Varicella Zoster in pregnancy

Neonatal Outcomes and Neurodevelopmental Disorders Following Maternal Herpes Zoster during Pregnancy: A Nationwide Retrospective Cohort Study

OBJECTIVE

To assess the association between maternal herpes zoster (HZ) during pregnancy, either before or after 20 weeks of gestation, and adverse neonatal outcomes, as well as neurodevelopmental disorders in offspring.

STUDY DESIGN

This nationwide, retrospective cohort study analyzed data from the National Health Insurance Research Database in Taiwan between 2017 and 2020. Among 630,456 eligible singleton pregnancies, 2,922 (0.46%) children were born to women diagnosed with HZ during pregnancy. The primary outcomes were adverse neonatal outcomes, including preterm delivery, low birth weight, low Apgar scores, and congenital defects. The secondary outcome was the diagnosis of a neurodevelopmental disorder within the first two years of life. Multivariable logistic regression models were used to evaluate the association between maternal HZ and adverse outcomes, with stabilized inverse probability of treatment weighting (SIPTW) employed as a sensitivity analysis to confirm robustness.

RESULTS

After adjusting for maternal age, socioeconomic deprivation, and gestational status using multivariable regression models, no significant associations were found between maternal HZ during pregnancy and adverse neonatal outcomes or neurodevelopmental disorders. Sensitivity analyses with SIPTW yielded similar results. Furthermore, maternal HZ diagnosed before or after 20 weeks of gestation was not significantly associated with an adverse neonatal outcome or neurodevelopmental disorder.

CONCLUSIONS

Maternal HZ during pregnancy, even before 20 weeks of gestation, was not associated with increased odds of adverse neonatal outcomes or neurodevelopmental disorders within the first two years of life. These findings reassure clinicians and pregnant women that an episode of HZ during pregnancy is highly unlikely to affect neonatal health or early neurodevelopment.

Varicella Zoster Virus Infection and Pregnancy: An Optimal Management Approach

Varicella-zoster virus is an α-herpes virus with a double-stranded DNA genome, which causes two main clinical pictures: varicella or chickenpox and herpes zoster. Chickenpox is the primary infection, predominantly affecting children, and it presents with fever and a cutaneous eruption consisting of a vesicular, pruritic, and painful rash. Herpes zoster is a viral infection that typically develops in adulthood as a result of the reactivation of the varicella-zoster virus. If acquired during pregnancy, chickenpox may be responsible for serious complications for the mother, the fetus, or the newborn. The most frequent complication of primary varicella-zoster virus infection in mothers is varicella pneumonia, while encephalitis and hepatitis are rare. The effects on the fetus due to chickenpox infection depend on the stage of pregnancy when the mother becomes infected. If the infection occurs during the first trimester, it does not increase the risk of miscarriage. However, if the infection occurs during the first or second trimester, it may cause fetal varicella syndrome or congenital varicella syndrome. During pregnancy, if the varicella-zoster virus reactivates, it usually does not cause harm to the fetus or lead to any birth defects. However, it may increase maternal morbidity due to herpes zoster and its complications. In the case of primary varicella-zoster virus infection in pregnant women, about 20% of newborns may get neonatal or infantile herpes zoster without any complications. However, it is recommended to start early treatment of herpes zoster in pregnant women as it is believed to accelerate the healing process of skin lesions and alleviate pain, reducing both its duration and severity. Through this narrative review, we discuss the approach to the optimal management of varicella-zoster virus infection during pregnancy.

Comparison of ELISA Versus FAMA Titers in Children After Chemotherapy and Hematopoietic Stem Cell Transplantation Who Received the Live Attenuated MAV/06 Strain Varicella Vaccine

BACKGROUND

Varicella can lead to severe complications in immunocompromised children, including those undergoing hematopoietic stem cell transplantation (HSCT) or chemotherapy. Preventing primary varicella zoster virus (VZV) infection is crucial in these populations to mitigate morbidity and mortality. This study aimed to evaluate the immunogenicity and safety of the live attenuated MAV/06 varicella vaccine in pediatric patients post-HSCT and post-chemotherapy. Additionally, it sought to compare fluorescent-antibody-to-membrane-antigen (FAMA) and enzyme-linked immunosorbent assay (ELISA) titers to establish effective cut-off levels for protection against varicella.

