Herpes zoster encephalitis an overview sciencedirect. Because hiv infection was an exclusion criterion, it is likely that we missed some patients with vzv encephalitis and hiv infection. Methods nationwide prospective cohort study of adults treated for microbiologically confirmed vzv encephalitis at danish departments of infectious diseases from 2015 to 2019. Varicella zoster virus is a unique virus because it can cause two different illnesses. Varicella zoster virus encephalitis in denmark from 2015 to. Severe and even fatal varicella has been reported in otherwise healthy children on highdose corticosteroids greater than 2 mgkgday of prednisone or equivalent for treatment of asthma and other illnesses. In this lesson, learn the symptoms and treatments for each of these infections. Varicella zoster virus encephalitis has been described during the course of or after varicella or zoster with various time frames. Varicella zoster virus encephalitis in denmark from 2015. Herpes simplex virus hsv and varicellazoster virus vzv are related viruses that both cause blistering rashes and are characterised by the ability to establish latent infection.
Varicellazoster virus pediatric opportunistic infection. Varicella zoster virus vzv infections are endemic worldwide. The diagnosis of herpes zoster virus encephalitis is based on clinical history, examination, neuroradiological imaging magnetic resonance imaging andor computed tomography scan. Knowledge of the epidemiology and clinical characteristics of varicella zoster virus vzv encephalitis remains limited. Varicella zoster virus encephalitis during treatment with. International guidelines advocate to use high dose acyclovir in vzv. The vaccine contains the same okamerck varicella zoster virus used in varicella and mmrv vaccines but at a much higher titer a minimum of 19,400 pfu versus 1,350 pfu in varicella vaccine. It has the ability to remain latent in neurons of the cranial nerves, dorsal root ganglia, and autonomic ganglia after primary infection and can reactivate later in life 1.
One of the potential complications of this infection is involvement of the central nervous system causing encephalitis. Varicella zoster virus vzv is a specific herpesvirus responsible for causing varicella, known as chickenpox, and herpes zoster, or zoster, known as shingles. Meningitis caused by varicella zoster virus vzv is rare in healthy population. Although the invitro data are impressive, limited information is available on its efficacy in the treatment of varicella zoster encephalitis 3. Varicella zoster virus centers for disease control and. The recurrent infection herpes zoster, also known as shingles has been recognized since ancient times. He complained of acute headache, nausea, and vomiting. It causes chickenpox varicella, a disease most commonly affecting children, teens, and young adults, and shingles herpes zoster in adults. Varicella zoster virus is one of the herpesviruses and it causes two diseases varicella or chickenpox, and herpes zoster also known as shingles. Shingles has no relationship to season and does not occur in epidemics. Varicella 353 22 varicella is an acute infectious disease caused by varicella zoster virus vzv. Cerebrospinal fluid analysis confirmed the diagnosis of vzv associated encephalitis and the patient was treated with intravenous acyclovir and steroids with full recovery back to preadmission neurological status.
The risk is especially high when corticosteroids are administered during the varicella incubation period. Time points of blood sampling are indicated in red. Varicella zoster meningoencephalitis following treatment. A skin biopsy sample stained positive for varicella zoster virus vzv, but negative for herpes simplex virus hsv. Vzv infection causes two clinically distinct forms of disease. Varicella zoster immune globulin vzig is indicated for a healthy fullterm infant who is exposed to chickenpox at home at age 2 weeks. Primary varicella infection chickenpox was not reliably distinguished from smallpox until the end of the 19th century. A 37yearold woman was admitted with seizures, confusion, and fever following weeks of apathy and selfneglect. Intravenous acyclovir has been shown to be effective in the treatment of initial and recurrent herpes simplex virus infections in immunocompetent and immunocompromised persons 1, 2. The diagnosis is made by serology and pcr in cerebrospinal fluid, while acyclovir is the cornerstone of treatment. Varicellazoster virus associated encephalitis in a.
Pdf the pharmacokinetic basis of oral valacyclovir. Varicella zoster virus encephalitis is known to be associated with immunosuppression, especially that caused by hiv. Herpes zoster virus encephalitis if not treated promptly can result in significant morbidity and mortality. The information in the brief version is excerpted directly from the fulltext guidelines. Varicellazoster virus encephalitis mimicking toxoplasmosis.
