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Xu Q, Zhou F, Yang D. Digital subtraction angiography-guided peripheral nerve stimulation via the foramen rotundum for refractory trigeminal postherpetic neuralgia: a case report and literature review. Front Neurol 2024; 15:1353882. [PMID: 38487331 PMCID: PMC10939014 DOI: 10.3389/fneur.2024.1353882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/15/2024] [Indexed: 03/17/2024] Open
Abstract
Postherpetic neuralgia (PHN) is a debilitating complication of varicella-zoster virus infection. This case report presents a novel approach to treating refractory trigeminal maxillary postherpetic neuralgia using digital subtraction angiography (DSA)-guided peripheral nerve stimulation via the foramen rotundum. A 72-year-old female with severe, treatment-resistant pain underwent this intervention. The results demonstrated the disappearance of tactile allodynia, a significant reduction in oral analgesic requirements, and no observed complications or side effects during a 3-year follow-up period. This case highlights the potential effectiveness of DSA-guided peripheral nerve stimulation using a new dorsal root ganglion (DRG) stimulator as an alternative therapy for refractory trigeminal postherpetic neuralgia (TPHN).
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Affiliation(s)
- Qingbang Xu
- Department of Pain Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education, Wuhan, China
| | - Fangyuan Zhou
- Department of Pain Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education, Wuhan, China
| | - Dong Yang
- Department of Pain Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education, Wuhan, China
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Chen K, Wang M, Long D, Zou D, Li X, Wang R, Wang Y, Yang L. Cerebrospinal Fluid Proteomic Profiles in Patients with Postherpetic Neuralgia. J Proteome Res 2023; 22:3879-3892. [PMID: 37966014 PMCID: PMC10696610 DOI: 10.1021/acs.jproteome.3c00547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/24/2023] [Accepted: 11/01/2023] [Indexed: 11/16/2023]
Abstract
The intrinsic mechanism of postherpetic neuralgia (PHN) remains unclear. Herein, we aimed to seek the hub proteins in the cerebrospinal fluid (CSF), which display significant changes between the PHN and nonpainful patients (Control). First, the proteomic results showed that compared with the Control-CSF, there were 100 upregulated and 50 downregulated differentially expressed proteins (DEPs) in the PHN-CSF. Besides, functional analyses including gene ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), and gene set enrichment analysis (GSEA) revealed that biological processes and pathways including complement activation, infection, coagulation, and lipid metabolism were activated, while synaptic organization was suppressed. Next, the protein-protein interaction (PPI) analysis indicated that increased PLG, F2, APOA1, APOA2, SERPINC1, and KNG1 and reduced APOE, which were all enriched in the top pathways according to the KEGG analysis, were defined as hub proteins. Finally, three of the hub proteins, such as PLG, APOA1, and APOE, were reconfirmed in a larger cohort using both enzyme-linked immunosorbent assay (ELISA) and Western blotting methods. Above all, the results indicated that PLG, APOA1, and APOE and their involved processes such as infection, inflammation, cholesterol metabolism, and coagulation shall be potential therapeutic approaches. (The raw mass spectrometry proteome data and search results have been deposited to the iProx-integrated Proteome Resources (http://www.iprox.cn) with the data set identifier IPX0007372000.).
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Affiliation(s)
- Kai Chen
- Department
of Pain Management, The Second Xiangya Hospital,
Central South University, Changsha 410011, China
- Department
of Anesthesiology, The Second Xiangya Hospital,
Central South University, Changsha, Hunan 410011, China
- Clinical
Research Center for Pain Medicine in Hunan Province, Changsha, Hunan 410011, China
- Hunan
Province Center for Clinical Anesthesia and Anesthesiology, Research Institute of Central South University, Changsha, Hunan 410083, China
| | - Meng Wang
- Department
of Pain Management, The Second Xiangya Hospital,
Central South University, Changsha 410011, China
- Department
of Anesthesiology, The Second Xiangya Hospital,
Central South University, Changsha, Hunan 410011, China
- Clinical
Research Center for Pain Medicine in Hunan Province, Changsha, Hunan 410011, China
- Hunan
Province Center for Clinical Anesthesia and Anesthesiology, Research Institute of Central South University, Changsha, Hunan 410083, China
| | - Dongju Long
- Department
of Pain Management, The Second Xiangya Hospital,
Central South University, Changsha 410011, China
- Department
of Anesthesiology, The Second Xiangya Hospital,
Central South University, Changsha, Hunan 410011, China
- Clinical
Research Center for Pain Medicine in Hunan Province, Changsha, Hunan 410011, China
- Hunan
Province Center for Clinical Anesthesia and Anesthesiology, Research Institute of Central South University, Changsha, Hunan 410083, China
| | - Dingquan Zou
- Department
of Pain Management, The Second Xiangya Hospital,
Central South University, Changsha 410011, China
- Department
of Anesthesiology, The Second Xiangya Hospital,
Central South University, Changsha, Hunan 410011, China
- Clinical
Research Center for Pain Medicine in Hunan Province, Changsha, Hunan 410011, China
- Hunan
Province Center for Clinical Anesthesia and Anesthesiology, Research Institute of Central South University, Changsha, Hunan 410083, China
| | - Xin Li
- Department
of Pain Management, The Second Xiangya Hospital,
Central South University, Changsha 410011, China
- Department
of Anesthesiology, The Second Xiangya Hospital,
Central South University, Changsha, Hunan 410011, China
- Clinical
Research Center for Pain Medicine in Hunan Province, Changsha, Hunan 410011, China
- Hunan
Province Center for Clinical Anesthesia and Anesthesiology, Research Institute of Central South University, Changsha, Hunan 410083, China
| | - Ruixuan Wang
- Bourns
Engineering, The University of California, Riverside, California 92521, United States
| | - Yaping Wang
- Department
of Pain Management, The Second Xiangya Hospital,
Central South University, Changsha 410011, China
- Department
of Anesthesiology, The Second Xiangya Hospital,
Central South University, Changsha, Hunan 410011, China
- Clinical
Research Center for Pain Medicine in Hunan Province, Changsha, Hunan 410011, China
- Hunan
Province Center for Clinical Anesthesia and Anesthesiology, Research Institute of Central South University, Changsha, Hunan 410083, China
| | - Lin Yang
- Department
of Pain Management, The Second Xiangya Hospital,
Central South University, Changsha 410011, China
- Department
of Anesthesiology, The Second Xiangya Hospital,
Central South University, Changsha, Hunan 410011, China
- Clinical
Research Center for Pain Medicine in Hunan Province, Changsha, Hunan 410011, China
- Hunan
Province Center for Clinical Anesthesia and Anesthesiology, Research Institute of Central South University, Changsha, Hunan 410083, China
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Cao X, Jiao B, Wen D, Duan G, Zhang M, Zhang C, Wu G, Zhang X. Evaluation of the correlation of dorsal root ganglia and spinal nerves with clinical symptoms in patients with postherpetic neuralgia using magnetic resonance neurography. PeerJ 2023; 11:e15998. [PMID: 37667753 PMCID: PMC10475274 DOI: 10.7717/peerj.15998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 08/08/2023] [Indexed: 09/06/2023] Open
Abstract
Purpose To assess changes of dorsal root ganglia (DRG) and spinal nerves in patients with postherpetic neuralgia (PHN), and investigate the correlation between DRG morphology and clinical symptoms in PHN patients using magnetic resonance neurography (MRN). Methods In this case-control study, forty-nine lesioned DRG in 30 patients and 49 normal DRG in 30 well-matched (age, sex, height, weight) healthy controls were assessed. Clinical symptoms of patients (pain, allodynia, itching, and numbness) were assessed. MRN features (DRG volume (VDRG), the largest diameter (Dmax) of spinal nerves, signal intensity of DRG and spinal nerves (M-value)) were measured in all participants. Multilinear regression analysis was used to evaluate the relationship between the DRG morphology and clinical symptoms in patients. Results The volume and relative M-value of lesioned DRG in patients were significantly higher than those on the same side of healthy controls (p = 0.013, p < 0.001, respectively). The mean Dmax and relative M-value of spinal nerves on the lesioned side were significantly higher than those on the contralateral and same side of healthy controls (p < 0.0001, p = 0.0001, p = 0.0011, p = 0.0053, respectively). No difference was found between the mean VDRG of the lesioned and contralateral sides. Multiple linear regression analysis revealed that disease duration was independent risk factor for the maximum rate of VDRG differences (p = 0.013). Conclusions DRG and spinal nerves on the lesioned side are swollen during PHN. Disease duration is an independent risk factor for morphological differences in the lesioned DRG of PHN patients. This study provides important guidance for individualized treatments of PHN.
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Affiliation(s)
- Xueqin Cao
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Bo Jiao
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Donglin Wen
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Guangyou Duan
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Wuhan, Hubei, China
| | - Mi Zhang
- Department of Anesthesiology, Zhongnan Hospital, Wuhan University, Wuhan, Hubei, China
| | - Caixia Zhang
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Gang Wu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xianwei Zhang
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Le N, Razick DI, Dhaliwal A, Akhtar M, Daniel E. A Rare Case of Varicella-Zoster Virus Encephalitis Presenting With Lost Ability to Play the Piano in an Immunocompetent Pediatric Patient. Cureus 2023; 15:e41383. [PMID: 37546052 PMCID: PMC10401066 DOI: 10.7759/cureus.41383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2023] [Indexed: 08/08/2023] Open
Abstract
Varicella-zoster virus (VZV) is a member of the alpha-herpesvirus family, which can occasionally cause severe neurological complications such as encephalitis. In this case report, we discuss a rare finding of VZV encephalitis in which an immunocompetent pediatric patient, vaccinated against varicella, presented with altered mental status and no vesicular rash. A 15-year-old male presented to the Emergency Department with progressively worsening altered mental status over the past three days. The patient's mother stated that he was exhibiting frequent memory lapses as well as the sudden loss of the ability to play the piano. After admission to the pediatric general floor, lumbar puncture was performed and cerebrospinal fluid analysis returned positive for VZV, confirmed by polymerase chain reaction. The patient was then started on intravenous (IV) acyclovir at a dose of 650 mg every 8 hours to treat VZV-induced encephalitis. While the patient continued to have intermittent episodes of confusion and headaches, his overall condition improved, and by day 4, he was able to resume playing the piano and ukulele. The patient was discharged on day 8 with no home medications, and a follow-up with this primary care physician was scheduled. This patient is one of only four recorded cases of VZV encephalitis in immunocompetent children. It is extremely rare to encounter pediatric patients with this diagnosis and, as such, can elude physicians when developing differential diagnoses. If VZV is suspected, a lumbar puncture should be performed promptly, and, if confirmed, IV acyclovir should be started. Furthermore, this case highlights the need for future research with regard to VZV and potential predisposing factors in immunocompetent patients.
