Herpes zoster in immunocompromised patients: incidence, timing, and risk factors

Characteristics and risk factors for infection in patients with ANCA-associated vasculitis: A systematic review and meta-analysis

OBJECTIVE

To summarize the characteristics and risk factors for infection in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV).

METHODS

PubMed, Embase, and Cochrane Library databases were searched for relevant articles from database inception to November 2023. The prevalence, odds ratio (OR), and mean difference (MD) with 95 % confidence intervals (CIs) were pooled using a random-effects model. Sensitivity and subgroup analysis were also performed.

RESULTS

Forty-one studies with 5343 patients with AAV were included, of whom 2890 patients experienced an infection. The pooled prevalence was 54.6 % (95 % CI, 48.4 % to 61.1 %) for all infections and 35.8 % (95 % CI, 31.0 % to 40.8 %) for severe infections; and prevalence of Pneumocystis jirovecii pneumonia, aspergillosis, candidiasis, cryptococcosis, herpes zoster, cytomegalovirus, and specific bacterial infections were pooled. The respiratory system was the most common infection site, followed by blood, urinary tract, skin and soft tissue, and digestive infections. Risk factors for infection included older age, end-stage renal disease, dialysis, diabetes, smoking, kidney and lung involvement, leukopenia; higher Birmingham Vasculitis Activity Score, and serum creatinine and C-reactive protein levels; and lower hemoglobin levels, and platelet and CD4 counts. In addition, use of cyclophosphamide, steroid pulse therapy, plasma exchange, and higher initial glucocorticoid dose were associated with significantly increased risk of infection.

CONCLUSION

In patients with AAV, therapy should take risk factors for infection into account. Risk factors should be modified wherever possible. Physicians should be familiar with the common infection sites and pathogens, and consider empiric therapy covering common pathogens for life-threatening infections.

Preventing infections in immunocompromised patients with kidney diseases: vaccines and antimicrobial prophylaxis

The coronavirus disease 2019 (COVID-19) pandemic revealed that our understanding of infectious complications and strategies to mitigate severe infections in patients with glomerular diseases is limited. Beyond COVID-19, there are several infections that specifically impact care of patients receiving immunosuppressive measures. This review will provide an overview of six different infectious complications frequently encountered in patients with glomerular diseases, and will focus on recent achievements in terms of vaccine developments and understanding of the use of specific antimicrobial prophylaxis. These include influenza virus, Streptococcus pneumoniae, reactivation of a chronic or past infection with hepatitis B virus in cases receiving B-cell depletion, reactivation of cytomegalovirus, and cases of Pneumocystis jirovecii pneumonia in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis. Varicella zoster virus infections are particularly frequent in patients with systemic lupus erythematosus and an inactivated vaccine is available to use as an alternative to the attenuated vaccine in patients receiving immunosuppressants. As with COVID-19 vaccines, vaccine responses are generally impaired in older patients, and after recent administration of B-cell depleting agents, and high doses of mycophenolate mofetil and other immunosuppressants. Strategies to curb infectious complications are manifold and will be outlined in this review.

Herpes zoster infection after rituximab induction therapy in patient with myeloperoxidase-antineutrophil cytoplasmic antibody-associated vasculitis: a case report

Induction treatment with rituximab-an anti-CD20 monoclonal antibody-may increase the risk of varicella-zoster virus (VZV) reactivation in patients with antineutrophil-cytoplasmic-antibody-associated vasculitis (AAV). Our case report shows VZV reactivation following rituximab treatment in AAV patients. The recombinant zoster vaccine should be recommended before the start of induction treatment with rituximab.

Herpes Zoster in the era of COVID 19: A prospective observational study to probe the association of herpes zoster with COVID 19 infection and vaccination

BACKGROUND

Herpes zoster (HZ) is caused by reactivation of the latent varicella zoster virus (VZV) following decline in cell-mediated immunity. All over the world, in the past couple of years, the Corona Virus 2019 (COVID-19) has emerged as a viral cause of severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) infection. Based on the current limited evidence, co-infection of COVID-19 with varicella zoster virus or reactivation of VZV after COVID-19 vaccination has been sporadically reported.

METHODS

All patients diagnosed with HZ, in Farwaniya Hospital in Kuwait, from March 2020 to July, 2021, having either (A) a positive COVID-19 Polymerase Chain Reaction (PCR) test or (B) been vaccinated against SARS-CoV-2 were enrolled in the study. All patients' demographic information, medical history, laboratory findings, and vaccination status was documented. All statistical analyses were performed using SPSS Statistics version 21.0 software.

RESULTS

Twelve cases infected with COVID-19 with a positive PCR (group 1) and five cases vaccinated against SARS-CoV-2 (group 2) were documented. Out of the twelve COVID-19 infected patients (group 1), only two patients (16.67%) required hospitalization, while the remaining ten patients had mild/moderate lymphopenia. Furthermore, among the twelve positive COVID-19 cases, four patients with HZ were diagnosed within the first week of COVID-19, while the remaining eight cases were diagnosed within eight weeks of COVID-19. Thoracic segments were affected in five cases (41.67%), cervical in one case (8.33%), cranial in two cases (16.67), lumbar in three cases (25.00%) and sacral in one case (8.33%). In group 2, three patients presented with HZ within four weeks of having received the first dose of the vaccine and two patients after the second dose. Blood investigations for all five vaccinated patients did not show any abnormalities. Cervical segments were affected in two patients (40%), and cranial, thoracic and lumbar segment in the remaining patients respectively (20%).

CONCLUSIONS

Experts must be aware of the probable increased risk of HZ during the Covid 19 pandemic. We propose appropriate curative and preventive measures against herpes zoster infection, including a systematic follow-up of these patients to ensure that they stick to extreme safety measures till the diagnosis of COVID-19 is omitted This article is protected by copyright. All rights reserved.

Vulvar herpes zoster infection: a rare and challenging diagnosis

A 26-year-old woman under immunosuppression with infliximab due to Crohn's disease was referred to the gynaecology emergency room with dispersed and coalescing vesicular lesions on the vulvar region extending to the right lower limb involving S2-S3 dermatome, associated with severe pain. Clinical history, physical examination and serological testing was consistent with herpes zoster infection. The patient was treated with valaciclovir for 14 days and cefradine for 7 days (due to the possibility of secondary bacterial infection). Significant symptomatic improvement was noted after 1 week. The 1-year follow-up was unremarkable. According to our knowledge and review of the literature, this is one of the few cases reported of vulvar herpes zoster, especially related to infliximab.

