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10.00 An obvious, deceptive, case of immunosuppression
A 69 year old man developed two month progressive short term memory difficulty and then presented with vomiting and confusion. He had bilateral lung transplants for bronchiectasis, immunosuppressed with tacrolimus and mycophenolate for two years. Examination revealed dry thoracic shingles.MRI demonstrated two intra-axial frontal lesions with faint peripheral enhancement, diffusion restriction and vasogenic oedema. Additionally, small foci of diffusion restriction were seen in the upper cervical cord and brainstem. Cerebrospinal fluid showed 340/mm3 lymphocytes, protein 1.2 g/L, normal glucose ratio and positive Varicella zoster virus (VZV) PCR.For possible VZV vasculopathy, he received steroids and acyclovir but unfortunately died of multi organ failure approximately two weeks from admission. Post mortem examination demonstrated necrotic frontal lesions with angiodestructive neoplastic B cell proliferation and EBV positivity. An infarct within the upper cervical cord was also seen with arteritis of one of the posterior spinal arteries. There was widespread perivenular inflammatory cell infiltrate. These findings were consistent with lymphomatoid granulomatosis with vasculitic changes; a rare EBV-driven lymphoproliferative disorder that affects the lungs, skin and central nervous system. Aetiology in this case is felt to be secondary to immunosuppression. However, the role of varicella is unclear and the native lungs have not been examined.
Journal Article
Germs!
Bertie's sister has chickenpox and Bertie thinks that if he can catch it he will not have to go to school and admit he did not do his homework--and that is just the first problem that Bertie faces in this trio of stories.
Book
398 Identification of Varicella Zoster by Novel Salivary and Esophageal Muscle Tissue Assay in Patients With Achalasia: A Two Center Prospective Study
INTRODUCTION:Achalasia is an esophageal motor disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) but the etiology of this neuronal damage is unknown. Varicella zoster virus (VZV) is an exclusively human neurotrophic alpha herpes virus that becomes latent in ganglionic neurons after initial infection. We tested the hypothesis that reactivation of latent VZV within esophageal enteric neurons initiates an inflammatory cascade that damages the innervation of the smooth muscle of the LES giving rise to achalasia. We aimed to determine whether VZV DNA, transcripts, and proteins are present in tissue and saliva of patients with achalasia and controls.METHODS:Fifteen patients with achalasia (60% Male, average age 60 years and BMI 28 kg/m2) diagnosed with high resolution manometry (7/15 with Type II Achalasia) who underwent surgical myotomy had prospective collection of saliva and LES muscle tissue with IRB approval. Salivary samples were collected by passive drool, DNA was extracted with the DNeasy Blood and Tissue Kit, and VZV DNA was amplified with PCR. All methods examined the presence of transcripts (cDNA) and DNA encoding VZV open reading frames (ORFs) 29, 40, and 67. Immunofluorescence (IMF) was used to demonstrate the neuronal markers, beta-3 tubulin or peripherin simultaneously with the VZV late protein, gE. Antigen retrieval at 100°C in citrate buffer (pH 6.0) was employed.RESULTS:VZV DNA was detected in the saliva in 12/15 (80%) of achalasia cases (Table 1). Transcripts encoding at least one ORF were found in esophageal myotomy samples 12/15 (80%), while DNA was detected in 7/15 (47%). All 15 patients had active VZV infection by salivary VZV DNA and/or VZV transcription in esophageal tissue (Figure 1). Detection of transcripts was more sensitive and specific indicator of tissue infection than DNA. IMF revealed the presence of gE within the cell bodies of enteric neurons (when present) (Figure 2). VZV DNA was not detected in the saliva of 20 controls.CONCLUSION:Direct ex-vivo examination of saliva and tissue from patients with achalasia revealed the presence of active VZV infection of the esophagus. Transcripts encoding VZV gene products, and DNA, support actively replicating virus, not just latent VZV. Immunocytochemistry suggested that enteric neurons were the site of VZV infection. These findings support VZV is a potential esophageal pathogen that reactivates from latency in enteric neurons to give rise to achalasia, which may be a therapeutic target.Table 1.Protein Detection by Saliva and Esophageal Muscle Tissue Assay
Journal Article
You can't eat your chicken pox, Amber Brown
At the end of third grade, Amber is excited about her trip with her aunt to London and Paris, where she will see her father again, but her plans change when she comes down with chicken pox.