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Affiliation(s)
- Nancy Le
- Neurology, California Northstate University College of Medicine, Elk Grove, USA
| | - Daniel I Razick
- Surgery, California Northstate University College of Medicine, Elk Grove, USA
| | - Anand Dhaliwal
- Surgery, California Northstate University College of Medicine, Elk Grove, USA
| | - Muzammil Akhtar
- Surgery, California Northstate University College of Medicine, Elk Grove, USA
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Macionis V. Chronic pain and local pain in usually painless conditions including neuroma may be due to compressive proximal neural lesion. FRONTIERS IN PAIN RESEARCH 2023; 4:1037376. [PMID: 36890855 PMCID: PMC9986610 DOI: 10.3389/fpain.2023.1037376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 01/12/2023] [Indexed: 02/22/2023] Open
Abstract
It has been unexplained why chronic pain does not invariably accompany chronic pain-prone disorders. This question-driven, hypothesis-based article suggests that the reason may be varying occurrence of concomitant peripheral compressive proximal neural lesion (cPNL), e.g., radiculopathy and entrapment plexopathies. Transition of acute to chronic pain may involve development or aggravation of cPNL. Nociceptive hypersensitivity induced and/or maintained by cPNL may be responsible for all types of general chronic pain as well as for pain in isolated tissue conditions that are usually painless, e.g., neuroma, scar, and Dupuytren's fibromatosis. Compressive PNL induces focal neuroinflammation, which can maintain dorsal root ganglion neuron (DRGn) hyperexcitability (i.e., peripheral sensitization) and thus fuel central sensitization (i.e., hyperexcitability of central nociceptive pathways) and a vicious cycle of chronic pain. DRGn hyperexcitability and cPNL may reciprocally maintain each other, because cPNL can result from reflexive myospasm-induced myofascial tension, muscle weakness, and consequent muscle imbalance- and/or pain-provoked compensatory overuse. Because of pain and motor fiber damage, cPNL can worsen the causative musculoskeletal dysfunction, which further accounts for the reciprocity between the latter two factors. Sensitization increases nerve vulnerability and thus catalyzes this cycle. Because of these mechanisms and relatively greater number of neurons involved, cPNL is more likely to maintain DRGn hyperexcitability in comparison to distal neural and non-neural lesions. Compressive PNL is associated with restricted neural mobility. Intermittent (dynamic) nature of cPNL may be essential in chronic pain, because healed (i.e., fibrotic) lesions are physiologically silent and, consequently, cannot provide nociceptive input. Not all patients may be equally susceptible to develop cPNL, because occurrence of cPNL may vary as vary patients' predisposition to musculoskeletal impairment. Sensitization is accompanied by pressure pain threshold decrease and consequent mechanical allodynia and hyperalgesia, which can cause unusual local pain via natural pressure exerted by space occupying lesions or by their examination. Worsening of local pain is similarly explainable. Neuroma pain may be due to cPNL-induced axonal mechanical sensitivity and hypersensitivity of the nociceptive nervi nervorum of the nerve trunk and its stump. Intermittence and symptomatic complexity of cPNL may be the cause of frequent misdiagnosis of chronic pain.
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A Guide to Preclinical Models of Zoster-Associated Pain and Postherpetic Neuralgia. Curr Top Microbiol Immunol 2022; 438:189-221. [PMID: 34524508 DOI: 10.1007/82_2021_240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Reactivation of latent varicella-zoster virus (VZV) causes herpes zoster (HZ), which is commonly accompanied by acute pain and pruritus over the time course of a zosteriform rash. Although the rash and associated pain are self-limiting, a considerable fraction of HZ cases will subsequently develop debilitating chronic pain states termed postherpetic neuralgia (PHN). How VZV causes acute pain and the mechanisms underlying the transition to PHN are far from clear. The human-specific nature of VZV has made in vivo modeling of pain following reactivation difficult to study because no single animal can reproduce reactivated VZV disease as observed in the clinic. Investigations of VZV pathogenesis following primary infection have benefited greatly from human tissues harbored in immune-deficient mice, but modeling of acute and chronic pain requires an intact nervous system with the capability of transmitting ascending and descending sensory signals. Several groups have found that subcutaneous VZV inoculation of the rat induces prolonged and measurable changes in nociceptive behavior, indicating sensitivity that partially mimics the development of mechanical allodynia and thermal hyperalgesia seen in HZ and PHN patients. Although it is not a model of reactivation, the rat is beginning to inform how VZV infection can evoke a pain response and induce long-lasting alterations to nociception. In this review, we will summarize the rat pain models from a practical perspective and discuss avenues that have opened for testing of novel treatments for both zoster-associated pain and chronic PHN conditions, which remain in critical need of effective therapies.
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Ma L, Liu S, Yi M, Wan Y. Spontaneous pain as a challenge of research and management in chronic pain. MEDICAL REVIEW (BERLIN, GERMANY) 2022; 2:308-319. [PMID: 37724190 PMCID: PMC10388751 DOI: 10.1515/mr-2022-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 05/31/2022] [Indexed: 09/20/2023]
Abstract
Spontaneous pain occurring without apparent external stimuli, is a significant complaint of individuals with chronic pain whose mechanisms, somewhat surprisingly, remain poorly understood. Over the past decades, neuroimaging studies start to reveal brain activities accompanying spontaneous pain. Meanwhile, a variety of animal models and behavioral tests have been established, including non-reflexive tests and free-choice tests, which have been shown to be effective in assessing spontaneous pain. For the spontaneous pain mechanisms, multiple lines of research mainly focus on three aspects: (1) sensitization of peripheral nociceptor receptors and ion channels, (2) spontaneous neuronal firing and abnormal activity patterns at the dorsal root ganglion and spinal cord level, (3) functional and structural alterations in the brain, particularly the limbic system and the medial pain pathway. Despite accumulating evidence revealing distinct neuronal mechanisms from evoked pain, we are still far from full understanding of spontaneous pain, leaving a big gap between bench and bedside for chronic pain treatment. A better understanding of the neural processes in chronic pain, with specific linkage as to which anatomical structures and molecules related to spontaneous pain perception and comorbidities, will greatly improve our ability to develop novel therapeutics.
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Affiliation(s)
- Longyu Ma
- Neuroscience Research Institute and Department of Neurobiology, School of Basic Medical Sciences, Peking University, Beijing, China
| | - Shuting Liu
- Neuroscience Research Institute and Department of Neurobiology, School of Basic Medical Sciences, Peking University, Beijing, China
| | - Ming Yi
- Neuroscience Research Institute and Department of Neurobiology, School of Basic Medical Sciences, Peking University, Beijing, China
- Key Laboratory for Neuroscience, Ministry of Education/National Health Commission, Peking University, Beijing, China
| | - You Wan
- Neuroscience Research Institute and Department of Neurobiology, School of Basic Medical Sciences, Peking University, Beijing, China
- Key Laboratory for Neuroscience, Ministry of Education/National Health Commission, Peking University, Beijing, China
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Dermawan A, Ting MJM, Chemmanam T, Lui C. Acute herpes zoster radiculopathy mimicking cervical radiculopathy after ChAdOx1 nCoV-19/AZD1222 vaccination. BMJ Case Rep 2022; 15:15/4/e248943. [PMID: 35459652 PMCID: PMC9036357 DOI: 10.1136/bcr-2022-248943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This case report describes an 84-year-old man who presented with 3 weeks of gradually worsening right arm weakness associated with a painful vesicular rash across his arm. This occurred 3 days after his first dose of the ChAdOx1 nCoV-19/AZD1222 (University of Oxford, AstraZeneca and the Serum Institute of India) vaccine. The diagnosis was complicated by the presence of right C5–C6 foraminal stenosis compressing on the C6 nerve root sheath on non-contrast MRI, leading to an initial diagnosis of cervical radiculopathy. However, a positive varicella zoster virus-PCR test and findings of abnormal contrast enhancement of his right C5–C7 nerve roots on gadolinium-enhanced MRI resulted in a revision of his diagnosis to zoster radiculopathy. He was subsequently commenced on oral valacilovir and made significant recovery. This report aims to highlight the diagnostic dilemma between cervical radiculopathy secondary to spondylosis and zoster radiculopathy and how an erroneous diagnosis could result in inappropriate, aggressive surgical intervention and delayed treatment with antiviral therapy.
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Affiliation(s)
- Andrew Dermawan
- General Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Matthew Jun Min Ting
- Geriatric department, St John of God Midland Public and Private Hospitals, Midland, Western Australia, Australia
| | - Thomas Chemmanam
- Neurology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,Neurology, St John of God Midland Public and Private Hospital, Midland, Australian Capital Territory, Australia
| | - Chok Lui
- Geriatric department, St John of God Midland Public and Private Hospitals, Midland, Western Australia, Australia
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Li Y, Tong L, Quek C, Feng Y. The Role of Nervous System and Immune System in Herpes Zoster Ophthalmicus Dissemination and Laterality - Current Views. Ocul Immunol Inflamm 2022; 31:810-818. [PMID: 35412940 DOI: 10.1080/09273948.2022.2058556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Herpes zoster ophthalmicus (HZO) is a sight-threatening condition that is defined as HZ involving the ophthalmic division of the trigeminal nerve. Cases of bilateral HZO in recent literature question the notion of HZO being a strictly unilateral disease. Its pathogenesis is a topic of debate and current literature on VZV dissemination lacks insight into the underlying immunology. This review focuses on novel research in immunology of HZO and aims to formulate hypotheses of spread of lesions through the CNS. METHODS A literature search was conducted on Entrez PubMed using the search terms "bilateral" and "herpes zoster ophthalmicus". Articles on ("Immunology" or "immune cells") and "herpes zoster ophthalmicus" were also searched for. Articles published from January 1942 to April 2020 that were in English language were included. RESULTS Our findings revealed that hypothesised mechanisms of dissemination causing bilateral ocular disease include transmission from nerves to vessel walls, the synergistic action of the immune and nervous systems through the action of substance P and the von Szily reaction. CONCLUSIONS These mechanisms may be investigated using newer models of animal experimentation. It is imperative to define the molecular mechanisms behind VZV transmission to improve methods of identification, treatment, and prevention of HZO.
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Affiliation(s)
- Yue Li
- Department of Ophthalmology, Beijing Key Laboratory of Restoration of Damaged Ocular Nerve, Peking University Third Hospital, Beijing, Haidian, China
| | - Louis Tong
- Cornea and External Eye Disease Service, Singapore National Eye Centre, Singapore, Singapore.,Ocular Surface Research Group, Singapore Eye Research Institute, Singapore, Singapore.,Clinical Program, Duke-National University of Singapore Medical School, Singapore, Singapore.,Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Chrystie Quek
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yun Feng
- Department of Ophthalmology, Beijing Key Laboratory of Restoration of Damaged Ocular Nerve, Peking University Third Hospital, Beijing, Haidian, China
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10
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Kim JH, Lee CS, Han WK, Sim JB, Nahm FS. Determining the Definitive Time Criterion for Postherpetic Neuralgia Using Infrared Thermographic Imaging. Pain Ther 2022; 11:591-600. [PMID: 35284992 PMCID: PMC9098764 DOI: 10.1007/s40122-022-00370-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/28/2022] [Indexed: 12/18/2022] Open
Abstract
Introduction The time criteria used in many studies of postherpetic neuralgia (PHN) are arbitrary and do not have supporting evidence. Therefore, this study sought to determine the definite time criterion for PHN by analyzing the skin temperature to estimate the time point when zoster-induced skin inflammatory reaction ends. Methods Infrared thermography was used to measure the difference in skin temperature between the affected and unaffected areas (ΔTemp) in the craniocervical and thoracic regions of patients with herpes zoster (HZ). Because the ΔTemp changes from a positive value to zero when the skin is no longer inflamed, a ΔTemp ≤ 0 was defined as the end of skin inflammation, and this time point was considered the starting point for PHN. This cutoff time point was estimated using receiver operating characteristic (ROC) curve analysis. Results A total of 503 patients were included in this study. The ROC curve analysis showed that the time point when the ΔTemp was ≤ 0 occurred at 12 weeks after HZ onset (95% confidence interval 11–15 weeks, area under the ROC curve 0.901). Using this time point as the time criterion of PHN, the sensitivity, specificity, and classification accuracy were 0.807, 0.905, and 0.871, respectively. Conclusions The transition of skin temperature from warm to cold occurs 12 weeks after HZ onset, which implies the end of local inflammation. Therefore, PHN associated with pathophysiologic change may be defined as 12 weeks after the skin rash. This finding provides a theoretical basis for the timing definition of PHN.
