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Knight CL. Physical Examination in Human Immunodeficiency Virus Disease. Med Clin North Am 2022; 106:527-536. [PMID: 35491072 DOI: 10.1016/j.mcna.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Human immunodeficiency virus (HIV)-associated disease is known for its protean manifestations. However, many of the characteristic findings on physical examination are not associated with HIV infection per se but the numerous opportunistic infections (OIs) that are common in patients with advanced HIV disease. Common findings of acute HIV infection include fever, adenopathy, rash, and oral ulcers. Chronic HIV infection is associated with skin, rheumatologic, and neurologic manifestations. OIs also cause skin, oropharyngeal, ocular, and neurologic manifestations. A skilled clinician can often recognize HIV disease based on the combination of these findings.
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2
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Chelidze K, Thomas C, Chang AY, Freeman EE. HIV-Related Skin Disease in the Era of Antiretroviral Therapy: Recognition and Management. Am J Clin Dermatol 2019; 20:423-442. [PMID: 30806959 DOI: 10.1007/s40257-019-00422-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Antiretroviral therapy (ART) has revolutionized the treatment and prognosis of people living with HIV (PLHIV). With increased survival and improved overall health, PLHIV are experiencing dermatologic issues both specific to HIV and common to the general population. In this new era of ART, it is crucial for dermatologists to have a strong understanding of the broad range of cutaneous disease and treatment options in this unique population. In this review, we outline the most common skin diseases in PLHIV, including HIV-associated malignancies, inflammatory conditions, and infections, and focus on the role of ART in altering epidemiology, clinical features, diagnosis, and treatment of cutaneous conditions.
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Affiliation(s)
- Khatiya Chelidze
- Weill Cornell Medical College, Massachusetts General Hospital, 1300 York Avenue, New York, NY, 10021, USA
| | - Cristina Thomas
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Bartlett Hall 6R, Boston, MA, 02114, USA
| | - Aileen Yenting Chang
- Department of Dermatology, University of California, San Francisco, 505 Paranassus Avenue, San Francisco, CA, 94143, USA
| | - Esther Ellen Freeman
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Bartlett Hall 6R, Boston, MA, 02114, USA.
- Medical Practice Evaluation Center, Mongan Institute, Massachusetts General Hospital, 100 Cambridge Street, 16th Floor, Boston, MA, 02114, USA.
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3
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Crum-Cianflone NF, Sullivan E. Vaccinations for the HIV-Infected Adult: A Review of the Current Recommendations, Part II. Infect Dis Ther 2017; 6:333-361. [PMID: 28780736 PMCID: PMC5595779 DOI: 10.1007/s40121-017-0165-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Indexed: 12/14/2022] Open
Abstract
Vaccination is a critical component for ensuring the ongoing health HIV-infected adults. Since this group may have reduced immune responses and shorter durations of protection post-vaccination, HIV-specific guidelines have been published. This review article provides a comprehensive discussion of the current guidelines and evidence-based data for vaccinating HIV-infected adults, including data on dosing schedules, immunogenicity studies, and safety. In the current paper, part II of the review, live vaccines, as well as vaccines for travelers and specific occupational groups, will be discussed.
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Affiliation(s)
- Nancy F Crum-Cianflone
- Internal Medicine Department, Scripps Mercy Hospital, San Diego, CA, USA.
- Infectious Disease Division, Scripps Mercy Hospital, San Diego, CA, USA.
- Infectious Disease Division, Naval Medical Center San Diego, San Diego, CA, USA.
| | - Eva Sullivan
- Pharmacy Department, Scripps Mercy Hospital, San Diego, CA, USA
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Bhalla P, Forrest GN, Gershon M, Zhou Y, Chen J, LaRussa P, Steinberg S, Gershon AA. Disseminated, persistent, and fatal infection due to the vaccine strain of varicella-zoster virus in an adult following stem cell transplantation. Clin Infect Dis 2014; 60:1068-74. [PMID: 25452596 DOI: 10.1093/cid/ciu970] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Live attenuated varicella vaccine is recommended for healthy individuals who are susceptible to varicella. Although the vaccine is safe, effective, and used worldwide, serious adverse events have been reported, mainly in immunocompromised patients who subsequently recovered. Here, we describe the fatality of an immunocompromised patient who received the varicella vaccine. His medical history provides a cautionary lens through which to view the decision of when vaccination is appropriate. A middle-aged man with non-Hodgkin lymphoma received chemotherapy and a stem cell transplant. He was vaccinated 4 years post-transplantation, despite diagnosis of a new low-grade lymphoma confined to the lymph nodes. Within 3 months of vaccination, he developed recurrent rashes with fever, malaise, weakness, hepatitis, weight loss, and renal failure. The syndrome was eventually determined to be associated with persistent disseminated zoster caused by the vaccine virus. This case illustrates a circumstance when a live viral vaccine should not be used.