Herpes Zoster Co-Infection in an Immunocompetent Patient With COVID-19

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has a broad spectrum of manifestations. A variety of dermatological manifestations were described. We present a case of an immunocompetent middle-aged man who presented with novel coronavirus disease 2019 (COVID-19) and later developed herpes zoster (HZ). The case highlights the possibility of COVID-19-related HZ. The highest infection control measures must be abided when managing patients with cutaneous complaints until COVID-19 is ruled out.

Ultrasound-Guided Serratus Anterior Plane Block for Intractable Herpes Zoster Pain in the Emergency Department

BACKGROUND

Herpes zoster (HZV) is a painful vesicular rash that occurs after reactivation in immunosuppressed patients. Analgesia in this patient population has been notoriously difficult. The serratus anterior and erector spinae plane block have both been described as effective thoracic analgesic techniques, but data are limited on their use in HZV.

CASE REPORT

A middle-aged man with a history of hypertension and hyperlipidemia presented to the emergency department (ED) with chest and back pain associated with cutaneous rash. Traditional pain regimens were not effective; therefore, a serratus anterior plane block was performed using 25 mL of 0.25% of bupivacaine. The patient's pain decreased from 10 to 2 in 20 min and the patient was discharged without further analgesia. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As opiate use decreases in prevalence and utility in the ED, alternatives to analgesia are sought. We describe the technique of regional anesthesia using a serratus anterior plane block as another modality that physicians can use to address HZV-related pain.

Incidence, Clinical Features, Management, and Prevention of Herpes Zoster in Patients Receiving Antitumor Necrosis Factor Therapy: A Clinical Review

Tumor necrosis factor (TNF) inhibitors have been used as an excellent therapeutic option in a variety of chronic inflammatory conditions. However, a recognized significant adverse effect of TNF inhibitor therapy is the increased risk of infections. The influence of TNF inhibitors on the course of coexisting or newly developed viral infections has not been extensively investigated. Therefore, we reviewed the recent publications to highlight the incidence, clinical features, management, and prevention of herpes zoster in patients who are receiving TNF inhibitors.

From Severe Herpes Zoster to Rare Suid Herpesvirus Encephalitis: A New Twist of the Varicellovirus Genus Infection in Patients with Kidney Diseases

Both the herpes zoster virus and suid herpesvirus type 1 (SuHV-1) belong to the Varicellovirus genus of the α-herpesviridae subfamily. They may cause opportunistic infections especially in patients with kidney diseases, varying from latent illness to overt lethality. Under these circumstances, impaired renal function is both the culprit for and victim of the infection. However, fulminant eruption of severe skin herpes zoster in lupus nephritis (LN) patients under prolonged immunosuppressive therapy is rare and even more rarely seen is the SuHV-1 encephalitis in human. Facing the evolution of these rare infections, we hence chose to review the clinical pathogenicity of these two viruses which were cognate in origin but distinct in virulence. As such, we began with the first of the two above viral diseases and proceeded with peculiar renal involvement, unique clinical symptoms and pertinent lethal risk. Of importance, LN was used to exemplify the reciprocally detrimental interactions between impaired renal function and suppressed immune response. Then in a manner similar to the gradient overlay, SuHV-1 encephalitis was discussed focusing on its neurotropic features, specific MRI findings and exclusive test of high throughput sequencing. Our report highlighted novel presentations of the Varicellovirus genus infection by providing a productive multidisciplinary communication with pointed disclosure of the renal involvement. It may therefore be of great medical relevance and educational value for clinicians, especially the unseasoned ones, to foresee and manage similar cases in susceptible patients.

Interventions for renal vasculitis in adults

BACKGROUND

Renal vasculitis presents as rapidly progressive glomerulonephritis and comprises of a group of conditions characterised by acute kidney injury (AKI), haematuria and proteinuria. Treatment of these conditions involve the use of steroid and non-steroid agents in combination with plasma exchange. Although immunosuppression overall has been very successful in treatment of these conditions, many questions remain unanswered in terms of dose and duration of therapy, the use of plasma exchange and the role of new therapies. This 2019 publication is an update of a review first published in 2008 and updated in 2015.

OBJECTIVES

To evaluate the benefits and harms of any intervention used for the treatment of renal vasculitis in adults.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 21 November 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials investigating any intervention for the treatment of renal vasculitis in adults.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. Statistical analyses were performed using a random effects model and results expressed as risk ratio (RR) with 95% confidence intervals (CI) for dichotomous outcomes or mean difference (MD) for continuous outcomes.