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Sollie M, Pind R, Madsen CB, Sørensen JA. Acupuncture (superficial dry-needling) as a treatment for chronic postherpetic neuralgia - a randomized clinical trial. Br J Pain 2022; 16:96-108. [PMID: 35111318 PMCID: PMC8801694 DOI: 10.1177/20494637211023075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Postherpetic neuralgia is a painful condition where finding sufficient treatment poses a great challenge. Acupuncture is often used as an alternative treatment for these pains, yet no randomized trials, using a sham-placebo have been performed to confirm its effect. Our objective was to investigate the efficacy of acupuncture compared to sham-acupuncture when treating chronic postherpetic dermal pain. METHODS We performed a sham-controlled double-blinded randomized clinical trial (RCT) with two arms. The intervention group received superficial dry-needling, and the control group received sham acupuncture using blunted needles. Twenty-six patients received two treatments. They filled out questionnaires at baseline and 1 month after treatment: (1) average and maximum pain (Numeric Rating Scale), (2) neuropathic pain (Neuropathic Pain Scale Inventory) and (3) Quality of Life (QoL) (Short-form 36). RESULTS Thirteen patients were allocated to the intervention group and 15 to the control group. We did not detect any significant changes in levels of pain and neuropathic pain. One QoL parameter, regarding emotional problems, reached a level of statistical significance. The sham-blinding was successful. This is the first RCT on the effect of acupuncture (superficial dry-needling) on postherpetic neuralgia (PHN), using a sham procedure as control. We observed no significant changes or tendencies in the measured levels of pain. One QoL parameter had significant improvement in the intervention group compared to the control group. CONCLUSION In conclusion, acupuncture was not superior to treatment with sham acupuncture. Though individual patients may experience some pain relief from acupuncture, our results do not support the routine use of this type of acupuncture to treat PHN.
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Affiliation(s)
- Martin Sollie
- Research Unit for Plastic Surgery, Odense University Hospital, Odense, Denmark,University of Southern Denmark, Odense, Denmark,OPEN – Open Patient Data Explorative Network, Odense University Hospital, Odense, Denmark,Martin Sollie, Research Unit for Plastic Surgery, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense C, Denmark.
| | | | - Christoffer Bing Madsen
- Research Unit for Plastic Surgery, Odense University Hospital, Odense, Denmark,University of Southern Denmark, Odense, Denmark
| | - Jens Ahm Sørensen
- Research Unit for Plastic Surgery, Odense University Hospital, Odense, Denmark,University of Southern Denmark, Odense, Denmark,OPEN – Open Patient Data Explorative Network, Odense University Hospital, Odense, Denmark
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12
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Doshi TL, Dworkin RH, Polomano RC, Carr DB, Edwards RR, Finnerup NB, Freeman RL, Paice JA, Weisman SJ, Raja SN. AAAPT Diagnostic Criteria for Acute Neuropathic Pain. PAIN MEDICINE 2021; 22:616-636. [PMID: 33575803 DOI: 10.1093/pm/pnaa407] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Acute neuropathic pain is a significant diagnostic challenge, and it is closely related to our understanding of both acute pain and neuropathic pain. Diagnostic criteria for acute neuropathic pain should reflect our mechanistic understanding and provide a framework for research on and treatment of these complex pain conditions. METHODS The Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the U.S. Food and Drug Administration (FDA), the American Pain Society (APS), and the American Academy of Pain Medicine (AAPM) collaborated to develop the ACTTION-APS-AAPM Pain Taxonomy (AAAPT) for acute pain. A working group of experts in research and clinical management of neuropathic pain was convened. Group members used literature review and expert opinion to develop diagnostic criteria for acute neuropathic pain, as well as three specific examples of acute neuropathic pain conditions, using the five dimensions of the AAAPT classification of acute pain. RESULTS AAAPT diagnostic criteria for acute neuropathic pain are presented. Application of these criteria to three specific conditions (pain related to herpes zoster, chemotherapy, and limb amputation) illustrates the spectrum of acute neuropathic pain and highlights unique features of each condition. CONCLUSIONS The proposed AAAPT diagnostic criteria for acute neuropathic pain can be applied to various acute neuropathic pain conditions. Both the general and condition-specific criteria may guide future research, assessment, and management of acute neuropathic pain.
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Affiliation(s)
- Tina L Doshi
- Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Robert H Dworkin
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, and Department of Neurology, Center for Human Experimental Therapeutics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Rosemary C Polomano
- Division of Biobehavioral Health Sciences, University of Pennsylvania-School of Nursing, Philadelphia, Pennsylvania, USA
| | - Daniel B Carr
- Public Health and Community Medicine Program, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Robert R Edwards
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, and Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Roy L Freeman
- Center for Autonomic and Peripheral Nerve Disorders, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Judith A Paice
- Cancer Pain Program, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Steven J Weisman
- Jane B. Pettit Pain and Headache Center, Children's Wisconsin, Departments of Anesthesiology and Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Srinivasa N Raja
- Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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13
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Meyer BC. Chronic neuroangiostrongyliasis: case study of chronic presentations in Hawaii. Parasitology 2021; 148:221-226. [PMID: 32907652 PMCID: PMC11010149 DOI: 10.1017/s0031182020001651] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/29/2020] [Accepted: 08/30/2020] [Indexed: 11/07/2022]
Abstract
This paper describes chronic features of neuroangiostrongyliasis (NAS), a long-term outcome of the disease that has not been adequately described. Current and past literature is predominantly limited to acute manifestations of NAS, and mention of chronic, ongoing clinical symptoms is usually limited to brief notes in a discussion of severe cases. This study investigated the long-term outcomes in ten individuals who were diagnosed with acute neuroangiostrongyliasis in Hawaii between 2009 and 2017. The study demonstrates a significant number of persons in Hawaii sustain residual symptoms for many years, including troublesome sensory paresthesia (abnormal spontaneous sensations of skin experienced as 'burning, pricking, pins and needles'; also described as allodynia or hyperesthesia) and extremity muscle pains. As a consequence, employment and economic hardships, domestic relocations, and psychological impairments affecting personal relationships occurred. The study summarizes common features of chronic disease, sensory paresthesia and hyperesthesia, diffuse muscular pain, insomnia, and accompanying emotional distress; highlights the frequently unsuccessful endeavours of individuals struggling to find effective treatment; proposes pathogenic mechanisms responsible for prolonged illness including possible reasons for differences in disease presentation in Hawaii compared to Southeast Asia.
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Affiliation(s)
- Bernard C. Meyer
- East Maui Community and Tropical Medicine, PO Box 756, Hana, Hawaii96713, USA
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14
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Markus J, van Montfoort M, de Jong JR, de Beer SA, Aronica EMA, Gorter RR. Histopathologic examination of resected nerves from children with anterior cutaneous nerve entrapment syndrome: Clues for pathogenesis? J Pediatr Surg 2020; 55:2783-2786. [PMID: 32156426 DOI: 10.1016/j.jpedsurg.2020.01.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Anterior cutaneous nerve entrapment syndrome (ACNES) has been described as a possible cause for chronic pain in the pediatric population. However, the exact pathophysiology of ACNES is unknown. It may be caused by compression or traction of cutaneous nerve branches of intercostal nerves, or it may be the result of an infection. Therefore, we present histopathological evidence to determine the pathophysiology of ACNES. METHODS A total of seven pediatric patients underwent a neurectomy for ACNES. All specimens were sent for histopathological evaluation, including immunohistochemical staining, to evaluate if there were any signs of infection, inflammation or compression. RESULTS Seven out of seven (100%) histopathological specimens showed non-specific nerve degeneration. Immunohistochemical evaluation showed there were several CD68-positive macrophages present in the specimens. Four out of seven (57%) specimens showed the presence of a few CD3-positive T-cells, however, this was not suggestive for inflammation or infection. CONCLUSION Our study supports the hypothesis that ACNES is caused by compression of the nerves rather than inflammation. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jasper Markus
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Department of Pediatric Surgery, Amsterdam, The Netherlands.
| | - Maurits van Montfoort
- Department of Neuropathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Justin R de Jong
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Department of Pediatric Surgery, Amsterdam, The Netherlands
| | - Sjoerd A de Beer
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Department of Pediatric Surgery, Amsterdam, The Netherlands
| | - Eleonora M A Aronica
- Department of Neuropathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ramon R Gorter
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Department of Pediatric Surgery, Amsterdam, The Netherlands
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15
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Faluk MA, Makadia S, Abdelmaseih R, Hasan SM, Abusaada K. A Rare Case of an Immunocompetent Male With Zoster Meningitis. J Investig Med High Impact Case Rep 2020; 8:2324709620952212. [PMID: 32830563 PMCID: PMC7448257 DOI: 10.1177/2324709620952212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Varicella zoster meningitis is an uncommon complication of herpes zoster,
especially in immunocompetent patients. We report a case of a healthy
45-year-old male who developed aseptic meningitis as a result of reactivated
varicella zoster virus infection. This case highlights the importance of
remaining cognizant of varicella zoster virus as a cause of meningitis in not
only the elderly or immunocompromised patients but also in patients who are
healthy.
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Affiliation(s)
- Mohammed Ali Faluk
- University of Central Florida, Orlando, FL, USA.,Ocala Regional Medical Center, Ocala, FL, USA
| | - Shraddhadevi Makadia
- University of Central Florida, Orlando, FL, USA.,Ocala Regional Medical Center, Ocala, FL, USA
| | - Ramy Abdelmaseih
- University of Central Florida, Orlando, FL, USA.,Ocala Regional Medical Center, Ocala, FL, USA
| | - S Mustajab Hasan
- University of Central Florida, Orlando, FL, USA.,Ocala Regional Medical Center, Ocala, FL, USA
| | - Khalid Abusaada
- University of Central Florida, Orlando, FL, USA.,Ocala Regional Medical Center, Ocala, FL, USA
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16
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Sollie M, Thomsen JB, Sørensen JA. Autologous fat grafting seems to alleviate postherpetic neuralgia - a feasibility study investigating patient-reported levels of pain. J Plast Reconstr Aesthet Surg 2020; 74:350-356. [PMID: 32917571 DOI: 10.1016/j.bjps.2020.08.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 05/21/2020] [Accepted: 08/14/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Postherpetic neuralgia (PHN) is a relatively common side effect after an outbreak of herpes zoster (HZ), characterized by chronic neuropathic dermal pain. No effective treatment exists today. Fat grafting has shown promise in alleviating neuropathic pain, yet the exact mechanism of action, at a biological level, is not yet known. We report on the first human study using autologous fat grafting for treating PHN. Our hypothesis was that fat grafting can alleviate pain and improve the quality of life (QoL) in patients suffering from PHN. If successful, this could be a safe, cost-effective alternative to analgesics. This safety and feasibility study aimed to investigate the possible pain-relieving effect of autologous fat grafting on PHN. METHODS Ten adult patients suffering from PHN underwent autologous fat grafting to a dermal area of neuralgia, with a 12-week follow up. The primary endpoint was patient-reported pain. Secondary endpoints were patient-reported changes in QoL, and the degree and quality of the neuropathic pain. RESULTS The pain was measured by using a visual analog scale (range: 0-10). We observed improvements in both the average and maximum level of pain with a reduction of (-4.0 ± 3.1) and (-5.1 ± 3.9), respectively, (Δ mean ± SD), P<0.05. All parameters investigating neuropathic pain were significantly reduced. No improvement was seen in the QoL. The average amount of fat grafted was 208 ml. We observed no serious adverse effects. CONCLUSION This study suggests that autologous fat grafting can relieve chronic pain resulting from HZ. The next step toward routine clinical translation is to perform a randomized, blinded, placebo-controlled trial with a more extended follow-up period.