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Affiliation(s)
- Preeti Bhalla
- Department of Medicine, Oregon Health Science University, Portland
| | - Graeme N Forrest
- Department of Medicine, Oregon Health Science University, Portland Portland Veterans Affairs Medical Center, Oregon
| | | | - Yan Zhou
- Department of Pathology and Cell Biology
| | - Jason Chen
- Department of Pathology and Cell Biology
| | - Philip LaRussa
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York
| | - Sharon Steinberg
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York
| | - Anne A Gershon
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York
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5
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Abstract
Vaccines are critical components for protecting HIV-infected adults from an increasing number of preventable diseases. However, missed opportunities for vaccination among HIV-infected persons persist, likely due to concerns regarding the safety and efficacy of vaccines, as well as the changing nature of vaccine guidelines. In addition, the optimal timing of vaccination among HIV-infected adults in regards to HIV stage and receipt of antiretroviral therapy remain important questions. This article provides a review of the current recommendations regarding vaccines among HIV-infected adults and a comprehensive summary of the evidence-based literature of the benefits and risks of vaccines among this vulnerable population.
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Affiliation(s)
- Nancy F. Crum-Cianflone
- Infectious Disease Clinic, Naval Medical Center San Diego, San Diego, California
- Department of Infectious Disease, Scripps Mercy Hospital, San Diego, California
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6
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Aziz M, Kessler H, Huhn G. Providers' lack of knowledge about herpes zoster in HIV-infected patients is among barriers to herpes zoster vaccination. Int J STD AIDS 2013; 24:433-9. [PMID: 23970744 DOI: 10.1177/0956462412472461] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Identification of perceptions about herpes zoster (HZ) disease, vaccine effectiveness and safety, and vaccine recommendations may impact immunization practices of physicians for HIV-infected patients. A survey was used to quantify knowledge of HZ as well as determine physician immunization perceptions and practices. There were 272/1700 respondents (16%). Correct answers for the incidence of varicella zoster virus (VZV) infection in adults and incidence of HZ in HIV-infected patients were recorded by 14% and 10% of providers, respectively. Providers reported poor knowledge of the incidence of disease recurrence in HIV-infected patients (41% correct), potency of HZ vaccine (47.5% correct) and mechanism of protection against reactivation of VZV (66% correct). Most (88%) agreed that HZ was a serious disease, and 73% believed that the burden of disease made vaccination important. A majority (75%) did not vaccinate HIV patients with HZ vaccine regardless of antiretroviral therapy status. Barriers to administration included safety concerns, concern that vaccine would not prevent HZ, risk of HZ dissemination, reimbursement issues and lack of Infectious Diseases Society of America (IDSA) guidelines. Only 38% of providers agreed that CDC guidelines were clear and 50% believed that clinical trials were needed prior to use of HZ vaccine in HIV-infected patients. Education about HZ is needed among HIV providers. Providers perceived vaccination as important, but data on vaccine safety and clear guidance from the CDC on this issue are lacking.
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Affiliation(s)
- M Aziz
- Rush University Medical Center/John H Stroger Hospital of Cook County, Chicago, IL, USA.