MAIN RESULTS

Forty studies (3764 patients) were included. Studies conducted earlier tended to have a higher risk of bias due to poor (or poorly reported) study design, broad inclusion criteria, less well developed disease definitions and low patient numbers. Later studies tend to have improved in all areas of quality, aided by the development of large international study groups. Induction therapy: Plasma exchange as adjunctive therapy may reduce the need for dialysis at three (2 studies: RR 0.43, 95% CI 0.23 to 0.78; I2 = 0%) and 12 months (6 studies: RR 0.45, 95% CI 0.29 to 0.72; I2 = 0%) (low certainty evidence). Plasma exchange may make little or no difference to death, serum creatinine (SCr), sustained remission or to serious or the total number of adverse events. Plasma exchange may increase the number of serious infections (5 studies: RR 1.26, 95% CI 1.03 to 1.54; I2 = 0%; low certainty evidence). Remission rates for pulse versus continuous cyclophosphamide (CPA) were equivalent but pulse treatment may increase the risk of relapse (4 studies: RR 1.79, 95% CI 1.11 to 2.87; I2 = 0%) (low certainty evidence) compared with continuous cyclophosphamide. Pulse CPA may make little or no difference to death at final follow-up, or SCr at any time point. More patients required dialysis in the pulse CPA group. Leukopenia was less common with pulse treatment; however, nausea was more common. Rituximab compared to CPA probably makes little or no difference to death, remission, relapse, severe adverse events, serious infections, or severe adverse events. Kidney function and dialysis were not reported. A single study reported no difference in the number of deaths, need for dialysis, or adverse events between mycophenolate mofetil (MMF) and CPA. Remission was reported to improve with MMF however more patients relapsed. A lower dose of steroids was probably as effective as high dose and may be safer, causing fewer infections; kidney function and relapse were not reported. There was little of no difference in death or remission between six and 12 pulses of CPA. There is low certainty evidence that there were less relapses with 12 pulses (2 studies: RR 1.57, 95% CI 0.96 to 2.56; I2 = 0%), but more infections (2 studies: RR 0.79, 95% CI 0.36 to 1.72; I2 = 45%). One study reported severe adverse events were less in patients receiving six compared to 12 pulses of CPA. Kidney function and dialysis were not reported. There is limited evidence from single studies about the effectiveness of intravenous immunoglobulin, avacopan, methotrexate, immunoadsorption, lymphocytapheresis, or etanercept. Maintenance therapy: Azathioprine (AZA) has equivalent efficacy as a maintenance agent to CPA with fewer episodes of leucopenia. MMF resulted in a higher relapse rate when tested against azathioprine in remission maintenance. Rituximab is an effective remission induction and maintenance agent. Oral co-trimoxazole did not reduce relapses in granulomatosis with polyangiitis. There were fewer relapses but more serious adverse events with leflunomide compared to methotrexate. There is limited evidence from single studies about the effectiveness of methotrexate versus CPA or AZA, cyclosporin versus CPA, extended versus standard AZA, and belimumab.

AUTHORS' CONCLUSIONS

Plasma exchange was effective in patients with severe AKI secondary to vasculitis. Pulse cyclophosphamide may result in an increased risk of relapse when compared to continuous oral use but a reduced total dose. Whilst CPA is standard induction treatment, rituximab and MMF were also effective. AZA, methotrexate and leflunomide were effective as maintenance therapy. Further studies are required to more clearly delineate the appropriate place of newer agents within an evidence-based therapeutic strategy.

Elevation of ambient temperature is associated with an increased risk of herpes zoster: a time-series analysis

Although varicella zoster (VZ) and herpes zoster (HZ) are caused by the same varicella zoster virus (VZV), the former is caused by primary infection while the latter is caused by reactivation of latent VZV, and their relationships with ambient temperature are also different. It is relatively well-established that VZ incidence declines with ambient temperature, but the relationship between HZ and ambient temperature is inconclusive. Thus, we investigated the effects of ambient temperature on the incidence of HZ in time-series analysis by using data from the Korean National Emergency Department Information System between 2014 and 2016. We applied a generalized linear model to investigate the relationship between ambient temperature and emergency room (ER) visits due to HZ, after controlling for confounders in seven metropolitan cities and nine provinces in South Korea. Region-specific estimates were pooled to obtain the national average estimates. There were a total of 61,957 ER visits nationwide for HZ during the study period. HZ significantly increased by 2.03% to 2.94% in the moving average lag models throughout 0 to 11 days with maximum percent increase of 2.94% (95% CI: 2.20, 3.68) in the 6-day moving average lag model.

Incidence and Risk Factors for Developing Herpes Zoster Among a Cohort of Patients Diagnosed With Lymphoma at a Community Cancer Center

BACKGROUND

Although most cases of herpes zoster (HZ) are self-limited, lymphoma patients are at greater risk for recurrences and more serious and atypical complications that can delay scheduled anti-lymphoma treatment or prevent its continuation.

PATIENTS AND METHODS

This is a cohort study with a retrospective chart review of 415 patients diagnosed with lymphoma to determine the incidence and risk factors for developing HZ among this population. Data collected included date of diagnosis, patient's age, last follow-up or death, stage and presentation of lymphoma, treatment type, baseline laboratory tests, and comorbidities. Patients with a diagnosis of HZ at any time during their course of illness were identified. Patients were divided into various subgroups to analyze their risk of developing HZ individually. The frequencies of each categorical variable were compared with χ² tests. Relative risks were calculated using 95% confidence intervals (CIs).

RESULTS

During a median follow-up of 8.9 years, 46 cases of HZ were identified, with an overall incidence density of 11.1%. Higher rates of HZ were associated with lymphocytopenia (P = .038), presentation (P = .030), stage (P = .034), autologous stem cell transplant (P = .019), multiple courses of chemotherapy (P = .035), and fludarabine therapy (P = .002). Those who received what we labeled as 'highly immunosuppressive chemotherapy' had 2.9 times the risk to develop HZ than those who did not receive this therapy (95% CI, 1.47-5.623; P < .001).

CONCLUSIONS

Receiving highly immunosuppressive chemotherapy is an independent risk factor for developing HZ. Patients with the risk factors described here might benefit from antiviral prophylaxis against HZ.

Avoidance of Harm From Treatment for ANCA-Associated Vasculitis

Purpose of review With established immunosuppressant treatment regimens for anti-neutrophil cytoplasm antibody-associated vasculitides (AAV), prognosis has significantly improved. The mainstay of treatment still comprises high-dose corticosteroids and cyclophosphamide for severe forms, although rituximab is being increasingly utilised instead of cyclophosphamide as induction therapy. AAV patients experience an excess of infections, malignancies and cardiovascular events as compared to the general population, which is a combination of the systemic inflammatory process associated with vasculitis and the adverse events from treatment.

Recent findings Successful therapy should focus on suppressing disease activity and minimising treatment-related toxicity. Infection is the largest contributor to morbidity and mortality in the first year of treatment, and annual pneumococcal and influenza vaccinations, Pneumocystis jiroveci prophylaxis and tuberculosis (TB) and Hepatitis B virus screening are advised. Patients on high-dose corticosteroid treatment should have regular blood sugar monitoring, a FRAX assessment with vitamin D and calcium supplementation, consideration of prophylaxis for gastric ulcers and a cardiovascular risk assessment. Patients who are treated with cyclophosphamide could also receive MESNA to reduce the risk of chemical cystitis. Cyclophosphamide, methotrexate and azathioprine all require blood monitoring schedules due to the risk of bone marrow suppression, liver and renal toxicity. Hypogammaglobulinaemia is a recognised risk of rituximab treatment. Patients of reproductive age need to be counselled on the infertility risks with cyclophosphamide and the teratogenicity associated with it, methotrexate and mycophenolate mofetil.