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Affiliation(s)
- Martin Sollie
- Research Unit of Plastic Surgery, Odense University Hospital. J. B. Winsløvsvej 4, indgang 20, 1. sal. 5000 Odense C, Denmark.
| | - Jørn Bo Thomsen
- Research Unit of Plastic Surgery, Odense University Hospital. J. B. Winsløvsvej 4, indgang 20, 1. sal. 5000 Odense C, Denmark
| | - Jens Ahm Sørensen
- Research Unit of Plastic Surgery, Odense University Hospital. J. B. Winsløvsvej 4, indgang 20, 1. sal. 5000 Odense C, Denmark
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17
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Chen GB, Tuan SH, Liou IH, Huang HY, Hu YC, Wu SY. Segmental zoster paresis of unilateral upper extremity: A case report and literature review. Medicine (Baltimore) 2020; 99:e20466. [PMID: 32664058 PMCID: PMC7360310 DOI: 10.1097/md.0000000000020466] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
RATIONALE Segmental zoster paresis (SZP) is a relatively rare neurologic complication of herpes zoster (HZ), and is characterized by focal asymmetric motor weakness in the myotome that corresponds to skin lesions of the dermatome. The upper extremities are the second most commonly involved regions after the face, and predominantly involve proximal muscles. The pathogenesis of SZP remains unclear; however, most of the reports indicate that it is the inflammation because of the spread of the herpes virus. PATIENT CONCERNS A 72-year-old man without trauma history of the left shoulder joint developed weakness of the left proximal upper extremity 10 days after vesicular eruption of HZ. DIAGNOSES His left shoulder girdle paresis was diagnosed with the upper truncus of the brachial plexus as a HZ complication according to a series of tests, including cervical magnetic resonance imaging (MRI), cerebral fluid analysis, sonography, and electrophysiological studies. INTERVENTIONS Acyclovir and prednisolone were administered during hospitalization to treat SZP. Meanwhile, analgesics and gabapentin were administered to control the patient's neuralgic pain. He also received inpatient (daily) and outpatient (3 times per week) physical therapy along with range of motion and strengthening exercises. OUTCOMES Partial improvement of the strength of the left shoulder girdle, and no improvement of the left deltoid muscle was observed 2 months after the interventions. LESSONS This case emphasizes that HZ infections may be complicated by segmental paresis and they should be considered in the differential diagnosis of acute paresis in the upper limb. Awareness of this disorder is important because it avoids unnecessary invasive investigations and interventions, leading to suitable treatments with favorable prognosis.
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Affiliation(s)
- Guan-Bo Chen
- Department of Internal Medicine, Kaohsiung Armed Forces General Hospital
| | - Sheng-Hui Tuan
- Department of Rehabilitation Medicine, Cishan Hospital, Ministry of Health and Welfare
- Department of Physical Therapy, Shu-Zen Junior College of Medicine and Management
| | - I-Hsiu Liou
- Department of Physical Medicine and Rehabilitation, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Hung-Ya Huang
- Department of Physical Medicine and Rehabilitation, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Ya-Chun Hu
- Department of Rehabilitation Medicine, Cishan Hospital, Ministry of Health and Welfare
| | - Shin-Yi Wu
- Department of Physical Medicine and Rehabilitation, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
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18
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Abstract
Neuropathic pain caused by a lesion or disease of the somatosensory nervous system is a common chronic pain condition with major impact on quality of life. Examples include trigeminal neuralgia, painful polyneuropathy, postherpetic neuralgia, and central poststroke pain. Most patients complain of an ongoing or intermittent spontaneous pain of, for example, burning, pricking, squeezing quality, which may be accompanied by evoked pain, particular to light touch and cold. Ectopic activity in, for example, nerve-end neuroma, compressed nerves or nerve roots, dorsal root ganglia, and the thalamus may in different conditions underlie the spontaneous pain. Evoked pain may spread to neighboring areas, and the underlying pathophysiology involves peripheral and central sensitization. Maladaptive structural changes and a number of cell-cell interactions and molecular signaling underlie the sensitization of nociceptive pathways. These include alteration in ion channels, activation of immune cells, glial-derived mediators, and epigenetic regulation. The major classes of therapeutics include drugs acting on α2δ subunits of calcium channels, sodium channels, and descending modulatory inhibitory pathways.
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Affiliation(s)
- Nanna Brix Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Neurology, Aarhus University Hospital, Aarhus, Denmark; and Department of Pharmacology, Heidelberg University, Heidelberg, Germany
| | - Rohini Kuner
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Neurology, Aarhus University Hospital, Aarhus, Denmark; and Department of Pharmacology, Heidelberg University, Heidelberg, Germany
| | - Troels Staehelin Jensen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Neurology, Aarhus University Hospital, Aarhus, Denmark; and Department of Pharmacology, Heidelberg University, Heidelberg, Germany
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19
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Abstract
BACKGROUND Approximately 1 million new cases of herpes zoster (HZ) occur in the United States annually, including 10%-20% with herpes zoster ophthalmicus (HZO). Postherpetic neuralgia, a debilitating pain syndrome occurs in 30% HZ, whereas 50% HZO develop ophthalmic complications. Diplopia from cranial nerve palsy occurs in less than 30% HZO, whereas optic neuropathy is seen in less than 1% HZO. We reviewed recent developments in the diagnosis, treatment, and prevention of HZ as well as neurological and ophthalmological complications of relevance to the neuro-ophthalmologist. EVIDENCE ACQUISITION We searched the English language literature on Pubmed and Google scholar for articles relevant to the various sections of this review. RESULTS Antiviral treatment should be initiated within 48-72 hours of onset of HZ and HZO to decrease pain and reduce complications. We recommend neuroimaging in all patients with neuro-ophthalmic manifestations such as diplopia and acute vision loss. Diagnostic confirmation using polymerase chain reaction and serology on paired serum and cerebrospinal fluid samples should be obtained in those with neurological signs and symptoms or abnormal imaging. Patients with neurological and/or retinal varicella zoster virus (VZV) infection should be treated promptly with intravenous acyclovir. Patients with isolated optic neuropathy or cranial nerve palsy can be managed with oral antivirals. The prognosis for visual recovery is good for patients with isolated optic neuropathy and excellent for patients with isolated ocular motor cranial nerve palsy. CONCLUSIONS HZ produces a spectrum of potentially blinding and life-threatening complications that adversely affect quality of life and increase health care costs. Individuals at risk for HZ, such as the elderly and immunocompromised, should be encouraged to receive the highly effective VZV vaccine to prevent HZ and its complications.
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20
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Ngo AL, Urits I, Yilmaz M, Fortier L, Anya A, Oh JH, Berger AA, Kassem H, Sanchez MG, Kaye AD, Urman RD, Herron EW, Cornett EM, Viswanath O. Postherpetic Neuralgia: Current Evidence on the Topical Film-Forming Spray with Bupivacaine Hydrochloride and a Review of Available Treatment Strategies. Adv Ther 2020; 37:2003-2016. [PMID: 32297285 PMCID: PMC7467465 DOI: 10.1007/s12325-020-01335-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW This is a comprehensive review of the literature about the use of bupivacaine hydrochloride for the treatment of post-herpetic neuralgia (PHN). It briefly reviews the background, biology, diagnosis and conventional treatment for PHN, and then introduces and compares the recent evidence for the use of topical bupivacaine. RECENT FINDINGS PHN is defined by pain lasting 90 days or more after the initial presentation of herpes zoster ("Shingles", HZ) rash and is the most common complication of this disease. A product of re-activation of the Varicella-Zoster virus (VZV), HZ is diagnosed more than 1 million times annually in the United States. Approximately 20% of patients with HZ will experience PHN and will continue to suffer intermittent neuropathic symptoms, including itching and pain, that is sharp, stabbing, throbbing or burning, with the pain localized to the site of their original rash. This long-lasting pain compares with the severity of long-standing rheumatics and osteo-arthritis and is accompanied by severe allodynia causing significant suffering, and a financial burden that is manifested in both healthcare costs and loss of quality-adjusted life years. Prevention of PHN may be achieved with the Zoster vaccine, although there is still a large segment of unvaccinated population. Moreover, the Zoster vaccine is not always effective for prevention. Current treatment includes medical (systemic tricyclic antidepressants, anticonvulsants and opioids, topical lidocaine and capsaicin) and interventional (subcutaneous Botox injections, nerve blocks and nerve stimulation) therapies. These therapies are not always effective, and each carries their own profile of side effects and risks. Moreover, up to 50% of patients with PHN are refractory to management. Recent evidence is emerging to support the use of topical local anesthetics for the treatment of PHN. Two small studies recently found topical lidocaine spray to be effective in treating paroxysmal pain attacks associated with PHN. Bupivacaine is a longer-lasting local anesthetic, and a film-forming formulation allows easy and durable application to the affected skin. Recent studies show that topical film-forming bupivacaine is safe and as effective as lidocaine for the treatment of PHN. PHN is an important though common complication of HZ and can cause long-lasting pain and disability. Current treatment for PNH is limited by efficacy and safety profiles of individual therapies. Recent evidence points to topical local anesthetics as an effective and safe alternative to conventional therapy. Film-forming bupivacaine may offer a durable and safe option for this otherwise difficult to treat syndrome.
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Affiliation(s)
- Anh L Ngo
- Harvard Medical School, Boston, MA, USA
- Department of Pain Medicine, Pain Specialty Group, Newington, NH, USA
| | - Ivan Urits
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | | | - Luc Fortier
- Georgetown University School of Medicine, Washington, DC, USA
| | - Anthony Anya
- Georgetown University School of Medicine, Washington, DC, USA
| | - Jae Hak Oh
- Georgetown University School of Medicine, Washington, DC, USA
| | - Amnon A Berger
- Department of Pain Medicine, Pain Specialty Group, Newington, NH, USA
| | - Hisham Kassem
- Department of Anesthesiology, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Manuel G Sanchez
- Department of Pain Medicine, Pain Specialty Group, Newington, NH, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Edwin W Herron
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Elyse M Cornett
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants, Envision Physician Services, Phoenix, AZ, USA
- Department of Anesthesiology, University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
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21
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Choi EM, Chung MH, Jun JH, Chun EH, Jun IJ, Park JH, Choi EH, Kim JE. Efficacy of intermittent epidural dexamethasone bolus for zoster-associated pain beyond the acute phase. Int J Med Sci 2020; 17:1811-1818. [PMID: 32714084 PMCID: PMC7378659 DOI: 10.7150/ijms.46038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 06/26/2020] [Indexed: 11/05/2022] Open
Abstract
Herpes zoster develops when latent varicella zoster virus is reactivated in the trigeminal or dorsal root ganglions. Zoster-associated pain (ZAP) is neuropathic pain caused by the herpes zoster virus. Histological studies of postherpetic neuralgia patients suggest that inflammation is involved in ZAP. The effectiveness of local anesthetic and steroid epidural injections in ZAP patients has been reported. However, most studies included patients with acute herpes zoster, and the safety and therapeutic effects of different doses of epidural steroids in ZAP patients remain elusive. In this study, we randomly assigned 42 patients with severe ZAP beyond the acute phase, as determined by a numeric rating scale (NRS) score ≥7, to receive continuous epidural infusion of local anesthetics with either a one-time 5-mg dose or intermittent repeated doses (15 mg total) of dexamethasone. We found that intermittent repeated epidural dexamethasone bolus resulted in reduced NRS scores and an increased likelihood of complete remission in ZAP patients without any adverse effects. Thus, our results suggest that intermittent repeated epidural dexamethasone administration is safe and effective for treatment of ZAP beyond the acute phase.