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Watanabe D, Otani N, Suzuki S, Dohi H, Hirota K, Yonemoto H, Koizumi Y, Otera H, Yajima K, Nishida Y, Uehira T, Shima M, Shirasaka T, Okuno T. Evaluation of VZV-specific cell-mediated immunity in adults infected with HIV-1 by using a simple IFN-γ release assay. J Med Virol 2013; 85:1313-20. [DOI: 10.1002/jmv.23611] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Dai Watanabe
- AIDS Medical Center; National Hospital Organization Osaka National Hospital; Osaka Japan
| | - Naruhito Otani
- Department of Public Health; Hyogo College of Medicine; Osaka Japan
| | - Sachiko Suzuki
- AIDS Medical Center; National Hospital Organization Osaka National Hospital; Osaka Japan
| | - Hiromi Dohi
- AIDS Medical Center; National Hospital Organization Osaka National Hospital; Osaka Japan
| | - Kazuyuki Hirota
- AIDS Medical Center; National Hospital Organization Osaka National Hospital; Osaka Japan
| | - Hitoshi Yonemoto
- AIDS Medical Center; National Hospital Organization Osaka National Hospital; Osaka Japan
| | - Yusuke Koizumi
- AIDS Medical Center; National Hospital Organization Osaka National Hospital; Osaka Japan
| | - Hiroshi Otera
- AIDS Medical Center; National Hospital Organization Osaka National Hospital; Osaka Japan
| | - Keishiro Yajima
- AIDS Medical Center; National Hospital Organization Osaka National Hospital; Osaka Japan
| | - Yasuharu Nishida
- AIDS Medical Center; National Hospital Organization Osaka National Hospital; Osaka Japan
| | - Tomoko Uehira
- AIDS Medical Center; National Hospital Organization Osaka National Hospital; Osaka Japan
| | - Masayuki Shima
- Department of Public Health; Hyogo College of Medicine; Osaka Japan
| | - Takuma Shirasaka
- AIDS Medical Center; National Hospital Organization Osaka National Hospital; Osaka Japan
| | - Toshiomi Okuno
- Department of Microbiology; Hyogo College of Medicine; Osaka Japan
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Ramamurthy M, Kannangai R, Abraham AM, Sridharan G. Viral Infections in Immunocompromised Hosts. ACTA ACUST UNITED AC 2012. [DOI: 10.1007/s40011-011-0008-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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9
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Clinical Guidelines for the Treatment and Prevention of Opportunistic Infections in HIV-infected Koreans. Infect Chemother 2012. [DOI: 10.3947/ic.2012.44.3.93] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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10
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Birlea M, Arendt G, Orhan E, Schmid DS, Bellini WJ, Schmidt C, Gilden D, Cohrs RJ. Subclinical reactivation of varicella zoster virus in all stages of HIV infection. J Neurol Sci 2011; 304:22-4. [PMID: 21419427 PMCID: PMC3176733 DOI: 10.1016/j.jns.2011.02.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Revised: 02/17/2011] [Accepted: 02/23/2011] [Indexed: 12/30/2022]
Abstract
Analysis of 200 paired serum and cerebrospinal fluid (CSF) samples from 180 HIV-positive individuals, 136 of whom had AIDS, revealed intrathecal synthesis of antibodies specific for varicella zoster virus (VZV) in 28 (16%) individuals, measles virus in 15 (8%), herpes simplex virus-1 (HSV-1) in 1 (0.6%), and HSV-2 in none. Of the 28 subjects with a positive VZV antibody specificity index, only 1 had zoster rash at the time of serum and CSF sampling; of the total 180 HIV-positive subjects, 146 (81%) had no history of zoster. Based on an estimated 33.4 million HIV-positive individuals worldwide, subclinical reactivation of VZV in even less than 16% of HIV-positive people suggests the possibility that millions of people have active VZV infection of the central nervous system. In cases of VZV vasculopathy, myelopathy and even zoster sine herpete, the CSF is often positive for anti-VZV antibody, but negative for VZV DNA. To rule out VZV infection of the nervous system, CSF must be tested for VZV DNA and anti-VZV IgG and IgM antibody.
