of tooth exfoliation, tooth devitalization and osteonecrosis by V-Z viruses are discussed in addition to the management of herpes zoster and post-zoster complications.     

Significance of herpes zoster in HIV/AIDS in Kweneng district, Botswana

OBJECTIVE: To determine the relevance of herpes zoster eruption or scar relative to other symptoms and signs of HIV/AIDS and to look for a syndromic model that could be used in the diagnosis of HIV infection. DESIGN: Retrospective case-control study on data from the results of HIV request forms in the district from 1st January 1993 to 31st March 1996. HIV request forms bearing ELISA positive results represented the cases. SETTING: All the 55 health facilities and one district hospital in Kweneng district, Botswana. SUBJECTS: Six hundred and forty one valid request forms across all age groups and both sexes were analysed. MAIN OUTCOME MEASURES: Proportion of herpes zoster among cases and controls. Sensitivity and specificity test values for herpes zoster as a screening test. Logistic regression on 11 symptoms and signs found to have a significant relationship to ELISA either on the chi 2 test or on tests for the attributes of an ideal screening test. RESULTS: Herpes zoster ranked sixth as the most common sign associated with a positive ELISA result. The difference in the proportion of herpes zoster among cases and controls was highly significant, (chi 2 = 13.1, OR 3.75, CI =1.7-9.3. p = 0.0003). The following also had a significant relationship; chronic diarrhoea, persistent generalised lymphadenopathy (PGL) and non-healing genital ulcers. In addition, herpes zoster and chronic diarrhoea were highly specific and had high positive predictive values for a positive HIV ELISA positive result in 95.5% cases; chronic diarrhoea, weight loss, herpes zoster, persistent generalised lymphadenopathy and non-healing genital ulcers. CONCLUSION: Herpes zoster is an important predictor of HIV/AIDS in Kweng district (PPV = 90%). Used in the above model, prediction rises up to 95.5%. In the absence of an HIV ELISA test, this model alone could be sufficient for a clinical diagnosis of HIV infection, at least in Kweneng. It is also suggested that the presence or a history of herpes zoster scar or eruption be elevated to the status of a major sign in the World Health Organization (WHO) clinical definition for AIDS surveillance.     

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.     

Hypotension in acyclovir therapy

A 51 year old man developed Herpes zoster on the right arm (C5/C6) treated subsequently with aciclovir infusions (500 mg, 3/day). Ten months before hospital admission he did have a radical resection of a epi-oro-hypopharyngeal carcinoma (T4/N1/G2, M0; lymphangiosis carcinomatosa) as well as a partial laryngeal resection for a recurrence 3 months later and removal of a cervical lymph node metastasis after two further months. During aciclovir treatment the patient experienced repeated bradycardia with hypotension verifiable with the tilt-table test. The bradycardias could not be further characterized by ECC. Neither sonography nor CT-scans gave an indication for infiltration of the cervical course of the vagus or glossopharyngeal nerves. Serum catecholamines were, however, markedly reduced. After cessation of aciclovir the bradycardias and hypotensive episodes disappeared. A final tilt-table test was unremarkable. A reversible autonomic neuropathy induced by aciclovir seems a possible explanation.     

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.     

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.     

Rare presentation of acute urinary retention secondary to herpes zoster

There are many causes of acute urinary retention. Reported here is a case of one of the more rare causes: herpes zoster. Fewer than 70 cases have been reported in the literature since 1890. In the present clinical environment where many patients are immunocompromised, reports of herpes zoster and its sequelae are no longer thought of as anecdotal. The virus may interrupt the detrusor reflex due to involvement of the sacral dorsal root ganglia. Urinary retention with sensory loss of both bladder and rectum as well as flaccid paralysis of the detrusor can develop in patients with herpes zoster. Fortunately, the outcome of this process is benign and full recovery of the detrusor is likely.     

Presumed bilateral herpes zoster ophthalmicus in an AIDS patient: a case report

A 31-year-old man with the acquired immunodeficiency syndrome presented with herpes zoster ophthalmicus on the right. Five days after he began treatment for the zoster pseudodendrites and skin lesions, he developed superficial punctate keratitis, uveitis, and crusting skin lesions in the left eye. After treatment, the ocular lesions resolved in both eyes without incident. The bilateral manifestation of herpes zoster ophthalmicus is a result of the increased severity associated with immunosuppression caused by the human immunodeficiency virus.     

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.