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Affiliation(s)
- Eun Mi Choi
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Mi Hwa Chung
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Joo Hyun Jun
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Eun Hee Chun
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - In-Jung Jun
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Jong Hee Park
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Eun-Ha Choi
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Jung Eun Kim
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
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22
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Abstract
Infections in immunosuppressed patients represent a particular challenge in the diagnostics and treatment. They often present with atypical and particularly severe courses, for which rapid diagnostics and treatment are decisive for treatment success. Opportunistic infections with human herpes viruses occur not only more frequently in immunocompromised patients compared to healthy people but also represent a special challenge. In the treatment of immunosuppressed patients, e.g. with human immunodeficiency virus infections and patients with solid organ transplantations, infections with herpes simplex virus, varicella zoster virus, Epstein-Barr virus and cytomegalovirus are particularly important. The symtoms are very variable, ranging from asymptomatic detection of viremia to vital life-threatening organ manifestations. This review article describes the most important clinical presentations of these opportunistic infections. Furthermore, the diagnostic, therapeutic and prophylactic strategies for human herpes viruses are summarized.
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Affiliation(s)
- N Floß
- Klinik für Infektiologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstraße 55, 45122, Essen, Deutschland
| | - S Dolff
- Klinik für Infektiologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstraße 55, 45122, Essen, Deutschland.
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23
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De Vloo P, Milosevic L, Gramer RM, Aguirre-Padilla DH, Dallapiazza RF, Lee DJ, Hutchison WD, Fasano A, Lozano AM. Complete resolution of postherpetic neuralgia following pallidotomy: case report. J Neurosurg 2019; 133:1229-1234. [PMID: 31561224 DOI: 10.3171/2019.7.jns191050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 07/08/2019] [Indexed: 11/06/2022]
Abstract
The authors report on a female patient with left-dominant Parkinson's disease with motor fluctuations and levodopa-induced dyskinesias and comorbid postherpetic neuralgia (PHN), who underwent a right-sided pallidotomy. Besides a substantial improvement in her Parkinson's symptoms, she reported an immediate and complete disappearance of PHN. This neuralgia had been long-standing, pharmacologically refractory, and severe (preoperative Brief Pain Inventory [BPI] pain severity score of 8.0, BPI pain interference score of 7.3, short-form McGill Pain Questionnaire sensory pain rating index of 7 and affective pain rating index of 10, Present Pain Intensity rank value of 4, and visual analog scale score of 81 mm; all postoperative scores were 0). She continued to be pain free at 16 months postoperatively.This peculiar finding adds substantially to the largely unrecognized evidence for the role of the pallidum in pain processing, based on previous electrophysiological, metabolic, anatomical, pharmacological, and clinical observations. Therefore, the potential of the pallidum as a neurosurgical target for neuropathic pain warrants further investigation.
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Affiliation(s)
- Philippe De Vloo
- 1Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- 2Department of Neurosurgery, University Hospitals Leuven, Vlaams-Brabant, Belgium
| | - Luka Milosevic
- 3Department of Physiology, Toronto Western Hospital and University of Toronto, Ontario, Canada
- 4Krembil Research Institute, University of Toronto, Ontario, Canada; and
| | - Robert M Gramer
- 1Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- 4Krembil Research Institute, University of Toronto, Ontario, Canada; and
| | | | - Robert F Dallapiazza
- 1Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Darrin J Lee
- 1Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - William D Hutchison
- 3Department of Physiology, Toronto Western Hospital and University of Toronto, Ontario, Canada
- 4Krembil Research Institute, University of Toronto, Ontario, Canada; and
| | - Alfonso Fasano
- 4Krembil Research Institute, University of Toronto, Ontario, Canada; and
- 5Division of Neurology, The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network Toronto, Ontario, Canada
| | - Andres M Lozano
- 1Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- 4Krembil Research Institute, University of Toronto, Ontario, Canada; and
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Sutherland JP, Steain M, Buckland ME, Rodriguez M, Cunningham AL, Slobedman B, Abendroth A. Persistence of a T Cell Infiltrate in Human Ganglia Years After Herpes Zoster and During Post-herpetic Neuralgia. Front Microbiol 2019; 10:2117. [PMID: 31572325 PMCID: PMC6749866 DOI: 10.3389/fmicb.2019.02117] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 08/28/2019] [Indexed: 12/14/2022] Open
Abstract
Varicella-zoster virus (VZV) is a human herpesvirus which causes varicella (chicken pox) during primary infection, establishes latency in sensory ganglia, and can reactivate from this site to cause herpes zoster (HZ) (shingles). A major complication of HZ is a severe and often debilitating pain called post-herpetic neuralgia (PHN) which persists long after the resolution of the HZ-associated rash. The underlying cause of PHN is not known, although it has been postulated that it may be a consequence of immune cell mediated damage. However, the nature of virus-immune cell interactions within ganglia during PHN is unknown. We obtained rare formalin fixed paraffin embedded sections cut from surgically excised ganglia from a PHN-affected patient years following HZ rash resolution. VZV DNA was readily detected by qPCR and regions of immune infiltration were detected by hematoxylin and eosin staining. Immunostaining using a range of antibodies against immune cell subsets revealed an immune cell response comprising of CD4+ and CD8+ T cells and CD20+ B cells. This study explores the immune cell repertoire present in ganglia during PHN and provides evidence for an ongoing immune cell inflammation years after HZ.
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Affiliation(s)
- Jeremy P Sutherland
- Emergency Department, Westmead Hospital, The University of Sydney, Sydney, NSW, Australia
| | - Megan Steain
- Discipline of Infectious Diseases and Immunology, The University of Sydney, Sydney, NSW, Australia
| | - Michael E Buckland
- Department of Neuropathology, Royal Prince Alfred Hospital, The University of Sydney, Sydney, NSW, Australia
| | - Michael Rodriguez
- Department of Pathology, The University of Sydney, Sydney, NSW, Australia
| | - Anthony L Cunningham
- Centre for Virus Research, Westmead Institute for Medical Research, Westmead, NSW, Australia
| | - Barry Slobedman
- Discipline of Infectious Diseases and Immunology, The University of Sydney, Sydney, NSW, Australia
| | - Allison Abendroth
- Discipline of Infectious Diseases and Immunology, The University of Sydney, Sydney, NSW, Australia
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Abstract
This prospective cohort study aimed to characterize the sensory profile during acute herpes zoster (AHZ) and to explore sensory signs as well as physical and psychosocial health as predictors for postherpetic neuralgia (PHN). Results of quantitative sensory testing of 74 patients with AHZ at the affected site and at the distant contralateral control site were compared to a healthy control group. Pain characteristics (Neuropathic Pain and Symptom Inventory and SES), physical functioning, and psychosocial health aspects (Pain Disability Index, SF-36, and STAI) were assessed by questionnaires. Patients with PHN (n = 13) at 6-month follow-up were compared to those without PHN (n = 45). Sensory signs at the affected site were thermal and vibratory hypesthesia, dynamic mechanical allodynia (DMA), pressure hyperalgesia, and high wind-up (18%-29%), as well as paradoxical heat sensations and pinprick hypalgesia (13.5%). The unaffected control site exhibited thermal and vibratory hypesthesia, DMA, and pressure hyperalgesia. Dynamic mechanical allodynia and pinprick hypalgesia were mutually exclusive. Postherpetic neuralgia was associated with DMA (38.5% vs 6.7%; P = 0.010) and vibratory hypesthesia (38.5% vs 11.1%; P = 0.036) at the control site, with mechanical gain and/or loss combined with normal thermal detection (affected site: 69.2% vs 31.1%; P = 0.023; control site: 53.8% vs 15.5%; P = 0.009). Pain Disability Index (P = 0.036) and SES affective pain perception scores (P = 0.031) were over 50% higher, and 6 of 8 SF-36 subscores were over 50% lower (P < 0.045) in PHN. Sensory profiles in AHZ indicate deafferentation and central but not peripheral sensitization. Sensory signs at distant body sites, strong affective pain perception, as well as reduced quality of life and physical functioning in the acute phase may reflect risk factors for the transition to PHN.
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Affiliation(s)
- Charles-Henri Rapin
- Centre de soins continus, Institutions Universitaires de Gériatrie de Genève, Geneva, Switzerland
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Post-herpetic Neuralgia. Pain 2019. [DOI: 10.1007/978-3-319-99124-5_268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Devor M. Rethinking the causes of pain in herpes zoster and postherpetic neuralgia: the ectopic pacemaker hypothesis. Pain Rep 2018; 3:e702. [PMID: 30706041 PMCID: PMC6344138 DOI: 10.1097/pr9.0000000000000702] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 10/10/2018] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION Pain in herpes zoster (HZ) and postherpetic neuralgia (PHN) is traditionally explained in terms of 2 processes: irritable nociceptors in the rash-inflamed skin and, later, deafferentation due to destruction of sensory neurons in one virally infected dorsal root ganglion. OBJECTIVES AND METHODS Consideration of the evidence supporting this explanation in light of contemporary understanding of the pain system finds it wanting. An alternative hypothesis is proposed as a replacement. RESULTS This model, the ectopic pacemaker hypothesis of HZ and PHN, proposes that pain in both conditions is driven by hyperexcitable ectopic pacemaker sites at various locations in primary sensory neurons affected by the causative varicella zoster virus infection. This peripheral input is exacerbated by central sensitization induced and maintained by the ectopic activity. CONCLUSIONS The shift in perspective regarding the pain mechanism in HZ/PHN has specific implications for clinical management.
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Affiliation(s)
- Marshall Devor
- Department of Cell and Developmental Biology, Institute of Life Sciences, and Center for Research on Pain, The Hebrew University of Jerusalem, Jerusalem, Israel
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Kang D, McAuley JH, Kassem MS, Gatt JM, Gustin SM. What does the grey matter decrease in the medial prefrontal cortex reflect in people with chronic pain? Eur J Pain 2018; 23:203-219. [PMID: 30101509 DOI: 10.1002/ejp.1304] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 08/05/2018] [Accepted: 08/07/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVE Alterations in the grey matter volume of several brain regions have been reported in people with chronic pain. The most consistent observation is a decrease in grey matter volume in the medial prefrontal cortex. These findings are important as the medial prefrontal cortex plays a critical role in emotional and cognitive processing in chronic pain. Although a logical cause of grey matter volume decrease may be neurodegeneration, this is not supported by the current evidence. Therefore, the purpose of this review was to evaluate the existing literature to unravel what the decrease in medial prefrontal cortex grey matter volume in people with chronic pain may represent on a biochemical and cellular level. DATABASES AND DATA TREATMENT A literature search for this topical review was conducted using PubMed and SCOPUS library. Search terms included chronic pain, pain, medial prefrontal cortex, anterior cingulate cortex, grey matter, neurochemistry, spectroscopy, magnetic resonance imaging, positron emission tomography, dendrite, neurodegeneration, glia, astrocyte, microglia, neurotransmitter, glutamate, GABA and different combinations of these terms. RESULTS Adopting a stress model of chronic pain, two major pathways are proposed that contribute to grey matter volume decrease in the medial prefrontal cortex: (a) changes in dendritic morphology as a result of hypothalamic-pituitary axis dysfunction and (b) neurotransmitter dysregulation, specifically glutamate and γ-Aminobutyric acid, which affects local microvasculature. CONCLUSION Our model proposes new mechanisms in chronic pain pathophysiology responsible for mPFC grey matter loss as alternatives to neurodegeneration. SIGNIFICANCE It is unclear what the decrease in medial prefrontal cortex grey matter volume represents in chronic pain. The most attractive reason is neurodegeneration. However, there is no evidence to support this. Our review reveals nondegenerative causes of decreased medial prefrontal grey matter to guide future research into chronic pain pathophysiology.