Dalmau laboratory, university of pennsylvania, philadelphia, pa. Herpes zoster encephalitis presenting as multiple cerebral. Varicella vaccine is less immunogenic and effective in normal adults than in normal children, although it does prevent serious disease in this group. Although the cutaneous lesions resolved with intravenous acyclovir, clinical features of meningoencephalitis persisted, along with evidence of varicella. Varicella zoster virus is one of the herpesviruses and it causes two diseases varicella or chickenpox, and herpes zoster. We describe a patient infected with human immunodeficiency virus hiv who had localized brain stem encephalitis due to varicella zoster virus vzv and no cutaneous eruption. However, the rash was absent in nine of 17 adult patients enrolled in our study with clinical encephalitis and a positive vzv pcr in csf. Failure to recognize occult infection may result in serious illness and. Here we report a young otherwise healthy man diagnosed with a vzv meningitis without rash. Chickenpox follows initial exposure to the virus and is typically a relatively mild, selflimited childhood illness with a characteristic exanthem.
Varicella zoster virus vzv is a leading cause of acute viral encephalitis but little is known about its clinical, biological and imaging features. Prior to the universal administration of varicella vaccine, approximately 4 million cases of varicella occurred annually in the united states. Manifestations following primary infection include. Treatment of vzv encephalitis is intravenous iv acyclovir for seven. An infection by herpes zoster virus is a common and important cause of encephalitis. Early recognition of secondary bacterial infection and appropriate followup are major issues.
Furthermore, the most favourable treatment regimen has not been determined. Varicella zoster virus vzv has a high level of infectivity and has a worldwide prevalence. Mri brain showed multiple foci of punctate microhaemorrhages throughout the corpus callosum, both temporal lobes, and left posterior cingulate. Varicella zoster virus vzv was once thought to be a fairly innocuous pathogen.
The federal bureau of prisons bop clinical guidance for the management of varicella zoster virus vzv infections provides recommendations for the medical management of federal inmates with varicella chickenpox and herpes zoster shingles, as well as for prevention and control measures. Typical symptoms such as a headache, vomiting, fever and altered consciousness appear, with or without the onset of typical rash. Virological etiology of the disease was verified by the detection of varicellazoster virus antibody in cerebrospinal fluid and by reduced serumcerebrospinal fluid varicellazoster virus igg ratios compared with normally high ratios of total igg and albumin. Herpes zoster shingles presents as a painful vesicular rash and is caused by reactivation of the varicellazoster virus within the dorsal root or cranial nerve ganglia. Breakthrough varicella is infection with wildtype varicellazoster virus vzv occurring in a vaccinated person more than 42 days after varicella vaccination. Csf testing for varicella zoster virus vzv by pcr returned positive, prompting a 21day course of iv acyclovir. Evidencebased information on varicella zoster encephalitis from hundreds of trustworthy sources for health and social care. Varicella zoster virus vzv infection of intra and extracranial arteries vzv vasculopathy may be associated with a granulomatous vasculitis characterized by vessel wall damage and transmural inflammation, with multinucleated giant cells andor epithelioid macrophages. In the 1980s the outcome of patients with herpes simplex virus hsv encephalitis was shown to be dramatically improved with aciclovir treatment. Even when clinical symptoms of chickenpox have resolved, vzv remains dormant in the nervous system of the. Varicella zoster encephalitis evidence search nice. Varicella zoster virus vzv human alphaherpesvirus 3 hhv3, usually referred to as the varicella zoster virus vzv, is one of nine herpesviruses known to infect humans.
Potent varicella zoster virus vzvspecific bcell and cd8 tcell response in fulminant zoster encephalitis. It develops by reactivation of latently persistent virus in the. Varicella zoster virus in the adult patient most commonly presents as shingles. Acute varicella zoster encephalitis without evidence of primary. Varicella zoster virus encephalitis during treatment with antitumor necrosis factor.
