Chickenpox infection after renal transplantation

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.

A case of varicella zoster infection in kidney transplant recipient using immunosuppressant

Kidney transplant recipients must take lifelong immunosuppression to prevent acute or chronic allograft injury. However, they are also at risk for opportunistic infections due to compromised immune cell functionality. Disseminated HZ in kidney transplant recipients can result in a very high overall mortality rate of up to 30%. Here we described a 23-year-old male patient who presented to the emergency room with a complaint of high-grade fever, chills, and non-dermatomal lesion of varicella zoster skin infection that affected the face and trunk. After investigation the patient was diagnosed with chickenpox clinically and was managed with complete recovery and early hospital discharge.

Delayed acyclovir therapy for disseminated varicella zoster in an adult kidney transplant recipient: a case report and literature review

Kidney transplant recipients are at increasing risk for reactivation of varicella-zoster virus (VZV) infection.

Presentation of case

A 31-year-old male was admitted with fever, chest pain, and dyspnea. Also, the complaints accompanied by generalized maculopapular, vesicular, hemorrhagic, itching, and painful rash with pustules and crusts on an erythematous base fill the entire body for the last 10 days. Chest computed tomography scan showed diffuse miliary and ground-glass opacities. The patient had a previous history of chickenpox infection in childhood, no recent contact with individuals suffering from VZV infection, and no known pretransplant serology for VZV. Due to the high clinical suspicion of reactivated VZV with pneumonitis and severe disseminated form, we started the treatment with intravenous acyclovir (ACV) for 10 days followed by oral ACV for a total of 21 days, along with stopping mycophenolate mofetil and increasing the prednisolone dose to 10 mg/d. The clinical status was improved and the rash receded with a flaked surface for old lesions.

Conclusion

We experienced a successful ACV treatment for delayed and severe VZV infection with a literature review of VZV pneumonitis among kidney transplant recipients. To the best of our knowledge, this is the first case that presented a disseminated skin form with pneumonitis of VZV from Syria. This case supports the initiation of antiviral therapy for transplant patients even after 72 hours the onset of the rash despite the lack of evidence in these circumstances.

Systemic lupus erythematosus with visceral varicella: A case report

BACKGROUND

As an autoimmune disease, systemic lupus erythaematosus (SLE) can affect multiple systems of the body and is mainly treated by steroids and immunosuppressive agents. SLE results in a long-term immunocompromised state with the potential of infection complications (e.g., bacterial, fungal and viral infections). Abdominal pain or acute abdomen are frequently the only manifestations of SLE at disease onset or during the early stage of the disease course. Thus, multidisciplinary collaboration is required to identify these patients because timely diagnosis and treatment are crucial for improving their prognosis.

CASE SUMMARY

Herein, we reported a case of an SLE patient with visceral varicella that was identified after the onset of abdominal pain. The 16-year-old female patient with SLE was admitted to our hospital due to initial attacks of abdominal pain and intermittent fever. The patient’s condition rapidly became aggravated within a short time after admission, with large areas of vesicular rash, severe pneumonia, respiratory failure, shock, and haematologic system and hepatic function impairment. Based on multidisciplinary collaboration, the patient was diagnosed with visceral disseminated varicella and was administered life support, antiviral (acyclovir), immunomodulatory (intravenous injection of human immunoglobulin), anti-infection (vancomycin) and anti-inflammatory (steroid) therapies. After treatment, her clinical symptoms and laboratory indicators gradually improved, and the patient was discharged.

CONCLUSION

SLE patients long treated with steroids and immunosuppressive agents are susceptible to various infections. Considering that visceral varicella with abdominal pain as the initial presentation is characterized by rapid progression and often coexists with serious complications, prompt diagnosis and early antiviral therapy are critical to prevent severe life-threatening complications.

Serologic screening and infectious diseases consultation in renal transplant candidates for measles, mumps, rubella and varicella

Background. Renal transplant recipients are at increased risk for developing complications of vaccine-preventable diseases. They benefit from a comprehensive pre-transplant evaluation when they might safely receive live vaccines. The primary aim of our study was to investigate the number of renal transplant recipients who were evaluated for serologic status against measles, mumps, rubella (MMR), and varicella. Secondarily, we investigated if pre-transplant Infectious Diseases consultation (IDC) improved vaccination rates.Methods. We retrospectively analyzed 282 kidney-alone and kidney-plus adult transplant recipients who were born in or after 1957. Patients were evaluated at Mayo Clinic, Florida Transplant Center between January 2015 and December 2017. Serologic status evaluation and vaccination rates were compared in two groups created based on IDC and no ID consultation (NIDC).Results. 235 (83%) of a total 282 patients received an IDC pre-transplantation. Varicella IgG levels were screened in all 235 IDC candidates. Among the IDC patients, mumps, measles and rubella IgG serologies were performed in 7 (3%), 143 (61%) and 144 (61%), respectively. Among 44 patients seronegative for any of MMR, 24 (55%) were vaccinated. Ten (66%) of 15 varicella seronegative patients were vaccinated. Zostavax was not given to 18% of IDC patients. Zostavax and MMR were administered more frequently in the IDC group compared to NIDC (p < .001 and p = 0.0016, respectively).Conclusion. Although the majority of patients had IDC, the screening rate for MMR serologies was lower than varicella. A protocol-driven serologic screening similar to the one for VZV is required for MMR. Pre-transplant IDC increases vaccination rates.