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Affiliation(s)
- David Kang
- Neuroscience Research Australia, Sydney, NSW, Australia.,UNSW Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - James H McAuley
- Neuroscience Research Australia, Sydney, NSW, Australia.,UNSW Medicine, UNSW Sydney, Sydney, NSW, Australia
| | | | - Justine M Gatt
- Neuroscience Research Australia, Sydney, NSW, Australia.,School of Psychology, UNSW Sydney, Sydney, NSW, Australia
| | - Sylvia M Gustin
- Neuroscience Research Australia, Sydney, NSW, Australia.,School of Psychology, UNSW Sydney, Sydney, NSW, Australia
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Liu Y, Wu BY, Ma ZS, Xu JJ, Yang B, Li H, Duan RS. A retrospective case series of segmental zoster paresis of limbs: clinical, electrophysiological and imaging characteristics. BMC Neurol 2018; 18:121. [PMID: 30131076 PMCID: PMC6102897 DOI: 10.1186/s12883-018-1130-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 08/15/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Segmental zoster paresis (SZP) of limbs, characterized by focal weakness of extremity, is recognized as a rare complication of herpes zoster (HZ). The following study analyzes the clinical characteristics and data from electromyography and MRI scans in patients with motor weakness after zoster infection. METHODS One thousand three hundred ninety-three patients from our database (Shandong Provincial Qianfoshan Hospital) suffering from HZ were retrospectively reviewed from June 2015 to July 2017. Patients who fulfilled the diagnostic criteria for SZP were included in the analysis. The clinical characteristics, as well as electromyography findings and MRI scans were analyzed. RESULTS SZP was present in 0.57% of patients with HZ (8/1393). The average age of symptom onset in 8 SZP patients was 69 years old (SD: 13, range 47-87). The severity of muscle weakness ranged from mild to severe. The electrophysiological testing revealed the characteristics of axonopathy. Radiculopathy (2/8), plexopathy (2/8), radiculoplexopathy (3/8) and combined radiculopathy and mononeuropathy (1/8) were also identified. MRI revealed hyperintensity of the affected spinal dorsal horns, nerve roots or peripheral nerves. CONCLUSIONS SZP is associated with obvious limb weakness, nerve axons lesions and localization to nerve roots, plexus or peripheral nerves.
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Affiliation(s)
- Ying Liu
- Department of Electromyography, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, 250014 People’s Republic of China
| | - Bing-Yun Wu
- Department of Electromyography, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, 250014 People’s Republic of China
| | - Zhen-Shen Ma
- Department of radiology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, 250014 People’s Republic of China
| | - Juan-Juan Xu
- Department of Electromyography, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, 250014 People’s Republic of China
| | - Bing Yang
- Department of Neurology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, 250014 People’s Republic of China
| | - Heng Li
- Department of Neurology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, 250014 People’s Republic of China
| | - Rui-Sheng Duan
- Department of Neurology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, 250014 People’s Republic of China
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Abstract
Neuropathic pain of the orofacial region can cause much distress in individuals presenting with this condition. It may be easily mistaken for dental pain, and hence many individuals may undergo unnecessary dental work. Knowledge of the types of neuropathic orofacial pain may assist in timely diagnosis and improvement of a patient's quality of life.
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Abstract
PURPOSE To study the contribution of each eye to the reflex tear response, after unilateral and bilateral topical anesthesia. METHOD A closed-eye, modified Schirmer test was performed bilaterally in 8 normal subjects, in a controlled environment chamber set to 23°C, 45% relative humidity, and 0.08 m/s airflow. Eye drops were instilled into each eye 10 minutes before the Schirmer test. Experiments were as follows: 1) bilateral saline (control), 2) unilateral anesthesia (ipsilateral anesthetic; contralateral saline), and 3) bilateral anesthesia. RESULTS There was no difference in between-eye wetting lengths in the saline control eyes (P = 0.394) or the bilaterally anesthetized eyes (P = 0.171). The wetting length was reduced in both eyes after bilateral anesthesia compared with saline controls (P = 0.001; P ≤ 0.0005). After unilateral anesthesia, the wetting length was reduced in the anesthetized eye compared with its saline control by 51.4% (P ≤ 0.0005) and compared with its fellow, unanesthetized eye (P = 0.005). The fellow eye value was also reduced compared with its saline control (P = 0.06). CONCLUSIONS The wetting length was reduced by topical anesthesia, when instilled bilaterally and ipsilaterally. The latter response implies an ipsilateral, reflex sensory drive to lacrimal secretion. In the unanesthetized fellow eye, the reduction compared with its saline control was not quite significant. This implies a relative lack of central, sensory, reflex cross-innervation, although the possibility cannot entirely be ruled out. These results are relevant to the possibility of reflex lacrimal compensation from a normal fellow eye, in cases of unilateral corneal anesthesia.
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Schutzer-Weissmann J, Farquhar-Smith P. Post-herpetic neuralgia - a review of current management and future directions. Expert Opin Pharmacother 2017; 18:1739-1750. [PMID: 29025327 DOI: 10.1080/14656566.2017.1392508] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Post-herpetic neuralgia (PHN) is common and treatment is often suboptimal with less than half of patients achieving adequate 50% pain relief. As an area of unmet clinical need and as an archetype of neuropathic pain, it deserves the attention of clinicians and researchers. Areas covered: This review summarises the epidemiology, pathophysiology, risk factors and clinical features of varicella infection. It describes the current and possible future management strategies for preventing varicella infection and reactivation and for treating PHN. Expert opinion: A highly successful Varicella Zoster (VZV) vaccine has not been universally adopted due to fears that it may increase Herpes Zoster (HZ) incidence - and thus PHN - in older, unvaccinated generations. This is a controversial theory but advances in the efficacy of vaccines against HZ may allay these fears and encourage more widespread adoption of the VZV vaccine. Treatment of PHN, as for any neuropathic pain, must be multidisciplinary and multimodal. Advances in sensory phenotyping technology and genomics may allow more individualised treatment. Traditional research methodologies are ill-suited to assess the kind of complex interventions that are necessary to achieve better clinical outcomes in this challenging field.
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Affiliation(s)
- John Schutzer-Weissmann
- a Department of Anaesthesia , Critical Care and Pain Medicine, The Royal Marsden Hospital , London , UK
| | - Paul Farquhar-Smith
- a Department of Anaesthesia , Critical Care and Pain Medicine, The Royal Marsden Hospital , London , UK
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Zhang G, Sun Y, Wang L, Tian H, Liang L. Association of serum Ninjurin2 levels with neurologic damage and postherpetic neuralgia occurrence: an observational cohort study in chinese herpeszoster patients. Oncotarget 2017; 8:71520-71527. [PMID: 29069724 PMCID: PMC5641067 DOI: 10.18632/oncotarget.17640] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 03/23/2017] [Indexed: 11/29/2022] Open
Abstract
Objectives Postherpetic neuralgia(PHN) is the most common complication of herpeszoster (HZ) infection. The study aimed to explore whether serum Ninjurin2 (for nerve injury-induced protein 2, NINJ2), a novel neurologic damage related protein, is associated with nerve injury and the occurrence of PHN. Results Seventy-four of the eighty patients completed the study. On the 7th day of AHN, the patients had significantly higher values of NINJ2, cold-sense dispersion (ΔCS), warm-sense dispersion (ΔWS), cold-pain dispersion (ΔCP), heat-pain dispersion (ΔHP) and NRS score compared to controls. Six months after herpes, thirty four patients developed PHN. The values of serum NINJ2, ΔCS, ΔWS, ΔCP and ΔHP in PHN patients remained higher than in the controls and the patients who did not develop PHN. The PHN patients had significantly lower values of serumNINJ2 than patients who did not develop PHN in the period of AHN. With partial correlations and multivariable logistic regressions, serum NINJ2 level was strongly predictive of PHN. Materials and Methods Eighty individuals with acute herpetic neuralgia (AHN) and 60 controls were recruited. The following nerve injury testing was performed on all of the patients including: the numerical rating scale (NRS) test, quantitative sensory testing (QST), and the investigation of serum NINJ2 levels on the 7th day of AHN; in addition, all of the patients repeated all of the items at 6 months after herpes. Conclusions The serum NINJ2 levels are associated with nerve injury, particularly with nerve recovery, and may be predictors of PHN occurrence.
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Affiliation(s)
- Guozhuan Zhang
- Department of Pain Management, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Yingjiao Sun
- Department of Pain Management, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Lei Wang
- Department of Pain Management, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Hui Tian
- Department of Thoracic Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Lishuang Liang
- Department of Pain Management, Qilu Hospital of Shandong University, Jinan, Shandong, China
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Shiraki K, Toyama N, Daikoku T, Yajima M. Herpes Zoster and Recurrent Herpes Zoster. Open Forum Infect Dis 2017; 4:ofx007. [PMID: 28480280 PMCID: PMC5414100 DOI: 10.1093/ofid/ofx007] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
Background The incidence of recurrent herpes zoster (HZ) and the relationship between initial and recurrent HZ are not clear. Methods The Miyazaki Dermatologist Society has surveyed ~5000 patients with HZ annually since 1997. A questionnaire regarding HZ and its recurrence was completed by the dermatologists. Results A total of 34 877 patients with HZ were registered at 43 clinics between June 2009 and November 2015. Among 16 784 patients seen at 10 of the 43 clinics, 1076 patients (6.41%) experienced recurrence. Herpes zoster was more frequent in female than in male patients (5.27 vs 4.25 in 1000 person-years, P < .001), as was HZ recurrence (7.63% vs 4.73%, P < .001). Two and three recurrences were observed in 49 and 3 patients, respectively. Recurrence in the same dermatome was observed in 16.3% of patients, and more frequently this occurred in the left side (P = .027). The number of HZ-experienced persons increased with age, and one third of the population had experienced HZ by the age of 80. Conclusions Recurrent HZ was observed in 6.41% of patients, with a higher incidence in women. Moreover, HZ experience reduced the HZ incidence to 31.7% of the incidence in the HZ-naive population.
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Affiliation(s)
- Kimiyasu Shiraki
- Department of Virology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Nozomu Toyama
- Toyama Dermatologic Clinic, Aburatsu, Nichinan City, Miyazaki, Japan
| | - Tohru Daikoku
- Department of Virology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Misako Yajima
- Department of Virology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
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Cruzat A, Hamrah P, Cavalcanti BM, Zheng L, Colby K, Pavan-Langston D. Corneal Reinnervation and Sensation Recovery in Patients With Herpes Zoster Ophthalmicus: An In Vivo and Ex Vivo Study of Corneal Nerves. Cornea 2016; 35:619-25. [PMID: 26989956 DOI: 10.1097/ico.0000000000000797] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE To study corneal reinnervation and sensation recovery in Herpes zoster ophthalmicus (HZO). METHODS Two patients with HZO were studied over time with serial corneal esthesiometry and laser in vivo confocal microscopy (IVCM). A Boston keratoprosthesis type 1 was implanted, and the explanted corneal tissues were examined by immunofluorescence histochemistry for βIII-tubulin to stain for corneal nerves. RESULTS The initial central corneal IVCM performed in each patient showed a complete lack of the subbasal nerve plexus, which was in accordance with severe loss of sensation (0 of 6 cm) measured by esthesiometry. When IVCM was repeated 2 years later before undergoing surgery, case 1 showed a persistent lack of central subbasal nerves and sensation (0 of 6). In contrast, case 2 showed regeneration of the central subbasal nerves (4786 μm/mm) with partial recovery of corneal sensation (2.5 of 6 cm). Immunostaining of the explanted corneal button in case 1 showed no corneal nerves, whereas case 2 showed central and peripheral corneal nerves. Eight months after surgery, IVCM was again repeated in the donor tissue around the Boston keratoprosthesis in both patients to study innervation of the corneal transplant. Case 1 showed no nerves, whereas case 2 showed new nerves growing from the periphery into the corneal graft. CONCLUSIONS We demonstrate that regaining corneal innervation and corneal function are possible in patients with HZO as shown by corneal sensation, IVCM, and ex vivo immunostaining, indicating zoster neural damage is not always permanent and it may recover over an extended period of time.