METHODS

The FAMA assay was conducted at the Vaccine Bio Research Institute, and a VARICELLA-ZOSTER ELISA (Vircell, Granada, Spain) kit, which relies on lysate from whole cells infected with VZV, was used to determine VZV IgG. A prospective cohort study was conducted with 76 pediatric patients under 18 years old who tested negative for VZV IgG via ELISA. Patients post-HSCT and post-chemotherapy were included. Participants received the MAV/06 varicella vaccine, and serologic responses were evaluated using ELISA and FAMA.

RESULTS

The median age of participants was 9.8 years, with acute lymphoid leukemia and acute myeloid leukemia being the most common underlying disease. Post-dose 1, the seropositive rate was 56.1% by ELISA and 97.2% by FAMA. Based on the FAMA seropositive cut-off ≥1:4, post-dose 1 geometric mean titers (GMTs) of seropositive patients in the post-HSCT group were 14.7 (95% CI, 11.3-19.1) versus 20.2 (95% CI, 13.0-31.3) in the post-chemotherapy group (p = 0.690). Based on a FAMA seropositive cut-off ≥1:16, the post-dose 1 GMT of patients considered seropositive in the post-HSCT group was 19.3 (95% CI, 15.6-24.0) versus 34.1 (95% CI, 21.0-55.4) in the post-chemotherapy group (p = 0.116), and post-dose 2 FAMA titers of 76.1 (95% CI, 14.6-398.1) in the post-HSCT group and 64.0 (95% CI, 11.4-358.1) in the post-HSCT group (p = 0.853) were observed. In patients with lower baseline FAMA titers (1:4 to 1:8), 66.7% in the post-HSCT group and 71.5% in the post-chemotherapy group achieved a greater than four-fold increase in FAMA titers post-dose 1, while those with higher baseline titers (≥1:16) did not. There were no serious adverse events or vaccine-related rashes occurring in any of the patients.

CONCLUSION

The MAV/06 varicella vaccine is immunogenic in pediatric patients post-HSCT and post-chemotherapy, particularly when administered in a two-dose schedule using a cut-off FAMA titer of <1:16.

Herpes zoster as the initial manifestation of varicella-zoster virus infection in a healthy toddler

Herpes zoster (HZ), commonly known as shingles, is a painful blistering rash in dermatomal distribution, caused by the reactivation of varicella-zoster virus (VZV) that was acquired during a primary varicella infection. While commonly afflicting adults, cases of HZ in paediatric patients are infrequently reported. Such cases are predominantly reported in children who have had prior exposure to VZV, either during pregnancy, early childhood or have been vaccinated with live attenuated VZV. This report presents the first known case to our knowledge of HZ as the initial manifestation of a VZV infection in an immunocompetent toddler in the UK. The report details the chronology of the infection event and discusses the clinical context behind HZ presentations in paediatrics globally. It provides a compelling illustration of the uncommon presentation of VZV infection in an immunocompetent child devoid of antecedent virus exposure, thus meriting acknowledgement and potentially further investigation as to the cause.

Genital VZV in a Third Trimester Pregnancy and the Critical Role of Interdisciplinary Planning

Introduction

Herpes simplex (HSV) and varicella zoster (VZV) viruses are harmful infectious agents in pregnancy due to their ability to impact maternal-fetal dyads through various modalities including vertical transmission, neonatal infection, and maternal morbidity. As a result, accurate diagnosis and prompt treatment of these infections in pregnancy is critical.

Case

A 19-year-old primigravida presented to our tertiary care center at 30 weeks' gestation with vulvar swelling, burning, and pain. Workup included direct PCR testing of a particularly erythematous area of the vulva which returned positive for VZV. The patient was treated with a 10-day course of acyclovir with resolution of her symptoms. She later had a full-term spontaneous vaginal delivery outside of the infectious window with no significant morbidity for either her or her neonate.