Herpes zoster is a reactivation of latent varicella infection. Pinkbook varicella epidemiology of vaccine preventable. It has the capacity to persist in the body after primary infection chicken pox. Vzv encephalitis is a rare opportunistic infection, occurring in 0. The pharmacokinetic basis of oral valacyclovir treatment of herpes simplex virus hsv or varicella zoster virus vzv meningitis, meningoencephalitis or encephalitis in adults. Both varicella and herpes zoster that are caused by varicellazoster virus vzv. Varicella chickenpox herpes zoster revised 2019 varicella chickenpox is the primary infection caused by the varicellazoster virus vzv. A diagnosis of antinmdar encephalitis with concomitant vzv detection was made. After discharge she had poor adherence to antitoxoplasmosis and antiretroviral drugs. Varicella zoster virus central nervous system infections escmid. Although the viruses vary in the clinical disorders they cause and in their molecular structure, they share several features that affect the course. Varicella zoster virus encephalitis radiology reference. Varicellazoster virus associated encephalitis in a patient. Primary infection with vzv results in varicella chickenpox, characterized by vesicular lesions in different stages of development on the face, trunk, and extremities.
Treatment approaches include supportive measures, antiviral therapy, administration of varicella zoster immune globulin vzig, and management of secondary bacterial infection. Primary vzv infection results in the diffuse vesicular rash of varicella, or chickenpox. Acute varicella zoster encephalitis without evidence of. Treatment of acyclovir and dexamethasone for 2 weeks led to complete resolution of meningitis and urinary retention. Multifocal varicellazoster virus vasculopathy without. From this reservoir they can reactivate to cause human morbidity and mortality. Varicella zoster virus infections of the central nervous system prognosis, diagnostics and treatment. Pdf varicella zoster virus encephalitis researchgate. Oct 14, 2019 varicella zoster virus in the adult patient most commonly presents as shingles.
Human alphaherpesvirus 3 hhv3, usually referred to as the varicella zoster virus vzv, is one of nine herpesviruses known to infect humans. May 25, 2018 varicella zoster virus vzv reactivation is a common infectious disease in neurology and vzv the second most frequent virus detected in encephalitis. Differential diagnosis was mainly between varicella zoster virus vzv associated encephalitis versus acyclovir toxicity. Varicella zoster virus vzv is a dna virus and is a member of the herpes virus family. In the general population, the incidence of herpes zoster is about 3.
Two hundred eighty two patients with vzv reactivation that were hospitalized in the department of neurology in the time from 2005 to 20. Varicellazoster virus encephalitis is a serious complication with an incidence of 1 to 2 per 10,000 cases of varicella in healthy persons and is. Patients typically are afebrile or have low fever and develop fewer than 50 skin lesions. In this primer, the authors discuss vzv pathogenesis, diagnosis, treatment. Vzv is a dna virus and is a member of the herpesvirus group. Management of herpes simplex and varicellazoster infections. Varicellazoster virus infections red book 2018 red book.
Characterization of virusspecific immune response during. Zoster associated encephalitis from disseminated vzv can develop within days of the disseminated rash, and should be strongly suspected in immunosuppressed patients. Unsuspected varicellazoster virus encephalitis in a child with. Varicellazoster virus infections of the central nervous system. Varicella zoster virus vzv causes varicella chickenpox and, upon reactivation following latency, zoster shingles. More than 95% of adults aged 20 years born in the united states have immunity to varicellazoster virus vzv, mostly due to primary vzv infection, known as varicella or chickenpox. Varicellazoster virus vzv is one of eight herpesviruses known to cause human infection and is distributed worldwide. The nmdar antibody csf titer later also returned positive 1. Neurologic complications of varicellazoster virus infection. Antinmdar encephalitis with concomitant varicella zoster. Shingles is a reactivation of latent vzv infection. Varicella zoster virus causes, symptoms, diagnosis. The objective of this study was to provide a comprehensive picture of the prevaccine epidemiology of the varicella zoster virus vzv to aid in the design of immunization programs and to adequately measure the impact of vaccination.
Jun 15, 2011 herpes zoster shingles presents as a painful vesicular rash and is caused by reactivation of the varicella zoster virus within the dorsal root or cranial nerve ganglia. Pdf brain stem encephalitis due to varicellazoster virus. Varicella zoster virus meningitis in a young immunocompetent. In march 2011, the fda approved a label change for zoster vaccine to include persons 50 through 59 years of age. Chickenpox for healthcare professionals varicella cdc. Herpes simplex viruses types 1 and 2 hsv1 and hsv2 and varicella zoster virus vzv establish latent infection in dorsal root ganglia for the entire life of the host. Varicella zoster virus vzv is a leading cause of acute viral encephalitis but little. Disseminated varicella zoster virus encephalitis the lancet. Herpes zoster encephalitis an overview sciencedirect topics. Pdf brain stem encephalitis due to varicellazoster. Pathogenesis and current approaches to control of varicella. The brief version is a compilation of the tables and boxed recommendations. Delays in starting treatment, particularly beyond 48 hours after hospital admission, are associated with a worse prognosis. Zosterassociated encephalitis from disseminated vzv can develop within days of the disseminated rash, and should be strongly suspected in immunosuppressed patients.