Summary A greater focus on identifying clinical and biological markers that will help identify those patients at greatest risk of relapse, e.g. GPA and PR3-ANCA specificity, from those patients at greatest risk of toxicity, e.g. increasing age and declining GFR, is required to allow treatment to be tailored accordingly.

The Uncommon Localization of Herpes Zoster

Introduction:

Herpes zoster is an acute, cutaneous viral infection caused by the reactivation of varicella-zoster virus (VZV) that is the cause of varicella. It is an acute neurological disease which can often lead to serious postherpetic neuralgia (PHN). Different nerves can be included with the skin rash in the area of its enervation especially cranial nerves (CV) and intercostal nerves.

Case report:

In this report we present a patient with herpes zoster which involved ulnar nerve with skin rash in the region of ulnar innervations in women with no disease previously diagnosed. The failure of her immune system may be explained by great emotional stress and overwork she had been exposed to with neglecting proper nutrition in that period.

Conclusion:

Herpes zoster may involve any nerve with characteristic skin rash in the area of its innervations, and failure in immune system which leads reactivation of VZV may be caused by other factors besides the underlying illness.

Advances in Epidemiological Studies of Herpes Zoster

Herpes zoster (HZ) is a varicella zoster virus (VZV) that attacks locality of nerves and skin, resulting information of clusters of blisters on the skin connected unilateral facial nerve and accompanying apparent nerve pain. Incidence ranges from 3.2 to 4.2 per 1000 populations per year in the United States. Influence factors of HZ include age, infection history with VZV, vaccination history of varicella vaccine, reduced immunocompetence, and other diseases. Current domestic studies on HZ mainly focus on clinical reports of case treatment. This study reviews advances in foreign epidemiological studies of HZ.

Superior Orbital Fissure Syndrome and Ophthalmoplegia Caused by Varicella Zoster Virus with No Skin Eruption in a Patient Treated with Tumor Necrosis Alpha Inhibitor

Varicella zoster virus lies dormant in the dorsal root ganglia after symptomatic chicken pox infection, usually in childhood. If the virus reactivates in the trigeminal ganglia, it can cause varicella zoster ophthalmicus, which can have severe ocular complications. We report a case of a 73-year-old woman in severe immunosuppression due to treatment with mycophenolate mofetil, glucocorticosteroids and a tumor necrosis factor alpha inhibitor. The reactivation caused superior orbital fissure syndrome, which has only rarely been described in relation to varicella zoster virus reactivation. In our case, the syndrome was seen along with severe encephalitis.

Interventions for renal vasculitis in adults

BACKGROUND

Renal vasculitis presents as rapidly progressive glomerulonephritis which comprises of a group of conditions characterised by acute kidney injury (AKI), haematuria and proteinuria. Treatment of these conditions comprises steroid and non-steroid agents in combination with plasma exchange. Although immunosuppression overall has been very successful in treatment of these conditions, many questions remain unanswered in terms of dose and duration of therapy, the use of plasma exchange and the role of new therapies. This an update of a review first published in 2008.

OBJECTIVES

To evaluate the benefits and harms of any intervention used for the treatment of renal vasculitis in adults.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Specialised Register up to 27 July 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review.

SELECTION CRITERIA

Randomised controlled trials investigating any intervention for the treatment of renal vasculitis in adults.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. Statistical analyses were performed using a random effects model and results expressed as risk ratio (RR) with 95% confidence intervals (CI) for dichotomous outcomes or mean difference (MD) for continuous outcomes.

MAIN RESULTS

Thirty one studies (2217 patients) were included. Studies conducted earlier tended to have a higher risk of bias due to poor (or poorly reported) study design, broad inclusion criteria, less well developed disease definitions and low patient numbers. Later studies tend to have improved in all areas of quality, aided by the development of large transnational study groups.Plasma exchange as adjunctive therapy significantly reduces the risk of end-stage kidney disease at three months (2 studies: RR 0.43, 95% CI 0.23 to 0.78) and 12 months (6 studies: RR 0.45, 95% CI 0.29 to 0.72). Four studies (300 patients) compared the use of pulse and continuous administration of cyclophosphamide. Remission rates were equivalent but pulse treatment causes an increased risk of relapse (4 studies: RR 1.79, 95% CI 1.11 to 2.87) compared with continuous cyclophosphamide. Azathioprine has equivalent efficacy as a maintenance agent to cyclophosphamide with fewer episodes of leucopenia. Mycophenolate mofetil may be equivalent to cyclophosphamide as an induction agent but resulted in a higher relapse rate when tested against azathioprine in remission maintenance. Rituximab is an effective remission induction agent. Methotrexate or leflunomide are potential choices in remission maintenance therapy. Oral co-trimoxazole did not reduce relapses significantly in granulomatosis with polyangiitis.

AUTHORS' CONCLUSIONS

Plasma exchange was effective in patients with severe AKI secondary to vasculitis. Pulse cyclophosphamide results in an increased risk of relapse when compared to continuous oral use but a reduced total dose. Whilst cyclophosphamide is standard induction treatment, rituximab and mycophenolate mofetil were also effective. Azathioprine, methotrexate and leflunomide were effective as maintenance therapy. Further studies are required to more clearly delineate the appropriate place of newer agents within an evidence-based therapeutic strategy.

Longitudinal risk of herpes zoster in patients with non-Hodgkin lymphoma receiving chemotherapy: A nationwide population-based study

This study investigated the incidence of and risk factors for herpes zoster in patients with non-Hodgkin lymphoma (NHL) who were receiving anti-lymphoma treatment. The overall incidence density of herpes zoster was 12.21% (472/3865); 11.79% (258/2188) of the patients received conventional chemotherapy and 12.76% (214/1677) of the patients received rituximab-containing chemotherapy. For the patients who received conventional chemotherapy, the risk factors included female gender, multiple courses of chemotherapy and autologous hematopoietic stem cell transplantation. For the patients who received rituximab-containing chemotherapy, the risk factors included female gender, diabetes mellitus, multiple courses of chemotherapy, autologous hematopoietic stem cell transplantation and higher accumulated rituximab dose. The majority of the herpes zoster episodes occurred within the first two years after the diagnosis of NHL. After adjusting for the propensity score matching, rituximab-containing chemotherapy was not associated with a higher overall incidence density of herpes zoster (P = 0.155). However, the addition of rituximab to conventional chemotherapy increased the short-term risk of herpes zoster with adjusted odd ratios of 1.38 (95% confidence intervals (CI) = 1.05–1.81, P = 0.021) and 1.37 (95% CI = 1.08–1.73, P = 0.010) during the 1-year and 2-year follow-up periods, respectively.