Book
P096 Vulvar zoster
BackgroundHerpes Zoster infection is part of the two distinct syndromes of infections secondary to varicella-zoster. The other syndrome being the primary infection of varicella (chickenpox) which is a contagious but benign illness. Reactivation of this primary infection results to herpes zoster or shingles. Shingles is a uniquely localized disease with unilateral radicular pain and a vesicular rash limited to the area of the skin innervated by a single dorsal root or cranial sensory ganglion. Clinically significant pain usually accompanies the dermatomal rash of herpes zoster. This pain may persist for weeks, months, or even years after the herpes zoster rash has healed, a debilitating complication known as (PHN) postherpetic neuralgia. This condition disables a individuals infected with shingles especially among the elderly. We are presented with a rare case of vulvar zoster in a 52 year old nulligravid. The case presented with pain, pruritus, rashes and eventually ulcers along the dermatomal line of the vulva. Clinical improvement was noted upon treatment with an anti-viral.DisclosureNo significant relationships.
Journal Article
8328 Understanding attitudes to the varicella vaccine in North West London: considerations for its introduction to the UK’s childhood vaccination schedule
Why did you do this work?Varicella zoster virus (VZV) can cause serious health complications in both children and adults.1 2 In November 2023, the Joint Committee on Vaccination and Immunisation recommended the introduction of the VZV vaccine to the UK’s childhood vaccination schedule.2 In order to guide VZV vaccination policy, the aim of this study was to understand attitudes towards vaccines among expectant parents (EPs) and healthcare professionals (HCPs) in North West London.What did you do?In March and April 2024, two surveys were distributed to participants via a QR code. One survey was given to EPs at the antenatal clinic at St Mary’s Hospital, London. The second survey was given to HCPs working at the same antenatal clinic and the neonatology department at Queen Charlotte’s and Chelsea Hospital, London. Baseline demographic data was collected from both groups, including sex, age, ethnicity, birthplace and highest education level. Participants rated statements on a five-item Likert scale from ‘strongly agree’ to ‘strongly disagree’ about their perception of VZV severity. Participants also reported whether their children had previously contracted VZV (where applicable), whether their children were vaccinated against VZV and their preferences regarding VZV vaccine administration.What did you find?215 EPs and 110 HCPs participated in this study. 13.0% of EPs reported that their children had previously contracted VZV, compared to 36.3% of HCPs. While more HCPs (27.3%) strongly agreed that VZV is usually a mild disease in children than EPs (20.9%), more EPs (59.1%) strongly agreed that it is better to have VZV during childhood instead of adulthood than HCPs (51.8%). Only 27.4% of EPs strongly agreed that VZV can cause serious complications compared to 60.9% of HCPs, yet a greater proportion of EPs (17.2%) had their children vaccinated against VZV than HCPs (14.5%). Despite this, a smaller proportion of EPs (41.4%) strongly agreed that they would recommend the VZV vaccine if it was offered in the UK than HCPs (60.9%). Moreover, 12.1% of EPs strongly agreed that they did not want extra vaccines added to the childhood vaccination schedule compared to 1.8% of HCPs. The first choice for VZV vaccine administration was in combination with the measles, mumps and rubella (MMR) vaccine as a 4-in-1 for both HCPs (29.1%) and EPs (26.5%).What does it mean?HCPs in North West London tended to show more positive opinions about the VZV vaccine than EPs. However, educational tools are indicated to provide more information about VZV for both HCPs and EPs and to facilitate communication regarding VZV vaccination.ReferencesSherman SM, Lingley-Heath N, Lai J, Sim J, Bedford H. Vaccine. 17 February 2023.https://www.gov.uk/government/publications/childhood-varicella-vaccination-programme-jcvi-advice-14-november-2023/jcvi-statement-on-a-childhood-varicella-chickenpox-vaccination-programme [Accessed 3rd October 2024].
Journal Article
Ultime notizie
Dei sette casi fatali i vaccini indicati come sospetti erano: in un caso il quadrivalente contro morbillo, parotite, rosolia e varicella e in sei casi l’antinfluenzale, in tre di questi la somministrazione era avvenuta contemporaneamente al vaccino anti-Covid. Invece per quanto riguarda le sole segnalazioni legate a eventi gravi il tasso più alto (16,3 per 100.000) si è osservato per i vaccini MPR (morbillo, parotite e rosolia) e MPRV-V (i tre più l’anti-varicella) e Antimeningococco C (14,2 per 100.000), anche se in misura notevolmente inferiore rispetto al 2021 (tabella I). Le segnalazioni di sospetta reazione avversa vengono raccolte giornalmente dalla Rete Nazionale di Farmacovigilanza gestita dall’AIFA che a sua volta convoglia i dati nel data base europeo Eudravigilance, gestito da EMA, rendendo disponibile l’informazione a livello internazionale. La sorveglianza sugli eventi avversi è particolarmente rigorosa data l’importanza dei vaccini sia in termini di salute pubblica che individuale, non solo come prevenzione di malattie infettive ma anche come protezione dei pazienti fragili. Se le evidenze di correlazione vaccino-evento non fossero cosi robuste, possono essere richiesti studi specifici denominati PASS (Post Authorisation Safety Studies).
Journal Article