Varicella infection following vaccination in a pediatric kidney transplant recipient

Live viral vaccines have historically been avoided in children after solid organ transplantation. Multiple reports of safety and immunogenicity, largely in the pediatric liver transplant population, have led to a reconsideration of this recommendation. Here, we report the case of a 4-year-old boy who inadvertently received the live attenuated MMR-varicella vaccine (MMRV) at a routine well-child visit 16 months after receiving a living donor kidney transplant. This was not known until after he was admitted with rash and documented disseminated varicella infection 5 weeks later. He was treated with intravenous acyclovir followed by oral therapy and recovered fully. This case and its discussion illustrate what is still unknown about the risk-to-benefit ratio of live viral vaccination in any individual transplant recipient. Criteria to determine which patients should receive these vaccines should be evaluated before their use after transplant becomes routine, and all recipients and their families should be counseled to have a low threshold to seek medical care for any febrile illness or rash after live viral vaccination.

Live vaccines after pediatric solid organ transplant: Proceedings of a consensus meeting, 2018

Growing evidence suggests receipt of live-attenuated viral vaccines after solid organ transplant (SOT) has occurred and is safe and needed due to lapses in herd immunity. A 2-day consortium of experts in infectious diseases, transplantation, vaccinology, and immunology was held with the objective to review evidence and create expert recommendations for clinicians when considering live viral vaccines post-SOT. For consideration of VV and MMR post-transplant, evidence exists only for kidney and liver transplant recipients. For MMR vaccine post-SOT, consider vaccination during outbreak or travel to endemic risk areas. Patients who have received antiproliferative agents (eg. mycophenolate mofetil), T cell-depleting agents, or rituximab; or have persistently elevated EBV viral loads, or are in a state of functional tolerance, should be vaccinated with caution and have a more in-depth evaluation to define benefit of vaccination and net state of immune suppression prior to considering vaccination. MMR and/or VV (not combined MMRV) is considered to be safe in patients who are clinically well, are greater than 1 year after liver or kidney transplant and 2 months after acute rejection episode, can be closely monitored, and meet specific criteria of "low-level" immune suppression as defined in the document.

Anaplasma phagocytophilum presenting with orchitis in a renal transplant recipient

Human granulocytic anaplasmosis (HGA), caused by Anaplasma phagocytophilum, is an emerging tick-borne disease. It is spread by the black-legged deer tick Ixodes scapularis that serves as the vector for six human pathogens. HGA is still rarely reported in solid organ transplant recipients. In solid organ transplant recipients, orchitis has been reported secondary to chickenpox, tuberculosis and infections due to Listeria monocytogenes and Nocardia asteroides. Orchitis as a presenting feature of HGA infection has only been reported in animals. We present a unique case of a renal transplant recipient with HGA that presented as orchitis. We also compare the clinical presentation and laboratory findings of our patient with other cases of HGA in transplant recipients. To the best of our knowledge, our patient is one of the first cases of A phagocytophilum mono-infection causing a classical presentation of orchitis in a transplant patient.

Varicella infections in patients with end stage renal disease: a systematic review

BACKGROUND

End stage renal disease (ESRD) is on the rise globally. Varicella infection among adult patients with ESRD has been reported to lead to multiple complications and even death. While varicella vaccination has been recommended in paediatric renal patients; recommendation on varicella vaccination among adult patients with ESRD remained sparse. This review is aimed at evaluating the impact of varicella infection among adult patients with ESRD and make a recommendation for vaccination.

METHODS

Three databases (PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL)) were searched in April 2018 with keywords 'varicella, chronic kidney failure, chronic kidney disease, renal replacement therapy, kidney transplantation, end stage renal disease, end stage renal failure, chicken pox, vaccine, vaccination and complications'.

RESULTS

29 articles were selected for review. The studies were mainly case reports, and they included measured outcomes: prevalence of seronegativity, impact (morbidity, length of stay, and mortality) of varicella among patients with ESRD, seroconversion rates and safety of varicella vaccination. The prevalence of seronegativity among varicella-infected ESRD adults was found to be at 42 to 100%. Nineteen deaths were reported. At least 54 patients have had complications from varicella infection. Seroconversion rate post vaccination was found to be around 64-94%.

CONCLUSION

Varicella is associated with significant morbidity and mortality rates in adult patients with ESRD. Varicella vaccination should be considered for the vulnerable, seronegative patients.

Incidence and mortality rates of varicella among end stage renal disease (ESRD) patients in Singapore General Hospital, a 12-year review

Background

End stage renal disease (ESRD)/ end stage renal failure (ESRF) is on the rise globally and especially in Singapore. Varicella or chickenpox is not uncommon among adults especially ESRD/ESRF patients. It has been reported to cause complications and even death among immunocompetent adults.

Methods

A retrospective data collection on patients with varicella infection and ESRD in Singapore General Hospital (SGH) from the year 2005 to 2016 was performed. Continuous data and categorical data were summarized as median (range) and count (%) respectively. The association of health care utilization (total length of hospital stay, readmission related to varicella, intensive care unit admission) and mortality with complication due to varicella were tested using chi-square and Mann-Whitney test for categorical and continuous outcomes respectively.

Results

Sixty-six patients with ESRD developed varicella during the study period (2005–2016). The case incidence rates for varicella among ESRD ranges from 97 to 267 per 100,000 populations with ESRD yearly. There were 9 deaths (13.6%). Mortality was higher among the ESRD patients with one or more varicella complications compared to patients without complications ((25% vs 7.1%, 95% CI for difference: − 1.1%, 36.9%, p = .063). Likewise, utilisation of intensive or high dependency units were higher among patients with complications compared to those without (20.8% vs 2.4%, 95% CI for difference: 1.6%, 35.3%, p = .012). Length of stay was twice as long in the group with complications compared to patients without (median (IQR) days: 14 (8, 21) vs 7 (5, 14), p = .065), although it did not reach statistical significance.

Conclusions

Varicella is associated with high morbidity and significant mortality rate in ESRD patients. Varicella vaccination is recommended for seronegative ESRD patients.