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Affiliation(s)
- Marius Birlea
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Gabriele Arendt
- Department of Neurology, University of Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Eser Orhan
- Department of Neurology, University of Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - D. Scott Schmid
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Christian Schmidt
- Department of Neurology, University of Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Don Gilden
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Microbiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Randall J. Cohrs
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
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11
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Compston LI, Li C, Sarkodie F, Owusu-Ofori S, Opare-Sem O, Allain JP. Prevalence of persistent and latent viruses in untreated patients infected with HIV-1 from Ghana, West Africa. J Med Virol 2009; 81:1860-8. [PMID: 19774687 DOI: 10.1002/jmv.21614] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Only limited epidemiological data, pertaining to the prevalence of common persistent viruses has been reported in Ghana. This study was conducted to determine the prevalence of persistent viruses in individuals with untreated HIV-1 infection and uninfected blood donors. Paired plasma and cellular samples from HIV-negative blood donors, asymptomatic HIV and symptomatic/AIDS cohorts were screened by multiplex PCR then qPCR for parvovirus B19 (B19V), hepatitis B virus (HBV), GB virus-C (GBV-C), cytomegalovirus (CMV), Epstein-Barr virus (EBV), human herpesvirus-8 (HHV-8) and varicella-zoster virus (VZV). IgG antibodies specific to each target virus were tested to determine exposure rates. No evidence of viraemia was found for B19V and VZV in any group. Prevalence of GBV-C plasma viraemia was significantly higher in asymptomatic and symptomatic HIV infection (16.7%) and (16.2%) than in blood donors (4%) P < 0.005. Occult HBV infection was significantly more frequent in symptomatic HIV infection (10.9%) compared to asymptomatic HIV (3.6%) and blood donors (1.6%) P < 0.005. Although there was a high background of EBV viraemia in cellular fractions of blood donors (8.3%), it was significantly higher in asymptomatic (44.6%) and symptomatic HIV (14.6%) P < 0.0001. For CMV, the significantly increased prevalence of viraemia was only observed in the plasma fraction of the symptomatic HIV-1/AIDS patients (7.6%) compared to asymptomatic individuals (1.8%) and blood donors (0.8%) P < or = 0.001. The background seroprevalence in blood donors was high for B19V (> or =64%), HBV (> or =70%), CMV and EBV (> or =90%) and was significantly increased in HIV infections for HBV, CMV, VZV (symptomatic HIV), and HHV-8 (asymptomatic and symptomatic HIV).
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Affiliation(s)
- Lara Isobel Compston
- Department of Haematology, Division of Transfusion Medicine, University of Cambridge, Cambridge Blood Centre, Cambridge CB2 2PT, United Kingdom
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12
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Delgado A, de Jesus Pedro R, Aoki F, Resende M, Trabasso P, Colombo A, de Oliveira M, Mikami Y, Moretti M. Clinical and microbiological assessment of patients with a long-term diagnosis of human immunodeficiency virus infection and Candida oral colonization. Clin Microbiol Infect 2009; 15:364-71. [DOI: 10.1111/j.1469-0691.2009.02707.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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13
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Glesby MJ, Hoover DR, Tan T, Shi Q, Gao W, French AL, Maurer T, Young M, Dehovitz J, Ru J, Anastos K. Herpes Zoster in Women With and at Risk for HIV. J Acquir Immune Defic Syndr 2004; 37:1604-9. [PMID: 15577417 DOI: 10.1097/00126334-200412150-00013] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Herpes zoster occurs at all CD4 cell counts in HIV-infected adults. It was hypothesized that even in the era of highly active antiretroviral therapy (HAART), zoster risk is higher in HIV-infected than uninfected women. METHODS Generalized estimating equations modeled self-reported occurrence of zoster between semiannual visits among 1832 HIV-infected and 489 HIV-uninfected women in the Women's Interagency HIV Study followed for up to 7.5 years. RESULTS A total of 337 (18.4%) HIV-infected and 7 (1.4%) HIV-uninfected women reported zoster at some time during follow-up. Using HIV-infected women with CD4 >750 cells/microL as the reference category, the odds ratios for reporting zoster since the prior visit were: 1.43 (95% CI 0.86-2.37) for CD4 500-749 cells/microL, 2.07 (95% CI 1.27-3.38) for CD4 350-499 cells/microL, 2.72 (95% CI 1.66-4.46) for CD4 200-349 cells/microL, and 3.16 (95% CI 1.92-5.18) for CD4 <200 cells/microL, compared with 0.11 (95% CI 0.046-0.26) for HIV-uninfected women. In multivariate analyses using visits from all HIV-infected women and only those who initiated HAART, lower CD4 cell count was more strongly associated with zoster incidence than were other clinical indicators. CONCLUSIONS Herpes zoster is associated with degree of immunosuppression in HIV-infected women, but even women with high CD4 counts are at greater risk of zoster than HIV-uninfected women.