Increased Incidence of Herpes Zoster and Postherpetic Neuralgia in Adult Patients following Traumatic Brain Injury: A Nationwide Population-Based Study in Taiwan

The aims of this study were to estimate the incidences of herpes zoster (HZ) and postherpetic neuralgia (PHN) in patients after traumatic brain injury (TBI). Furthermore, we aimed to explore the risk factors of the development of HZ and PHN in patients after TBI. This population-based, longitudinal analysis was conducted using the Taiwan National Health Insurance Research Database (consisting of 1,000,000 beneficiaries) from 1996 to 2010. Using the longitudinal National Health Insurance Research Database, we conducted a retrospective population-based cohort study to evaluate the incidence of HZ and PHN in adult TBI patients and controls. Kaplan-Meier analysis and Cox regression were used to compare differences in the development of HZ and PHN. The effects of gender, comorbidity and surgery on the risk of HZ and PHN development were assessed by subgroup analyses. Over a 15-year follow-up, the cumulative incidence of HZ in 28,234 TBI patients (604.00/100,000 person-years) was significantly higher than 34,085 controls (322.21/100,000 person-years) (P<0.0001, by log-rank test). Females showed a significantly higher incidence of HZ than males (p for interaction = 0.0010). The time to HZ development in the follow-up period was 5.9 years in TBI patients compared to 9.9 years in the control set (p <0.0001). TBI patients were 2.93 and 2.11 times likely to develop HZ and PHN, respectively, than the general population. The incidences of HZ and PHN in TBI patients were also significantly greater than for controls in the CCI = 0 subgroup. To our knowledge, this is the first population-based cohort study to reveal that TBI is an independent risk factor for HZ and PHN in TBI patients, especially in females. Physician should pay attention to the possibility of HZ and PHN in TBI patients and be aware that HZ vaccination early after brain trauma may lower the incidence of HZ and PHN.

Clinical manifestations of herpes zoster, its comorbidities, and its complications in north of iran from 2007 to 2013

Background. Herpes zoster infection is a painful worldwide disease. Inappropriate and delayed treatment causes prolongation of the disease with debilitating symptoms and postherpetic neuralgia. Method. A cross-sectional study evaluated shingles cases admitted in a teaching hospital with one-year followup in north of Iran from 2007 to 2013. Results. From 132 patients, 60.4% were male. Head and neck involvement occurred in 78 people (59.1%), thoracoabdominal region in 37 cases (28%), and extremities in 16 cases (12.1%), and one case (0.8%) got multisites involvement. 54 cases (40.9%) had predisposing factors including diabetes mellitus in 26 cases (19.7%), malignancy in 15 (11.4%), immunosuppressive medication in 7 (5.03%), HIV infection in 3 (2.3%), radiotherapy in 2 (1.5%), and tuberculosis in one patient (0.8%). The most common symptoms were pain (95.5%), weakness (56%), fever (31.1%), headache (30.3%), ocular complaints (27.3%), itching (24.2%), and dizziness (5.3%). 21 cases (15.9%) had bacterial superinfection on blistering areas and overall 18 cases (13.6%) had opium addiction. 4 cases (3.03%) died during admission because of comorbidities. Postherpetic neuralgia was reported in 56 patients (42.5%) after three months and seven cases (5%) in one-year followup. Conclusion. Shortening interval between skin lesion manifestation and starting medication can accelerate lesion improvement and decrease disease course, extension, and complication.

A nationwide population-based cohort study to identify the correlation between heart failure and the subsequent risk of herpes zoster

Background

The association between heart failure (HF) and herpes zoster has rarely been studied. We investigated the hypothesis that HF may increase the risk of herpes zoster in Taiwan using a nationwide Taiwanese population-based claims database.

Method

Our study cohort consisted of patients who received a diagnosis of HF in 2001 ~ 2009 (N = 4785). For a comparison cohort, three age- and gender-matched control patients for every patient in the study cohort were selected using random sampling (N = 14,355). All subjects were tracked for 1 year from the date of cohort entry to identify whether or not they had developed herpes zoster. Cox proportional-hazard regressions were performed to evaluate 1-year herpes zoster-free survival rates.

Results

The main finding of this study was that patients with HF seemed to be at an increased risk of developing herpes zoster. Of the total patients, 211 patients developed herpes zoster during the 1-year follow-up period, among whom 83 were HF patients and 128 were in the comparison cohort. The adjusted hazard ratio (AHR) of herpes zoster in patients with HF was higher (AHR: 2.07; 95% confidence interval (CI): 1.54 ~ 2.78; p < 0.001) than that of the controls during the 1-year follow-up. Our study also investigated whether HF is a gender-dependent risk factor for herpes zoster. We found that male patients with HF had an increased risk of developing herpes zoster (AHR: 2.30 95% CI: 1.51 ~ 3.50; p < 0.001).

Conclusions

The findings of our population-based study suggest that patients with HF may have an increased risk of herpes zoster. These health associations should be taken into consideration, and further studies should focused on the cost-effectiveness of the herpes zoster vaccine should be designed for HF patients.

Vaccination of patients with autoimmune inflammatory rheumatic diseases

Patients with autoimmune inflammatory rheumatic diseases (AIRDs) are at increased risk of infections. This risk has been further increased by the introduction of biologic agents over the past two decades. One of the most effective strategies to prevent infection is vaccination. However, patients with an AIRD have a compromised immune system, which is further impaired by medication. Another important issue is the possibility of triggering a broad nonspecific response by vaccination, potentially resulting in increased activity of the underlying autoimmune disease. In this Review, we provide an analysis of data on vaccination of patients with an AIRD. Both the efficacy and the safety of vaccination are addressed, together with the epidemiology of vaccine-preventable infectious diseases in different subgroups of adults with AIRDs. Special attention is given to vaccination of patients who are treated with biologic agents.

