Disseminated herpes zoster with cauda equina symptoms

A retrospective observational study on disseminated herpes zoster in immunocompetent patients

INTRODUCTION

Disseminated herpes zoster (DHZ) is a severe infection associated with high incidences and mortality rates in immunocompromised patients. Although studies have shown its occurrence in immunocompetent patients, its epidemiology, clinical presentation, and treatment outcomes in this cohort remain unknown. Thus, this study aimed to examine the clinical presentation, treatment, complications, and outcomes of DHZ in immunocompetent patients and compare these findings with previous studies.

METHODS

We included 20 immunocompetent patients of DHZ at our institution and reviewed 42 previously published cases. We then investigated the clinical features, predisposing factors, laboratory findings, treatment, and outcomes of all cases including in-hospital mortality, neurological dysfunction at discharge, and postherpetic neuralgia. We compared DHZ-immunocompetent patients to DHZ-immunocompromised patients.

RESULTS

Patients had a median age of 71.5 years and were predominantly male. The trigeminal area was the most common site of initial rash, with a mean dissemination time of 6.5 days. Pain was the most common symptom, followed by fever (approximately 40 % of cases); acyclovir was the most used treatment. Additionally, the in-hospital mortality was 0 %, neuropathy at discharge was observed in approximately 10 % of patients, and postherpetic neuralgia was present in approximately 40 % of patients. In the immunocompromised cases, the mortality rate was 12 %, which was higher than in our cases; however, the rates of neuropathy and postherpetic neuralgia were lower.

CONCLUSIONS

This study provides new insights into the clinical presentation, treatment, and outcomes of DHZ cases in immunocompetent patients, highlighting its tendency for residual neurological damage despite having low mortality rates.

Formulation Optimization and Evaluation of Nanocochleate Gel of Famciclovir for the Treatment of Herpes Zoster

BACKGROUND

Herpes zoster is a viral infection triggered due to the reactivation of the varicella- zoster virus in the posterior dorsal root ganglion. Herpes zoster infections occur mostly in the facial, cervical and thoracic regions of the body, beginning with pain and resulting in the vesicular eruption. Recently, this infection was observed during the COVID-19 pandemic and also after the induction of mRNA-based vaccine for coronavirus at an extended level. Nanocochleates are cylindrical (cigarshape) microstructure lipid-based versatile carriers for drug delivery systems. Famciclovir is an antiviral agent employed for the treatment of Herpes zoster infections.

OBJECTIVE

The current research patent aims to develop a novel nanocochleate gel of Famciclovir for the treatment of herpes zoster infections with higher efficacy.

METHODS

The interaction studies using FTIR were carried out and indicated no such interactions between the drug and lipids. The nanocochleates were developed using hydrogel, trapping, liposome before cochleate dialysis, direct calcium dialysis and binary aqueous-aqueous emulsion methods, respectively. The 3² Box-Behnken design was applied by considering the concentration of lipids (phosphatidylcholine and cholesterol) and speed of rotation as independent factors, whereas particle size and entrapment efficiency as dependable factors.

RESULTS

The developed nanocochleates were estimated for the particle size (276.3 nm), zeta potential (-16.7 mV), polydispersity index (0.241), entrapment efficiency (73.87±0.19%) and in vitro diffusion release (>98.8% in 10 h). The optimized batch was further converted into the topical gel using carbopol 940 as a gelling agent. The prepared gel was smooth, rapidly spreadable with a viscosity (5998.72 cp), drug content (95.3%) and remained stable during stability studies.

CONCLUSION

A novel nanocochleate gel of Famciclovir was successfully developed for the treatment of infections associated with Herpes Zoster with sustained release action.

Elsberg Syndrome, Lumbosacral Radiculopathy, and Myelitis Due to Herpes Zoster in a Patient With Smoldering Myeloma

Herpes zoster (HZ) is a common illness caused by the reactivation of latent varicella zoster virus (VZV) due to waning immunity, often secondary to old age or an underlying immunocompromised state. Its complications can manifest in variety of ways, including persistent neuralgias, vasculopathies, and stroke. Here, we describe a case of a 45-year-old man with a history of cryptogenic stroke and smoldering myeloma who was admitted with sacral HZ complicated by right lumbosacral radiculopathy and myelitis, otherwise known as Elsberg syndrome (ES). He was found to have an enhancing lesion in the peripheral conus medullaris on magnetic resonance imaging (MRI) with nonspecific inflammation and necrosis on biopsy pathology and cerebrospinal fluid (CSF) polymerase chain reaction (PCR) positive for VZV. The patient was initially treated with intravenous acyclovir and dexamethasone and discharged with a steroid taper and indefinite valacyclovir therapy. Twelve months postdischarge, the patient’s right lumbosacral radiculopathy and myelitis had almost completely resolved; however, he continued to require bladder self-catheterization. We believe that the patient’s underlying smoldering myeloma lead to an immunocompromised state, allowing for reactivation of latent VZV, resulting in both the patient’s cryptogenic stroke years earlier and recent ES.

Treatment of Elsberg Syndrome Causes Fever of Unknown Origin Attributable to Drug Reaction

A 56-year-old male with a history of non-adherence to HIV anti-retroviral therapy (ART) presented with Elsberg syndrome - varicella reactivation causing fever, painful dermatomal rash, weakness of bilateral lower extremities, and urinary and bowel dysfunction. On the third day of hospitalization, the patient developed altered mental status. An investigation for encephalitis and myelitis revealed a CD4 count of 150 cells/uL, viral load of about 150,000 copies/mL, and MRI of the lumbar spine demonstrating thickening of the cauda equina. Cerebrospinal fluid (CSF) from lumbar puncture confirmed the presence of varicella-zoster virus (VZV). Treatment with acyclovir for 21 days was initiated. However, the patient developed a persistent fever. Evaluation for the source of the fever resulted in identification of anti-viral therapy as the cause. In conclusion, the present report provides a unique example of acyclovir-induced fever developed on treatment of Elsberg syndrome.