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Affiliation(s)
- Marshall J Glesby
- Division of International Medicine and Infectious Diseases, Department of Medicine, Weill Medical College of Cornell University, New York, NY 10021, USA.
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14
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Breton G, Bouldouyre MA, Gervais A, Duval X, Longuet P, Leport C, Vildé JL. Failure of valacyclovir for herpes zoster in a moderately immunocompromised HIV-infected patient. AIDS Patient Care STDS 2004; 18:255-7. [PMID: 15186709 DOI: 10.1089/108729104323075990] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Whereas valacyclovir is widely used and is recommended by some authors in moderately immunocompromised HIV-infected patients, its use has not been validated by clinical studies. We report a case of herpes zoster in an HIV-infected patient for whom neurologic complication was not avoided despite valacyclovir therapy. Clinical outcome was favorable after intravenous acyclovir. This case suggests careful monitoring of valacyclovir in HIV-infected patients is necessary.
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Affiliation(s)
- G Breton
- Department of Infectious and Tropical Diseases Bichat Claude Bernard Hospital, Paris, France.
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15
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López-Gómez M, López-Ruz MA, Jiménez-Alonso JF. Infarto cerebral por virus de la varicela-zóster en paciente con infección por el VIH. Enferm Infecc Microbiol Clin 2003; 21:532-3. [PMID: 14572391 DOI: 10.1016/s0213-005x(03)73003-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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16
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Franco-Paredes C, Bellehemeur T, Merchant A, Sanghi P, DiazGranados C, Rimland D. Aseptic meningitis and optic neuritis preceding varicella-zoster progressive outer retinal necrosis in a patient with AIDS. AIDS 2002; 16:1045-9. [PMID: 11953471 DOI: 10.1097/00002030-200205030-00011] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Varicella-Zoster Virus (VZV) is the second most common ocular pathogen in patients with HIV infection. VZV retinitis is estimated to occur in 0.6% of patients with HIV infection and may occur in one of two clinical syndromes. The first is the acute retinal necrosis syndrome, which also may be seen in immunocompetent hosts. The second clinical syndrome occurs in patients with CD4 cell counts typically < 50 x 10(6)/l and is termed progressive outer retinal necrosis. VZV retinitis has been reported to occur simultaneously with other VZV central nervous system manifestations such as encephalitis and myelitis in HIV-infected patients. In addition, VZV retrobulbar optic neuritis heralding VZV retinitis has recently been described in HIV-infected patients who had suffered a recent episode of dermatomal herpes zoster. Herein we report the case of an HIV-infected individual who presented with VZV meningitis and retrobulbar optic neuritis that preceded the onset of progressive outer retinal necrosis. We also review of the literature of seven additional reported cases of retrobulbar optic neuritis preceding the onset of VZV retinitis.
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Affiliation(s)
- Carlos Franco-Paredes
- Division of Infectious Diseases, Department of Medicine, Veterans Affairs Medical Center, Emory University School of Medicine, 69 Butler Street, Atlanta, GA 30303, USA
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Abstract
Infections by VZV, the virus that causes chickenpox and herpes zoster, usually are diagnosed by the classic clinical presentations. In immunocompromised patients, however, the atypical presentation can make the diagnosis more challenging. Although varicella typically follows an uncomplicated course in children, adults and immunocompromised patients can develop complications involving several organs; some complications may be fatal. Prevention of disease with the vaccine is ideal. When varicella or zoster infection does occur, proper treatment should be initiated, depending on the age and immune status of the patient.
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Affiliation(s)
- T Minsue Chen
- Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
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18
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Abstract
Suppression of the immune system by human immunodeficiency virus (HIV) infection or immunosuppressive therapy following transplantation increases susceptibility to CNS infection. Examination of the level and type of immunosuppression, in addition to the clinical and radiologic findings at the time of diagnosis can aid the clinician in determining the most likely etiology of infection. This article discusses how suppression of the host immune status modifies the presentation and diagnosis of selected CNS infections and the recommended treatment for these infections.
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Affiliation(s)
- Joseph R Zunt
- Department of Neurology, University of Washington School of Medicine, Seattle, Washington 98104, USA.