No increased risk of herpes zoster found in cirrhotic patients: a nationwide population-based study in Taiwan

Background

The association between liver cirrhosis (LC) and herpes zoster has rarely been studied. We investigated the hypothesis that LC, known as an immunodeficiency disease, may increase the risk of herpes zoster using a national health insurance database in Taiwan.

Materials and Methods

The study cohort included cirrhotic patients between 1998 and 2005 (n = 4667), and a ratio of 1∶5 randomly sampled age- and gender-matched control patients (n = 23,335). All subjects were followed up for 5 years from the date of cohort entry to identify whether or not they had developed herpes zoster. Cox proportional-hazard regressions were performed to evaluate 5-year herpes zoster-free survival rates.

Results

Of all patients, 523 patients developed herpes zoster during the 5-year follow-up period, among whom 82 were LC patients and 441 were in the comparison cohort. The adjusted hazard ratio (AHR) of herpes zoster in patients with LC was not higher (AHR: 0.77, 95% confidence interval: 0.59–1.01, p = 0.06) than that of the controls during the 5-year follow-up. No increased risk of herpes zoster was found in LC patients after stratification by age, gender, urbanization level, income, geographic region, and all comorbidities.

Conclusions

This large nationwide population-based cohort study suggests that there is no increased risk for herpes zoster among people who have LC compared to a matching population.

The epidemiology of herpes zoster in patients with newly diagnosed cancer

BACKGROUND

Given the limited literature, we conducted a study to examine the epidemiology of herpes zoster (HZ) among newly diagnosed cancer patients.

METHODS

We identified adult health plan members of Kaiser Permanente Northern California diagnosed with invasive cancer from 2001 to 2005. Electronic health records with inpatient and outpatient diagnoses, laboratory tests, and antiviral medications were used to identify HZ diagnoses from 2001 to 2006. HZ diagnoses and associated complications were confirmed by medical chart review. Treatment with chemotherapy and corticosteroids was used to classify patients by immunosuppression level.

RESULTS

Among 14,670 cancer patients, 424 were diagnosed with HZ during follow-up (median 22 months). The incidence of HZ was 31/1,000 person-year (PY) in patients with hematologic malignancies and 12/1,000 PY in patients with solid tumors. The corresponding 2-year cumulative incidence of HZ was approximately 6% and 2%, respectively. Compared with incidence rates of HZ reported in a general US population, the age- and sex-standardized rates of HZ were 4.8 times higher [95% confidence interval (CI), 4.0-5.6] in patients with hematologic malignancies and 1.9 times higher (95% CI, 1.7-2.1) in those with solid tumors. HZ risk increased with increasing level of immunosuppression. Among HZ cases, 19% with hematologic malignancies and 14% with solid tumors had HZ-associated pain for at least 30 days. The corresponding numbers for nonpain-related complications were 30% and 18%, respectively.

CONCLUSIONS

Cancer patients are at substantially increased risk of HZ and among those with HZ, complications are relatively common.

IMPACT

Better HZ prevention and treatment options for cancer patients are needed.

Risk of cancer among patients with herpes zoster infection: a population-based study

BACKGROUND

Whether the risk of cancer is increased among patients with herpes zoster is unclear. We investigated the risk of cancer among patients with herpes zoster using a nationwide health registry in Taiwan.

METHODS

We identified 35 871 patients with newly diagnosed herpes zoster during 2000-2008 from the National Health Insurance Research Database in Taiwan. We analyzed the standardized incidence ratios for various types of cancer.

RESULTS

Among patients with herpes zoster, 895 cases of cancer were reported. Patients with herpes zoster were not at increased risk of cancer (standardized incidence ratio 0.99, 95% confidence interval 0.93-1.06). Among the subgroups stratified by sex, age and years of follow-up, there was also no increased risk of overall cancer.

INTERPRETATION

Herpes zoster is not associated with increased risk of cancer in the general population. These findings do not support extensive investigations for occult cancer or enhanced surveillance for cancer in patients with herpes zoster.

Complications of long-term therapy for ANCA-associated systemic vasculitis

The antineutrophil cytoplasmic antibody (ANCA)-associated systemic vasculitides (AASVs) include granulomatosis with polyangiitis and microscopic polyangiitis. These conditions are characterized by small-vessel inflammation and necrosis, predominantly in pulmonary and renal vascular beds. Untreated AASV has a poor prognosis, although the advent of effective immunosuppressive therapy (the mainstay of which remains cyclophosphamide with high-dose corticosteroids) has markedly improved patients' survival (78% at 5 years). Patients with AASV, however, continue to have an increased mortality compared to the general population. Mortality is greatest in the first year after diagnosis and remains consistently elevated in subsequent years. Patients with AASV also experience increased rates of infections, malignancies and cardiovascular events as compared to the general population. Current treatments for AASV, although effective in controlling the aggressive systemic disease, incur substantial long-term toxic effects. Long-term immunosuppressive therapy also has notable deleterious effects on bone health and fertility. The long-term safety profiles of biological therapies (such as rituximab) are yet to be evaluated in patients with AASV, but represent a promising treatment option. The challenge for the future is to develop specific therapies with improved safety profiles that can cure these diseases.

Risk of Herpes zoster in patients with underlying diseases: a retrospective hospital-based cohort study

Purpose

To determine the incidence of Herpes zoster in patients with one of 17 specific underlying diseases compared with that in patients with other underlying diseases.

Methods

We conducted a retrospective hospital-based cohort study using data from patients’ electronic medical records for the period 2001–2007 of the Kitano Hospital Research Database. These analyses included 55,492 patients with one of 17 underlying diseases, which were those reported as related to the contraction of Herpes zoster. Of these, 769 patients contracted Herpes zoster. The main outcome measure was the clinical diagnosis of Herpes zoster.