Conclusion

Although a rare presentation, the presence of a genital lesion or labial swelling during pregnancy warrants workup for VZV, particularly among patients known to be varicella nonimmune. If genital VZV is diagnosed during pregnancy, the development of contingency plans through interdisciplinary collaboration should be pursued to ensure a safe delivery and postpartum course for both the maternal-fetal dyad as well as other patients on the unit and the provider care team.

Herpes zoster infection in pregnancy: features and consequences

Herpes (varicella) zoster (HZ) infection occurs in 4 people per 1000 in the general US population (irrespective of prior varicella infection and vaccination status) each year and has been the subject of scientific inquiry for decades. The consequences of infection are myriad and may depend on the dermatome of involvement as well as host factors such as age, comorbidities, prior treatment or immunization, and immunologic status. Pregnancy is associated with an altered immune and hormonal status in the mother. While maternal HZ infection during pregnancy is not uncommon, the implications for both mother and child are not well established, although multiple studies of perinatal maternal HZ infection suggest no intrauterine transmission to the fetus. We review the current literature on herpes zoster infection in pregnancy, including epidemiology, diagnosis, potential immunologic sequelae, and strategies for prevention and treatment.

Pralatrexate inhibited the replication of varicella zoster virus and vesicular stomatitis virus: An old dog with new tricks

Varicella zoster virus (VZV) is associated with herpes zoster (HZ) or herpes zoster ophthalmicus (HZO). All antiviral agents currently licensed for the management of VZV replication via modulating different mechanisms, and the resistance is on the rise. There is a need to develop new antiviral agents with distinct mechanisms of action and adequate safety profiles. Pralatrexate (PDX) is a fourth-generation anti-folate agent with an inhibitory activity on folate (FA) metabolism and has been used as an anti-tumor drug. We observed that PDX possessed potent inhibitory activity against VZV infection. In this study, we reported the antiviral effects and the underlying mechanism of PDX against VZV infection. The results showed that PDX not only inhibited VZV replication in vitro and in mice corneal tissues but also reduced the inflammatory response and apoptosis induced by viral infection. Furthermore, PDX treatment showed a similar anti-VSV inhibitory effect in both in vitro and in vivo models. Mechanistically, PDX inhibited viral replication by interrupting the substrate supply for de novo purine and thymidine synthesis. In conclusion, this study discovered the potent antiviral activity of PDX with a novel mechanism and presented a new strategy for VZV treatment that targets a cellular metabolic mechanism essential for viral replication. The present study provided a new insight into the development of broad-spectrum antiviral agents.

Seroprevalence of VZV and HSV-2 Antibodies among Women of Childbearing Age Referring to Health Centres of Mashhad, Iran: The Need for Consideration of VZV Vaccination Program

Background

Infections with herpes simplex virus type 2 (HSV-2) and varicella-zoster virus (VZV) are associated with serious maternal and neonatal health consequences. The literature review reveals a research gap regarding the seroprevalence of HSV-2 and VZV among women of reproductive age in Mashhad, Northeast of Iran. The present study aims to evaluate the seroprevalence of these viruses among a group of women in Mashhad, Iran.

Methods

Sera were collected by health center personnel using a cluster sampling method from healthy women with specific age characteristics residing in three distinct socioeconomic regions of the city. The participants, aged 20-35, were divided into three groups (20-25, 26-30, and 31-35 years). The levels of VZV and HSV-2 IgG antibodies were evaluated using commercial ELISA kits. Subsequently, the results were analyzed using SPSS software.

Results

A total of 93 women were included in the study. Anti-HSV-2 IgG antibody was detected in 3 out of 93 participants (7.5%), while anti-VZV IgG antibody was found positive in 80 out of 93 individuals (83.3%). The HSV-2 positive cases were concurrently positive for the VZV antibody. There was no significant difference in the positivity of anti-HSV-2 and anti-VZV antibody positivity within age groups or socioeconomic status (P > 0.05).

Conclusions

The high seroprevalence of VZV among nonvaccinated participants indicates a widespread presence of the virus and underscores its potentially serious impact on community health. Therefore, it is recommended that a VZV vaccination program be considered by the health system. Furthermore, the reactivation of latent HSV-2, whether symptomatic or asymptomatic, during pregnancy should not be disregarded as a life-threatening threat.