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19
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Abstract
Varicella-zoster virus (VZV), a member of the human herpesvirus family, causes childhood chickenpox (varicella), becomes latent in sensory ganglia, and reactivates years later in immunocompromised and elderly persons to produce shingles (herpes zoster). Early in the AIDS epidemic, zoster was noted in adults and children infected with HIV. Severe and debilitating zoster-associated dermatological, ophthalmic, and neurological complications may occur in patients infected with HIV. Antiviral therapy can modify the duration of zoster and alleviate its attendant complications. Varicella vaccine may boost the immunity and prevent virus reactivation. VZV immune globulin (VZIG) prevents or modifies clinical illness in persons who have been exposed to varicella or zoster.
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Affiliation(s)
- A Vafai
- Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
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20
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Affiliation(s)
- J W Casiglia
- Harvard School of Dental Medicine, Boston, MA 02115, USA
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21
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Affiliation(s)
- C Rongkavilit
- Division of Pediatric Infectious Diseases, University of Miami School of Medicine, Florida, USA
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22
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Abstract
Oral lesions are important in the clinical spectrum of HIV/AIDS, arousing suspicion of acute seroconversion illness (aphthous ulceration and candidiasis), suggesting HIV infection in the undiagnosed individual (candidiasis, hairy leukoplakia, Kaposi's sarcoma, necrotizing ulcerative gingivitis), indicating clinical disease progression and predicting development of AIDS (candidiasis, hairy leukoplakia), and marking immune suppression in HIV-infected individuals (candidiasis, hairy leukoplakia, necrotizing periodontal disease, Kaposi's sarcoma, long-standing herpes infection, major aphthous ulcers). In addition, oral lesions are included in staging systems for HIV disease progression and as entry criteria or endpoints in clinical trials of antiretroviral drugs. Recognition and management of these oral conditions is important for the health and quality of life of the individual with HIV/AIDS. In keeping with this, the U.S. Department of Health Services Clinical Practice Guideline for Evaluation and Management of Early HIV Infection includes recommendations that an oral examination, emphasizing oral mucosal surfaces, be conducted by the primary care provider at each visit, a dental examination by a dentist should be done at least two times a year, and patients should be informed of the importance of oral care and educated about common HIV-related oral lesions and associated symptoms.
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Affiliation(s)
- L L Patton
- Department of Dental Ecology, School of Dentistry, University of North Carolina, Chapel Hill, USA.
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23
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Abstract
The central nervous system (CNS) is susceptible to bacterial, viral, and fungal infections, and prion diseases. Examination of the cerebrospinal fluid (CSF) is crucial in diagnosing these infections. Cerebrospinal tests may directly identify an organism and its nucleic acid and surface constituents by culture, polymerase chain reaction (PCR), or antigen detection. Alternatively, antibody to an organism may be identified in CSF by enzyme-linked immunosorbent assay (ELISA), Western blot, or complement fixation assay. This article discusses how these CSF tests are performed and addresses the sensitivity and specificity of such tests for the diagnosis of selected CNS infections.
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Affiliation(s)
- J R Zunt
- Acting Assistant Professor, Department of Neurology, University of Washington School of Medicine, Seattle, Washington 98104, USA.
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24
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Rivera-Hidalgo F, Stanford TW. Oral mucosal lesions caused by infective microorganisms. I. Viruses and bacteria. Periodontol 2000 1999; 21:106-24. [PMID: 10551178 DOI: 10.1111/j.1600-0757.1999.tb00171.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- F Rivera-Hidalgo
- Department of Periodontics, Baylor College of Dentistry, Texas A&M University System, Dallas, USA
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25
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Abstract
Patients presenting with neurologic symptoms and evidence of focal brain disorders should be evaluated immediately. The clinical presentation of focal brain lesions reflects the function in the area of brain involved. Typical symptoms or signs can include motor or sensory deficits, visual complaints, headache, seizures, or changing level of arousal. Initial studies of key importance include magnetic resonance brain imaging with and without a contrast agent such as gadolinium. When clinically safe, lumbar puncture for detailed cerebrospinal fluid (CSF) analysis is very helpful in the differential diagnosis. Combined clinical, radiologic, and diagnostic evaluation of the CSF can often provide solid evidence of the cause of the lesion(s) and may obviate the need for brain biopsy. The status of systemic human immunodeficiency virus (HIV) infection is important in the differential diagnosis, choice of therapy, and prognosis. Thus, concurrent evaluation of the history and status of the HIV infection is vital. Determination of a specific cause of symptomatic focal lesions is important; this should be pursued aggressively unless the global status of the subject suggests that therapy would be futile. With current therapy, many patients presenting with aggressive focal brain lesions can be successfully treated and can return to productive lives.