Results

The adjusted hazard ratios (95% confidence interval) for Herpes zoster in patients with the 17 diseases were compared with other patients, with the following results: brain tumor [3.84 (2.51–5.88)], lung cancer [2.28 (1.61–3.22)], breast cancer [2.41 (1.52–3.82)], esophageal cancer [4.19 (2.16–8.11)], gastric cancer [1.95 (1.39–2.72)], colorectal cancer [1.85 (1.33–2.56)], gynecologic cancer [3.45 (2.08–5.70)], malignant lymphoma [8.23 (6.53–10.38)], systemic lupus erythematosus [3.90 (2.66–5.70)], rheumatoid arthritis [2.00 (1.60–2.50)], diabetes mellitus [2.44 (2.10–2.85)], hypertension [2.04 (1.75–2.38)], renal failure [2.14 (1.65–2.79)], and disk hernia [2.18 (1.52–3.13)].

Conclusions

Patients with diabetes mellitus, renal failure, and malignancies have a 1.8–8.4-fold higher risk of a Herpes zoster event than patients with other diseases. Future studies should investigate alteration of the immune system in the underlying diseases and approaches for Herpes zoster prevention.

EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases

OBJECTIVES

To develop evidence-based European League Against Rheumatism (EULAR) recommendations for vaccination in patients with autoimmune inflammatory rheumatic diseases (AIIRD).

METHODS

A EULAR task force was composed of experts representing 11 European countries, consisting of eight rheumatologists, four clinical immunologists, one rheumatologist/clinical immunologist, one infectious disease physician, one nephrologist, one paediatrician/rheumatologist and one clinical epidemiologist. Key questions were formulated and the eligible spectrum of AIIRD, immunosuppressive drugs and vaccines were defined in order to perform a systematic literature review. A search was made of Medline from 1966 to October 2009 as well as abstracts from the EULAR meetings of 2008 and 2009 and the American College of Rheumatology (ACR) meetings of 2007 and 2008. Evidence was graded in categories I-IV, the strength of recommendations was graded in categories A-D and Delphi voting was applied to determine the level of agreement between the experts of the task force.

RESULTS

Eight key questions and 13 recommendations addressing vaccination in patients with AIIRD were formulated. The strength of each recommendation was determined. Delphi voting revealed a very high level of agreement with the recommendations among the experts of the task force. Finally, a research agenda was proposed.

CONCLUSION

Recommendations for vaccination in patients with AIIRD based on the currently available evidence and expert opinion were formulated. More research is needed, particularly regarding the incidence of vaccine-preventable infectious diseases and the safety of vaccination in patients with AIIRD.

Vaccination in adult patients with auto-immune inflammatory rheumatic diseases: a systematic literature review for the European League Against Rheumatism evidence-based recommendations for vaccination in adult patients with auto-immune inflammatory rheumatic diseases

OBJECTIVES

To present the systematic literature review (SLR), which formed the basis for the European League Against Rheumatism (EULAR) evidence-based recommendations for vaccination in adult patients with auto-immune inflammatory rheumatic diseases (AIIRD).

METHODS

AIIRD, vaccines and immunomodulating drugs, as well as eight key questions were defined by the multidisciplinary expert committee commissioned by EULAR for developing the recommendations. A SLR was performed using MedLine through October 2009 and including data from meta-analyses, systematic reviews, randomized trials, and observational studies, excluding case series with ≤ 5 participants. Articles in English and regarding patients ≥ 16 years of age, were eligible.

RESULTS

Several vaccine-preventable infections (VPI) occur more often in AIIRD-patients and most vaccines are efficacious in AIIRD-patients, even when treated with immunomodulating agents, except rituximab. There does not appear to be an increase in vaccination-related harms in vaccinated patients with AIIRD in comparison with unvaccinated patients with AIIRD. However, these studies are underpowered and therefore not conclusive.

CONCLUSION

Based on the current evidence from the literature, recommendations for vaccination in patients with AIIRD were made. However, more research is needed in particular regarding incidence of VPI, harms of vaccination and the influence of (new and established) immunomodulating agents on vaccination efficacy.

Incidence and risk of hospitalisation due to shingles and chickenpox in patients with rheumatic diseases treated with TNF antagonists

OBJECTIVE

To estimate the incidence of hospitalisation due to varicella zoster virus (VZV) infection in patients treated with tumour necrosis factor (TNF) antagonists for inflammatory rheumatic conditions and to compare it with the expected rate in the general population.

METHODS

Secondary data analysis was performed of two large databases: (1) the national registry of rheumatic diseases patients treated with biological agents (BIOBADASER); and (2) the national hospital discharge database Conjunto Mínimo Básico de Datos al Alta Hospitalaria. Hospitalisations due to shingles or chickenpox were analysed. For each condition the incidence rate (IR) and the age and gender standardised IR per 100,000 person-years plus the standardised incidence ratio (SIR) and the standardised incidence difference (SID) were estimated.

RESULTS

In patients exposed to TNF antagonists, the estimated IR of hospitalisation due to shingles was 32 cases per 100,000 patient-years (95% CI 14 to 78), the expected rate in the general population was 3.4 (95% CI 3.2 to 3.5), the SIR was 9 (95% CI 3 to 20) and the SID was 26 (95% CI 14 to 37). The estimated IR of hospitalisation due to chickenpox was 26 cases per 100,000 (95% CI 10 to 69), the expected rate was 1.9 (95% CI 1.8 to 2.0), the SIR was 19 (95% CI 5 to 47) and the SID 33 (95% CI 21 to 45).

CONCLUSIONS

Patients suffering rheumatic diseases exposed to TNF antagonists are hospitalised due to VZV infections significantly more frequently than expected in the general population. Since the absolute IR of hospitalisations due to chickenpox and shingles is low in these patients, the implementation of risky preventive measures may not be justified at present.

Incidence of herpes zoster in patients with giant cell arteritis: a population-based cohort study

OBJECTIVES

To determine the incidence of herpes zoster (HZ) in GCA.

METHODS

Utilizing the resources of the Rochester Epidemiology Project, all incident cases of GCA diagnosed between 1 January 1950 and 31 December 2004 were identified. For each GCA patient, two subjects without GCA of the same gender and similar age and length of medical history were randomly selected from the population. Patients were followed until death, last contact or 31 December 2006.

RESULTS

The study population included 204 GCA patients and 407 non-GCA subjects. The GCA cohort had 163 (79%) women and 41 (21%) men, with a mean age of 76.0 (8.2) years. The non-GCA cohort had 325 (80%) women and 82 (20%) men, with a mean age of 75.6 (8.4) years. During follow-up, 21 GCA patients and 38 non-GCA subjects developed HZ. There was no difference in the development of HZ in GCA patients compared with non-GCA patients [hazard ratio (HR): 1.22; 95% CI 0.71, 2.08; adjusted for age, sex and calendar year]. No GCA patient and one non-GCA subject developed HZ within 6 months of index date. The frequency of post-herpetic neuralgia was similar between both groups (P = 0.64).