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Affiliation(s)
- Andrea Cruzat
- *Cornea Service, Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, MA;†Department of Ophthalmology, Pontificia Universidad Católica de Chile, Santiago, Chile;‡New England Eye Center, Department of Ophthalmology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA;§Eye Center, Somerville Hospital, Department of Surgery, Cambridge Health Alliance, Somerville, MA; and¶Department of Ophthalmology, University of Chicago, Chicago, IL
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Borchers AT, Gershwin ME. The clinical relevance of complex regional pain syndrome type I: The Emperor's New Clothes. Autoimmun Rev 2016; 16:22-33. [PMID: 27666818 DOI: 10.1016/j.autrev.2016.09.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 08/08/2016] [Indexed: 02/06/2023]
Abstract
The management of patients with chronic pain is a nearly daily challenge to rheumatologists, neurologists, orthopedic surgeons, pain specialists and indeed a issue in nearly every clinical practice. Among the myriad of causes of pain are often included a unique syndrome, generally referred to as complex regional pain syndrome type I (CRPS). Unfortunately CRPS I has become a catch all phase and there are serious questions on whether it exists at all; this has led to an extraordinary number of poorly defined diagnostic criteria. It has also led to an etiologic quagmire that includes features as diverse as autoimmunity to simple trauma. These, in turn, have led to overdiagnosis and often overzealous use of pain medications, including narcotics. In a previous paper, we raised the issue of whether CRPS type I reflected a valid diagnosis. Indeed, the diagnostic criteria for CRPS I, and therefore the diagnosis itself, is unreliable for a number of reasons: 1) the underlying pathophysiology of the signs and symptoms of CPRS I are not biologically plausible; 2) there are no consistent laboratory or imaging testing available; 3) the signs and symptoms fluctuate over time without a medical explanation; 4) the definitions of most studies are derived from statistical analysis with little consideration to required sample size, i.e. power calculations; 5) interobserver reliability in the assessment of the signs and symptoms are often only fair to moderate, and agreement on the diagnosis of "CRPS I" is poor. Even physicians who still believe in the concept of "CRPS I" admit that it is vastly overdiagnosed and has become a diagnosis of last resort, often without a complete differential diagnosis and an alternative explanation. Finally, one of the most convincing arguments that there is no clinical entity as "CRPS I" comes from the enormous heterogeneity in sign and symptom profiles and the heterogeneity of pathophysiological mechanisms postulated. This observation is underscored by the diversity of responses among "CRPS I" patients to essentially all treatment modalities. It has even led to the concept that the signs and symptoms of CRPS can spread throughout the body, as if it is an infectious disease, without any medical plausible explanation. If true progress is to be made in helping patients with pain, it will require entirely new and different concepts and abandoning CRPS I as a legitimate diagnosis.
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Affiliation(s)
- Andrea T Borchers
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, Davis, CA 95616, United States
| | - M Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, Davis, CA 95616, United States.
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Xǔ G, Xu S, Tang WZ, Xú G, Cheng C, Xu J. Local Injection of Methylcobalamin Combined with Lidocaine for Acute Herpetic Neuralgia. PAIN MEDICINE 2015; 17:572-581. [PMID: 26814241 DOI: 10.1093/pm/pnv005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 08/19/2015] [Accepted: 09/06/2015] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the efficacy of methylcobalamin combined with lidocaine for acute herpetic neuralgia. DESIGN Randomized controlled trial with longitudinal analysis. SUBJECTS The authors recruited 204 patients (>50 years) with T5-10 dermatomal acute herpetic neuralgia with rash onset within 7 days. Patients were divided into two groups based on the time of onset: immediate-early (IE, 1-3 days) and early stage (ES, 4-7 days) groups and then subdivided randomly into control (IE-Ctl, ES-Ctl) and treatment (IE-Tr, ES-Tr) groups. METHODS Control groups received intramuscular methylcobalamin in addition to local lidocaine injection, while treatment groups received local methylcobalamin combined with lidocaine injection for 14 days. Treatment efficacy was assessed based on rash healing time, alteration in pain intensity, and interference with quality of life. Multilevel mixed modeling and survival analysis were employed to examine treatment responses. RESULTS There was no significant difference in the rash healing time between IE and ES. The mean pain scores in IE-Tr (2.4 ± 0.7) and ES-Tr (1.3 ± 0.7) decreased significantly compared with those in the control groups. The median satisfactory response time was 6 days in ES-Tr and 11 days in IE-Tr. The benefit ratio for ES-Tr versus IE-Tr was 14.94. The subjects in IE-Tr and ES-Tr had higher quality of life scores (81.2 ± 6.9 vs 88.3 ± 8.6, respectively) than those in the control groups. The incidence of postherpetic neuralgia was 1.1% at 3 months. CONCLUSIONS Local methylcobalamin combined with lidocaine, optimally administered within 4-7 days of onset, may be an effective therapeutic option for acute herpetic neuralgia.
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Affiliation(s)
- Gang Xǔ
- *Department of Rehabilitation Medicine, Affiliated Tenth People's Hospital of Tongji University, Shanghai, China;
| | - Site Xu
- Mechatronic Engineering and Automation School, Shanghai University, Shanghai, China
| | - Wei-Zhen Tang
- *Department of Rehabilitation Medicine, Affiliated Tenth People's Hospital of Tongji University, Shanghai, China
| | - Gang Xú
- *Department of Rehabilitation Medicine, Affiliated Tenth People's Hospital of Tongji University, Shanghai, China
| | - Chao Cheng
- *Department of Rehabilitation Medicine, Affiliated Tenth People's Hospital of Tongji University, Shanghai, China
| | - Jie Xu
- *Department of Rehabilitation Medicine, Affiliated Tenth People's Hospital of Tongji University, Shanghai, China
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Abstract
Varicella zoster virus (VZV) is a ubiquitous, exclusively human alphaherpesvirus. Primary infection usually results in varicella (chickenpox), after which VZV becomes latent in ganglionic neurons along the entire neuraxis. As VZV-specific cell-mediated immunity declines in elderly and immunocompromised individuals, VZV reactivates and causes herpes zoster (shingles), frequently complicated by postherpetic neuralgia. VZV reactivation also produces multiple serious neurological and ocular diseases, such as cranial nerve palsies, meningoencephalitis, myelopathy, and VZV vasculopathy, including giant cell arteritis, with or without associated rash. Herein, we review the clinical, laboratory, imaging, and pathological features of neurological complications of VZV reactivation as well as diagnostic tests to verify VZV infection of the nervous system. Updates on the physical state of VZV DNA and viral gene expression in latently infected ganglia, neuronal, and primate models to study varicella pathogenesis and immunity are presented along with innovations in the immunization of elderly individuals to prevent VZV reactivation.
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Affiliation(s)
- Don Gilden
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, 12700, USA; Department of Immunology & Microbiology, University of Colorado School of Medicine, Aurora, Colorado, 12800, USA
| | - Maria Nagel
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, 12700, USA
| | - Randall Cohrs
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, 12700, USA; Department of Immunology & Microbiology, University of Colorado School of Medicine, Aurora, Colorado, 12800, USA
| | - Ravi Mahalingam
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, 12700, USA
| | - Nicholas Baird
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, 12700, USA
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Galetta KM, Gilden D. Zeroing in on zoster: A tale of many disorders produced by one virus. J Neurol Sci 2015; 358:38-45. [PMID: 26454371 PMCID: PMC4628852 DOI: 10.1016/j.jns.2015.10.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 09/30/2015] [Accepted: 10/01/2015] [Indexed: 12/21/2022]
Abstract
While herpes zoster infection has been recognized since antiquity, chickenpox (varicella) was confused with smallpox until the 1800s, when both illnesses became better understood. In the 20th century, varicella zoster virus (VZV) was shown to cause varicella upon primary (first-time) infection and herpes zoster (shingles) after reactivation of latent VZV. Scientific progress over the past 50 years has rapidly advanced the understanding and prevention of disease produced by VZV. Combined imaging and virological studies continue to reveal the protean neurological, ocular and visceral disorders produced by VZV.
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Affiliation(s)
- Kristin M Galetta
- Department of Neurology, Brigham and Women's Hospital, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Don Gilden
- Departments of Neurology and Immunology & Microbiology, University of Colorado School of Medicine, Aurora, CO, USA.
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Bayat A, Burbelo PD, Browne SK, Quinlivan M, Martinez B, Holland SM, Buvanendran A, Kroin JS, Mannes AJ, Breuer J, Cohen JI, Iadarola MJ. Anti-cytokine autoantibodies in postherpetic neuralgia. J Transl Med 2015; 13:333. [PMID: 26482341 PMCID: PMC4617715 DOI: 10.1186/s12967-015-0695-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 10/10/2015] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The mechanisms by which varicella zoster virus (VZV) reactivation causes postherpetic neuralgia (PHN), a debilitating chronic pain condition, have not been fully elucidated. Based on previous studies identifying a causative role for anti-cytokine autoantibodies in patients with opportunistic infections, we explored this possibility in PHN. METHODS Sera from herpes zoster (HZ) patients without and with PHN (N = 115 and 83, respectively) were examined for the presence of autoantibodies against multiple cytokines, and other known autoantigens. In addition, a cohort of patients with complex regional pain syndrome or neuropathic pain was tested for autoantibodies against selected cytokines. Antibody levels against VZV, Epstein Barr virus, and herpes simplex virus-2 were also measured in the HZ and PHN patients. Patient sera with high levels of anti-cytokine autoantibodies were functionally tested for in vitro neutralizing activity. RESULTS Six PHN subjects demonstrated markedly elevated levels of single, autoantibodies against interferon-α, interferon-γ, GM-CSF, or interleukin-6. In contrast, the HZ and the pain control group showed low or no autoantibodies, respectively, against these four cytokines. Further analysis revealed that one PHN patient with high levels of anti-interleukin-6 autoantibodies had a markedly depressed antibody level to VZV, potentially reflecting poor T cell immunity against VZV. In vitro functional testing revealed that three of the five anti-cytokine autoantibody positive PHN subjects had neutralizing autoantibodies against interferon-α, GM-CSF or interleukin-6. In contrast, none of the HZ patients without PHN had neutralizing autoantibodies. CONCLUSIONS These results suggest the possibility that sporadic anti-cytokine autoantibodies in some subjects may cause an autoimmune immunodeficiency syndrome leading to uncontrolled VZV reactivation, nerve damage and subsequent PHN.
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Affiliation(s)
- Ahmad Bayat
- Department of Perioperative Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, 20892, USA.
| | - Peter D Burbelo
- Dental Clinical Research Core, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, 20892, USA.
| | - Sarah K Browne
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA.
| | - Mark Quinlivan
- Division of Infection and Immunity, University College London, London, WC1E 6BT, UK.
| | - Bianca Martinez
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA.
| | - Steven M Holland
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA.
| | - Asokumar Buvanendran
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL, 60612, USA.
| | - Jeffrey S Kroin
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL, 60612, USA.
| | - Andrew J Mannes
- Department of Perioperative Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, 20892, USA.
| | - Judith Breuer
- Division of Infection and Immunity, University College London, London, WC1E 6BT, UK.
| | - Jeffrey I Cohen
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA.
| | - Michael J Iadarola
- Department of Perioperative Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, 20892, USA.