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Affiliation(s)
- DB Clifford
- Washington University, Box 8111, Neurology, 660 South Euclid, St. Louis, MO 63110, USA
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Bouhour D. Question 1: quelles sont les personnes à risque d'infections à VZV compliquées et/ou sévères. Med Mal Infect 1998. [DOI: 10.1016/s0399-077x(98)80097-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Hannouche D. Ensemble des questions zona ophtalmique: épidémiologie, complications, traitements, analyse de la littérature. Med Mal Infect 1998. [DOI: 10.1016/s0399-077x(98)80102-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Question 2. Med Mal Infect 1998. [DOI: 10.1016/s0399-077x(98)80093-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Kleinschmidt-DeMasters BK, Mahalingam R, Shimek C, Marcoux HL, Wellish M, Tyler KL, Gilden DH. Profound cerebrospinal fluid pleocytosis and Froin's Syndrome secondary to widespread necrotizing vasculitis in an HIV-positive patient with varicella zoster virus encephalomyelitis. J Neurol Sci 1998; 159:213-8. [PMID: 9741410 DOI: 10.1016/s0022-510x(98)00171-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Demonstration of the direct involvement of cranial blood vessels by varicella zoster virus (VZV) is facilitated by immunohistochemistry (IHC), in situ hybridization (ISH) and polymerase chain reaction (PCR) techniques. The extent to which an inflammatory vasculitis serves as the pathogenic mechanism for VZV encephalomyelitis (VZVE) is still, however, debated. Most VZVE patients are immunocompromised and show little inflammation, either pre-mortem in cerebrospinal fluid (CSF) or at autopsy. We describe an HIV-positive patient with a moderately depressed CD4 count (304) who presented with massively elevated CSF protein (1800 mg/dl), bloody CSF and pleocytosis (1300 white blood cells (WBC)/mm3). His CSF was positive for VZV DNA by PCR. He was treated with acyclovir and foscarnet, but died. At autopsy, an unusually widespread, inflammatory, transmural vasculitis caused by VZV affected meningeal vessels at virtually all brain stem and spinal cord levels, causing multiple subpial hemorrhages and necrosis. Virus DNA in multiple areas of brain, brainstem and spinal cord was readily revealed by PCR, but not by the presence of viral inclusions, IHC or ISH. This case, with a clinically confusing presentation for VZVE, illustrates the extensive, albeit infrequent, degree of necrotizing vasculitis and CSF abnormalities that VZV is capable of producing. Antiviral therapy may have inhibited VZV genome replication and subsequent antigen production, resulting in negative ISH and IHC studies, but generated increased VZV genomic fragments that were detectable by the more sensitive PCR technique.
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Meenken C, van den Horn GJ, de Smet MD, van der Meer JT. Optic neuritis heralding varicella zoster virus retinitis in a patient with acquired immunodeficiency syndrome. Ann Neurol 1998; 43:534-6. [PMID: 9546338 DOI: 10.1002/ana.410430420] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We report on a 29-year-old severely compromised acquired immunodeficiency syndrome patient who developed retrobulbar optic neuritis 5 weeks after an episode of cutaneous herpes zoster infection. During the optic neuritis, varicella zoster virus could be demonstrated in the cerebrospinal fluid. The neuritis responded well to treatment with foscarnet, but, 3 weeks into therapy, varicella zoster retinitis developed. Additional treatment with intravenous acyclovir stopped progression of the retinitis and resulted in healing of the retinal lesions. This case suggests that retrobulbar optic neuritis can be regarded as a prodrome of imminent acute retinal necrosis. Early recognition and prompt therapy with combined antivirals may prevent the development of this devastating ocular complication of varicella zoster infection.
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Affiliation(s)
- C Meenken
- Department of Ophthalmology, Academic Medical Center, University of Amsterdam, The Netherlands
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