CONCLUSIONS

Patients with GCA do not appear to be at increased risk of HZ compared with the general population, even during the first 6 months of therapy when glucocorticoid doses are usually highest.

[Cytomegalovirus and other herpes virus infections in systemic diseases]

Reactivation of Herpesviridae is well known among transplant patients, but has not been sufficiently studied in patients who receive immunosuppressive treatment for systemic inflammatory diseases. CMV infection seems relatively rare; it is easily diagnosed by real-time PCR, a fast and reliable diagnostic tool. CMV disease is most often manifested in the form of lung disease, hepatitis, or colitis. The highest risks are associated with steroid or cyclophosphamide boluses and methotrexate. Prophylactic treatment cannot be recommended in clinical practice. The utility of monitoring viremia and of preemptive therapy must be evaluated. Herpes zoster is the most frequent viral infection in systemic diseases. Most immunosuppressive treatments, except methotrexate, promote its occurrence. Visceral involvement is quite rare, and outcome almost always favorable. Prophylactic treatment cannot be recommended.

Herpes zoster risk factors in a national cohort of veterans with rheumatoid arthritis

BACKGROUND

Herpes zoster occurs more commonly in patients taking immunosuppressive medications, although the risk associated with different medications is poorly understood.

METHODS

We conducted a retrospective cohort study involving 20,357 patients who were followed in the Veterans Affairs healthcare system and treated for rheumatoid arthritis from October 1998 through June 2005. Cox proportional hazards regression was used to determine risk factors for herpes zoster and herpes zoster-free survival. Chart review was performed to validate the diagnosis of herpes zoster.

RESULTS

The incidence of herpes zoster was 9.96 episodes per 1000 patient-years. In time-to-event analysis, patients receiving medications used to treat mild rheumatoid arthritis were less likely to have an episode of herpes zoster than patients receiving medications used to treat moderate and severe rheumatoid arthritis (P < .001). Independent risk factors for herpes zoster included older age, prednisone use, medications used to treat moderate and severe rheumatoid arthritis, malignancy, chronic lung disease, renal failure, and liver disease. Among patients receiving tumor necrosis factor-alpha antagonists, etanercept (hazard ratio, 0.62) and adalimumab (hazard ratio, 0.53) were associated with a lower risk of herpes zoster. There was excellent agreement between the International Classification of Diseases, Version 9, Clinical Modification diagnosis of herpes zoster and diagnosis by chart review (kappa = 0.92).

CONCLUSIONS

Risk factors for herpes zoster included older age, prednisone use, medications used to treat moderate and severe rheumatoid arthritis, and several comorbid medical conditions. These results demonstrate that the Department of Veterans Affairs' national administrative databases can be used to study rare adverse drug events.

Herpes zoster in patients taking TNFalpha antagonists for chronic inflammatory joint disease

OBJECTIVE

To assess the rate of occurrence and outcomes of herpes zoster in patients taking TNFalpha antagonists.

METHODS

Retrospective review of the medical records of 300 patients who received TNFalpha antagonists to treat chronic inflammatory joint disease.

RESULTS

We identified 9 (9/300, 3%) patients who experienced herpes zoster, 6 women and 3 men, with rheumatoid arthritis (n=7) or ankylosing spondylitis (n=2). The drug was infliximab in 4 patients, adalimumab in 2 patients, and etanercept in 3 patients, including 2 patients with a prior history of infliximab therapy (for 12 and 36 months, respectively). Mean treatment duration at the occurrence of herpes zoster was 27 months (range, 6-42 months).

DISCUSSION

Glucocorticoid therapy (n=7) and methotrexate therapy (n=6) were the only risk factors identified in our study. Mean follow-up was 26 months. All 9 patients achieved a full recovery with antiviral treatment and interruption of the TNFalpha antagonist. One patient experienced a recurrence after resuming TNFalpha antagonist therapy.

CONCLUSION

The scant data in the literature suggest a higher risk of herpes zoster with anti-TNFalpha antibodies than with the soluble receptor. The role for concomitant treatments (glucocorticoids and methotrexate) should be taken into account.

Safety of biologic therapy in rheumatoid arthritis and other autoimmune diseases: focus on rituximab

OBJECTIVES

To review the safety of biologic agents used to treat rheumatoid arthritis (RA) and other autoimmune diseases, with a focus on rituximab.

METHODS

Information was gathered from a search of the PubMed database and from major congress abstract listings through June 2007.

RESULTS

Rituximab is approved for treating RA in patients with an inadequate response to TNF inhibitors and is under study in other indications for RA and other autoimmune disorders. The current safety profile of rituximab in RA is known from Phase II and III studies conducted preapproval, treating approximately 750 patients, as well as from long-term extension studies with repeated therapy. Clinical trials have established that the most common adverse events are infusion-associated reactions, seen in 29 to 40% of patients, most of which are mild to moderate and occur following the first rituximab infusion, with incidence and severity decreasing with subsequent infusions. Rates of infections and serious infections to date are within the range expected for RA patients treated with other biologic agents, but the longer term effects of B-cell depletion and the effects of repeated treatment on the risk of infections are uncertain. Information is limited for rituximab safety in other autoimmune disorders but current data do not suggest that there is a significant difference in adverse events from that previously reported.

CONCLUSIONS

Rituximab is an important addition to the rheumatologist's armamentarium for the treatment of difficult RA and ongoing trials will determine its utility in other indications for RA and other autoimmune conditions. The true safety profile of rituximab will emerge as larger numbers of patients are treated in routine clinical practice.

Targeting B lymphocytes as therapy for ANCA-associated vasculitis

This article focuses on the initial results achieved with the more selective immunosuppressive approach of B-lymphocyte depletion in patients who fail cyclophosphamide or have contraindications for its use in the treatment of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). This novel approach has sparked hope for patients and physicians in their search for effective, well-tolerated therapy for AAV. B-cell depletion is now undergoing rigorous investigation in randomized clinical trials.