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Chao CT, Chiang CK, Huang JW, Hung KY. Vitamin D is closely linked to the clinical courses of herpes zoster: From pathogenesis to complications. Med Hypotheses 2015; 85:452-7. [DOI: 10.1016/j.mehy.2015.06.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 06/29/2015] [Indexed: 12/18/2022]
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Hu K, Harris DL, Yamaguchi T, von Andrian UH, Hamrah P. A Dual Role for Corneal Dendritic Cells in Herpes Simplex Keratitis: Local Suppression of Corneal Damage and Promotion of Systemic Viral Dissemination. PLoS One 2015; 10:e0137123. [PMID: 26332302 PMCID: PMC4557979 DOI: 10.1371/journal.pone.0137123] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 08/12/2015] [Indexed: 12/20/2022] Open
Abstract
The cornea is the shield to the foreign world and thus, a primary site for peripheral infections. However, transparency and vision are incompatible with inflammation and scarring that may result from infections. Thus, the cornea is required to perform a delicate balance between fighting infections and preserving vision. To date, little is known about the specific role of antigen-presenting cells in viral keratitis. In this study, utilizing an established murine model of primary acute herpes simplex virus (HSV)-1 keratitis, we demonstrate that primary HSV keratitis results in increased conventional dendritic cells (cDCs) and macrophages within 24 hours after infection. Local depletion of cDCs in CD11c-DTR mice by subconjuntival diphtheria toxin injections, led to increased viral proliferation, and influx of inflammatory cells, resulting in increased scarring and clinical keratitis. In addition, while HSV infection resulted in significant corneal nerve destruction, local depletion of cDCs resulted in a much more severe loss of corneal nerves. Further, local cDC depletion resulted in decreased corneal nerve infection, and subsequently decreased and delayed systemic viral transmission in the trigeminal ganglion and draining lymph node, resulting in decreased mortality of mice. In contrast, sham depletion or depletion of macrophages through local injection of clodronate liposomes had neither a significant impact on the cornea, nor an effect on systemic viral transmission. In conclusion, we demonstrate that corneal cDCs may play a primary role in local corneal defense during viral keratitis and preserve vision, at the cost of inducing systemic viral dissemination, leading to increased mortality.
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Affiliation(s)
- Kai Hu
- Schepens Eye Research Institute, Massachusetts Eye & Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, United States of America
- Cornea Service, Massachusetts Eye & Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, United States of America
- Immune Disease Institute, Program in Cellular and Molecular Medicine at Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Deshea L. Harris
- Schepens Eye Research Institute, Massachusetts Eye & Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, United States of America
- Immune Disease Institute, Program in Cellular and Molecular Medicine at Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Ophthalmology, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Takefumi Yamaguchi
- Schepens Eye Research Institute, Massachusetts Eye & Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, United States of America
- Cornea Service, Massachusetts Eye & Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, United States of America
- Immune Disease Institute, Program in Cellular and Molecular Medicine at Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ulrich H. von Andrian
- Immune Disease Institute, Program in Cellular and Molecular Medicine at Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Immunology, Department of Microbiology & Immunobiology, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Pedram Hamrah
- Schepens Eye Research Institute, Massachusetts Eye & Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, United States of America
- Cornea Service, Massachusetts Eye & Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, United States of America
- Immune Disease Institute, Program in Cellular and Molecular Medicine at Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Ophthalmology, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, United States of America
- * E-mail:
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Arima Y, Kamimura D, Atsumi T, Harada M, Kawamoto T, Nishikawa N, Stofkova A, Ohki T, Higuchi K, Morimoto Y, Wieghofer P, Okada Y, Mori Y, Sakoda S, Saika S, Yoshioka Y, Komuro I, Yamashita T, Hirano T, Prinz M, Murakami M. A pain-mediated neural signal induces relapse in murine autoimmune encephalomyelitis, a multiple sclerosis model. eLife 2015; 4. [PMID: 26193120 PMCID: PMC4530187 DOI: 10.7554/elife.08733] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 07/14/2015] [Indexed: 12/16/2022] Open
Abstract
Although pain is a common symptom of various diseases and disorders, its contribution to disease pathogenesis is not well understood. Here we show using murine experimental autoimmune encephalomyelitis (EAE), a model for multiple sclerosis (MS), that pain induces EAE relapse. Mechanistic analysis showed that pain induction activates a sensory-sympathetic signal followed by a chemokine-mediated accumulation of MHC class II+CD11b+ cells that showed antigen-presentation activity at specific ventral vessels in the fifth lumbar cord of EAE-recovered mice. Following this accumulation, various immune cells including pathogenic CD4+ T cells recruited in the spinal cord in a manner dependent on a local chemokine inducer in endothelial cells, resulting in EAE relapse. Our results demonstrate that a pain-mediated neural signal can be transformed into an inflammation reaction at specific vessels to induce disease relapse, thus making this signal a potential therapeutic target. DOI:http://dx.doi.org/10.7554/eLife.08733.001 Multiple sclerosis (or MS for short) is a disease in which the insulating covers of nerve cells in the brain and spinal cord become inflamed and damaged. Depending on which nerves are affected, this disease can cause a wide range of symptoms, ranging from numbness and muscle spasms to visual disturbances and chronic pain. Many other diseases and disorders also have pain as a symptom, but it is not well understood if pain itself can directly contribute to the development of disease. Most people with MS will, initially, experience periods when their symptoms get worse (called ‘relapses’), which are then followed by periods of improvement. Arima, Kamimura et al. investigated whether the sensation of pain itself could trigger a relapse in a mouse model of MS. The experiments showed that a painful sensation could trigger a relapse in the mice via the so-called ‘gateway reflex’. This reflex describes the phenomenon whereby nerve impulses lead to the release of signaling molecules that cause the walls of nearby blood vessels to open and allow immune cells to move from the bloodstream to the central nervous system. This in turn stimulates the development of inflammation, which causes an imbalance in the affected sites of the central nervous system. These findings demonstrate that pain itself triggers a signal—sent via nerve impulses followed by the release of signaling molecules—that can lead to a relapse; and suggest that interfering with this signal could potentially help to treat to protect against relapses in MS. Following on from this work, it will be important to confirm if the gateway reflex exists in humans, and whether it is linked to other diseases that don't involve the central nervous system. DOI:http://dx.doi.org/10.7554/eLife.08733.002
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Affiliation(s)
- Yasunobu Arima
- Division of Molecular Neuroimmunology, Institute for Genetic Medicine, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Daisuke Kamimura
- Division of Molecular Neuroimmunology, Institute for Genetic Medicine, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Toru Atsumi
- Division of Molecular Neuroimmunology, Institute for Genetic Medicine, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaya Harada
- Division of Molecular Neuroimmunology, Institute for Genetic Medicine, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | | | - Naoki Nishikawa
- Division of Molecular Neuroimmunology, Institute for Genetic Medicine, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Andrea Stofkova
- Division of Molecular Neuroimmunology, Institute for Genetic Medicine, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takuto Ohki
- Division of Molecular Neuroimmunology, Institute for Genetic Medicine, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kotaro Higuchi
- Division of Molecular Neuroimmunology, Institute for Genetic Medicine, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuji Morimoto
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Peter Wieghofer
- Institute of Neuropathology, Faculty of Biology, University of Freiburg, Freiburg, Germany
| | - Yuka Okada
- Department of Ophthalmology, Wakayama Medical University, Wakayama, Japan
| | - Yuki Mori
- Laboratory of Biofunctional Imaging, WPI Immunology Frontier Research Center, Osaka University, Osaka, Japan
| | - Saburo Sakoda
- Department of Neurology, National Hospital Organization Toneyama Hospital, Osaka, Japan
| | - Shizuya Saika
- Department of Ophthalmology, Wakayama Medical University, Wakayama, Japan
| | - Yoshichika Yoshioka
- Laboratory of Biofunctional Imaging, WPI Immunology Frontier Research Center, Osaka University, Osaka, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Toshihide Yamashita
- Laboratory of Molecular Neuroscience, Graduate School of Medicine, Graduate School of Frontier Biosciences, Osaka University, Osaka, Japan
| | | | - Marco Prinz
- BIOSS Centre for Biological Signalling Studies, University of Freiburg, Freiburg, Germany
| | - Masaaki Murakami
- Division of Molecular Neuroimmunology, Institute for Genetic Medicine, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Zerboni L, Arvin A. Neuronal Subtype and Satellite Cell Tropism Are Determinants of Varicella-Zoster Virus Virulence in Human Dorsal Root Ganglia Xenografts In Vivo. PLoS Pathog 2015; 11:e1004989. [PMID: 26090802 PMCID: PMC4474629 DOI: 10.1371/journal.ppat.1004989] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 05/28/2015] [Indexed: 11/18/2022] Open
Abstract
Varicella zoster virus (VZV), a human alphaherpesvirus, causes varicella during primary infection. VZV reactivation from neuronal latency may cause herpes zoster, post herpetic neuralgia (PHN) and other neurologic syndromes. To investigate VZV neuropathogenesis, we developed a model using human dorsal root ganglia (DRG) xenografts in immunodeficient (SCID) mice. The SCID DRG model provides an opportunity to examine characteristics of VZV infection that occur in the context of the specialized architecture of DRG, in which nerve cell bodies are ensheathed by satellite glial cells (SGC) which support neuronal homeostasis. We hypothesized that VZV exhibits neuron-subtype specific tropism and that VZV tropism for SGC contributes to VZV-related ganglionopathy. Based on quantitative analyses of viral and cell protein expression in DRG tissue sections, we demonstrated that, whereas DRG neurons had an immature neuronal phenotype prior to implantation, subtype heterogeneity was observed within 20 weeks and SGC retained the capacity to maintain neuronal homeostasis longterm. Profiling VZV protein expression in DRG neurons showed that VZV enters peripherin+ nociceptive and RT97+ mechanoreceptive neurons by both axonal transport and contiguous spread from SGC, but replication in RT97+ neurons is blocked. Restriction occurs even when the SGC surrounding the neuronal cell body were infected and after entry and ORF61 expression, but before IE62 or IE63 protein expression. Notably, although contiguous VZV spread with loss of SGC support would be predicted to affect survival of both nociceptive and mechanoreceptive neurons, RT97+ neurons showed selective loss relative to peripherin+ neurons at later times in DRG infection. Profiling cell factors that were upregulated in VZV-infected DRG indicated that VZV infection induced marked pro-inflammatory responses, as well as proteins of the interferon pathway and neuroprotective responses. These neuropathologic changes observed in sensory ganglia infected with VZV may help to explain the neurologic sequelae often associated with zoster and PHN. Varicella zoster virus (VZV) causes varicella; herpes zoster results from VZV reactivation and is associated with post herpetic neuralgia (PHN). We hypothesized that VZV exhibits neuron-subtype specific tropism and that VZV tropism for satellite glial cells (SGC) results in loss of SGC functions that support neurons and contributes to VZV-related ganglionopathy. Using human DRG xenografts in SCID mice, we demonstrated that initial VZV access to neuronal cell bodies occurs by the axonal route, followed by axonal and contiguous spread between neuron-satellite cell complexes. VZV replication is restricted in mechanoreceptive neurons compared to nociceptive neurons. Despite restricted infection, mechanoreceptive neurons were selectively depleted in association with SGC loss following acute DRG infection. VZV infection of DRG triggers release of pro-inflammatory cytokines that cause neuronal damage. These observations may help to explain the neurologic sequelae often associated with herpes zoster and PHN.
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Affiliation(s)
- Leigh Zerboni
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States of America
- * E-mail:
| | - Ann Arvin
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States of America
- Departments of Pediatrics and Microbiology & Immunology, Stanford University School of Medicine, Stanford, California, United States of America
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Is magnesium sulfate effective for pain in chronic postherpetic neuralgia patients comparing with ketamine infusion therapy? J Clin Anesth 2015; 27:296-300. [DOI: 10.1016/j.jclinane.2015.02.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 02/17/2015] [Indexed: 12/19/2022]
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49
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Paster Z, Morris CM. Treatment of the Localized Pain of Postherpetic Neuralgia. Postgrad Med 2015; 122:91-107. [DOI: 10.3810/pgm.2010.01.2103] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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50
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Chronic Pain Syndromes, Mechanisms, and Current Treatments. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2015; 131:565-611. [DOI: 10.1016/bs.pmbts.2015.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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