Vzv is a dna virus and a member of the herpes virus group. Varicellazoster virus is a unique virus because it can cause two different illnesses. Epidemiology of varicella zoster virus infection in canada. Primary varicella zoster virus infection results in chickenpox varicella, which may result in complications including encephalitis, pneumonia either direct viral pneumonia or secondary bacterial pneumonia, or bronchitis either viral bronchitis or secondary bacterial bronchitis. Varicella zoster virus vzv reactivation is one of the most common neurological infectious diseases and vzv the second most frequent virus causing encephalitis or meningitis 1,2,3. Shingles is a painful vesicular eruption localized to a specific dermatome of the body. Varicella zoster virus vzv infection causes two clinically distinct forms of disease. Herpes simplex virus hsv and varicella zoster virus vzv are related viruses that both cause blistering rashes and are characterised by the ability to establish latent infection. Varicellazoster virus vzv was once thought to be a fairly innocuous pathogen. We describe a patient infected with human immunodeficiency virus hiv who had localized brain stem encephalitis due to varicellazoster virus vzv and no cutaneous eruption. Feb 15, 2019 varicella zoster virus vzv is the cause of chickenpox and herpes zoster also called shingles.
Varicella zoster virus encephalitis is a serious complication with an incidence of 1 to 2 per 10,000 cases of varicella in healthy persons and is seen more frequently in infants and adults. Aug 07, 2018 empiric adult emergency treatment for herpes simplex virus hsv meningoencephalitis and varicella zoster virus vzv encephalitis consists of acyclovir 10 mgkg infused over 1 h q8h for 1421 days. Varicella zoster virus vzv causes a wide spectrum of disorders including chickenpox, herpes zoster, and central nervous system cns infections. Herpes zoster encephalitis is one of the most dangerous complications of varicella zoster virus infection. Mri of the brain performed in 2533 patients with encephalitismeningitis did not show any signs of infection in the brain parenchyma. Varicellazoster virus adult and adolescent opportunistic. We studied a prospective cohort of 20 hivnegative patients presenting with acute vzv encephalitis caused by primary infection or reactivation.
Varicella zoster virus infections in neurological patients. A time course of symptom onset, treatment, and hospital stay. Sep 05, 2019 adult and adolescent opportunistic infection. This study investigated characteristics of clinical and laboratory features in patients with vzv infection. Fortunately, modern advances, including an available vaccine to prevent varicella, a therapeutic vaccine to diminish the incidence and ameliorate. Predominantly immunocompromised patients are affected by reactivation of this virus with primary clinical features of rash and neurological symptoms. Acyclovir and disseminated varicella zoster and encephalitis. Primary varicella infection chickenpox was not reliably distinguished from smallpox until the end of. Federal bureau of prisons management of vzv infections clinical guidance december 2016 1 1.
Varicellazoster virus encephalitis in an aids patient p. Purpose the federal bureau of prisons bop clinical guidance for the management of varicella zoster virus vzv infections provides recommendations for the medical management of federal inmates with varicella chickenpox and herpes zoster shingles, as well as for prevention and. Primary infections typically involve the skin or mucous mem branes, causing a characteristic vesicular rash. Vzv reactivation is increasingly prevalent in immunosuppressed and elderly patients. Varicellazoster virus vzv is a common viral agent of encephalitis. The morbidity and mortality due to the primary and secondary diseases that vzv causes, varicella and herpes zoster hz, are significant. Hiv1 infection and cerebral toxoplasmosis were diagnosed 4 months before, with good clinical and radiologic response to sulfadiazine and pyrimethamine after 1 month1 figure, a. Like other herpesviruses, vzv has the capacity to persist in the body after the primary first infection as a latent infection. Pdf varicella zoster virus in the adult patient most commonly presents as shingles. New microbiologica, 33, 271274, 2010 varicella zoster virus encephalitis during treatment with antitumor necrosis factor. Varicellazoster virus vzv is a dna virus and is a member of the herpes virus family.
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