Safety of anti-varicella zoster virus vaccination in patients with multiple sclerosis treated with natalizumab: A case series

The vaccination with live attenuated vaccines is generally not recommended during natalizumab (NTZ), as it is included among immunosuppressive/immunomodulating therapies. Nevertheless, considering the lack of evidence of a non-Central Nervous System (CNS) immunosuppressive effect of NTZ, after a risk/benefit evaluation, we decided to vaccinate four multiple sclerosis (MS) patients (three with an indication to switch to ocrelizumab for high-risk Progressive Multifocal Leukoencephalopathy (PML) and one for pregnancy planning). No vaccine-related adverse events of any type nor varicella zoster virus (VZV) infections were observed. To the best of our knowledge, these case series represent the first description of the good safety profile of anti-VZV vaccination in MS patients during NTZ treatment.

Active prospective national surveillance for congenital and neonatal varicella in Australia shows potential prevention opportunities

To compare the incidence and outcomes of congenital and neonatal varicella in Australia in the pre-vaccination (1995-1997) and post-vaccination era (after 2005 to November 2020), active prospective national surveillance for congenital varicella syndrome (CVS) and neonatal varicella infection (NVI) was conducted through the Australian Paediatric Surveillance Unit (APSU). Compared with 1995-1997, there was a 91.5% reduction in the incidence of CVS and a 91.3% reduction in the incidence of NVI in 2009-2020. However, almost half of the mothers in 2009-2020 were born overseas and came from countries without a vaccination program. Although there has been a substantial and sustained decrease in the reported incidence of CVS and NVI in Australia since 2006, congenital and neonatal varicella infections persist. Thus, there is an opportunity for targeted screening of varicella in young migrant, asylum seeker and refugee women at risk of varicella infection and prioritisation for vaccination to prevent CVS and NVI.

Varicella-Zoster Virus Prevalence among Pregnant Women: A European Epidemiological Review

Europe has faced a massive spread of the varicella-zoster virus through the years. Since the introduction of an effective vaccine, complications and severe forms of chickenpox have been restricted. Nevertheless, among the population, some categories need specific care, such as pregnant women, who present one of the most fragile conditions facing this infection, both for the mother and the fetus. In this review, we highlight how the varicella-zoster virus can be dangerous during pregnancy, underlining the problem of treatment and vaccination, and collect information about the European epidemiology among this particular category of women.

Human Maternal-Fetal Interface Cellular Models to Assess Antiviral Drug Toxicity during Pregnancy

Pregnancy is a period of elevated risk for viral disease severity, resulting in serious health consequences for both the mother and the fetus; yet antiviral drugs lack comprehensive safety and efficacy data for use among pregnant women. In fact, pregnant women are systematically excluded from therapeutic clinical trials to prevent potential fetal harm. Current FDA-recommended reproductive toxicity assessments are studied using small animals which often do not accurately predict the human toxicological profiles of drug candidates. Here, we review the potential of human maternal-fetal interface cellular models in reproductive toxicity assessment of antiviral drugs. We specifically focus on the 2- and 3-dimensional maternal placental models of different gestational stages and those of fetal embryogenesis and organ development. Screening of drug candidates in physiologically relevant human maternal-fetal cellular models will be beneficial to prioritize selection of safe antiviral therapeutics for clinical trials in pregnant women.

Infections and Pregnancy: Effects on Maternal and Child Health

Pregnancy causes physiological and immunological adaptations that allow the mother and fetus to communicate with precision in order to promote a healthy pregnancy. At the same time, these adaptations may make pregnant women more susceptible to infections, resulting in a variety of pregnancy complications; those pathogens may also be vertically transmitted to the fetus, resulting in adverse pregnancy outcomes. Even though the placenta has developed a robust microbial defense to restrict vertical microbial transmission, certain microbial pathogens have evolved mechanisms to avoid the placental barrier and cause congenital diseases. Recent mechanistic studies have begun to uncover the striking role of the maternal microbiota in pregnancy outcomes. In this review, we discuss how microbial pathogens overcome the placental barrier to cause congenital diseases. A better understanding of the placental control of fetal infection should provide new insights into future translational research.