S2k guidelines for the diagnosis and treatment of herpes zoster and postherpetic neuralgia.

The present guidelines are aimed at residents and board-certified specialists in the fields of dermatology, ophthalmology, ENT, pediatrics, neurology, virology, infectious diseases, anesthesiology, general medicine and any other medical specialties involved in the management of patients with herpes zoster. They are also intended as a guide for policymakers and health insurance funds. The guidelines were developed by dermatologists, virologists, ophthalmologists, ENT physicians, neurologists, pediatricians and anesthesiologists/pain specialists using a formal consensus process (S2k). Readers are provided with an overview of the clinical and molecular diagnostic workup, including antigen detection, antibody tests and viral culture. Special diagnostic situations and complicated disease courses are discussed. The authors address general and special aspects of antiviral therapy for herpes zoster and postherpetic neuralgia. Furthermore, the guidelines provide detailed information on pain management including a schematic overview, and they conclude with a discussion of topical treatment options.

Preventing vertical virus infections: the role of serologic screening of pregnant women.

Several virus infections affect the pregnancy itself as well as the foetal development (rubella, PVB19, VZV, HSV, HCMV, HBV, HIV). Prevention can be established by vaccination or an assessment of the immunity status as well as by chemotherapy. The following review provides an update to current aspects focusing on the role of serologic screening.

Prevalence of K65R in patients treated with tenofovir disoproxil fumarate: recommendations based on the Frankfurt HIV Cohort Study Resistance Database (FHCS-RD).

Mutations in the genome of HIV-1 can compromise the success of antiretroviral treatments (ARTs) in HIV-1-infected individuals. The Frankfurt HIV Cohort Study Resistance Database (FHCS-RD) has previously documented a decline in the burden of resistance-associated mutations (RAMs) following the implementation of several new antiretroviral therapy regimens in 2007. In the current study, the annual burden of RAMs documented in the FHCS-RD in 2005-2013 was set in relation to the annual number of all cohort patients, drug regimens, available resistance tests, and prevalence for each RAM on relevant codons of reverse transcriptase (RT) and protease (PR) genes. A specific focus was put on the prevalence of the tenofovir disoproxil fumarate (TDF) signature mutation K65R in HIV-1 RT in relation to the application of TDF within ART. Between 2005 and 2012, a total of 4423 HIV genotyping data sets from 4509 patients were analysed. All mutations show a consistent decline, and the most impressive decrease was observed for thymidine analogue mutations (TAMs). The frequency of non-TAMs and PR mutations also decreased, but generally to a lower extent. The prevalence of K65R decreased from 2.6 % in 2005 to 0.2 % in 2012 despite increased use of TDF-containing ART. Both the improved strategic use of TDF in ARTs and generally more effective ART regimens may have resulted in decreasing RAM prevalences in FHCS-RD since 2007. These trends challenge the cost-effectiveness of resistance testing prior to failing ART.

Vaccination against infectious diseases: what is promising?

Vaccination has proven to be one of the best weapons protecting the mankind against infectious diseases. Along with the huge progress in microbiology, numerous highly efficacious and safe vaccines have been produced by conventional technology (cultivation), by the use of molecular biology (genetic modification), or by synthetic chemistry. Sterilising prevention is achieved by the stimulation of antibody production, while the stimulation of cell-mediated immune responses may prevent the outbreak of disease in consequence of an acute or reactivated infection. From several examples, two rules are deduced to evaluate the perspectives of future vaccine developments: They are promising, if (1) the natural infectious disease induces immunity or (2) passive immunisation (transfer of antibodies, adoptive transfer of lymphocytes) is successful in preventing infection.

Durability of protective antibody titres is not enhanced by a two-dose schedule of an ASO3-adjuvanted pandemic H1N1 influenza vaccine in adult HIV-1-infected patients.

The immune response after influenza vaccination is impaired in HIV-infected individuals and can be enhanced by a second dose. The durability of the antibody protection and its clinical benefit is not known. We investigated clinical symptoms and antibody titres against H1N1 influenza A following no dose, 1 dose, or 2 doses of an ASO3-adjuvanted H1N1 vaccine in HIV-infected patients. Seroprotection was found in 7.9%, 52.2%, and 57.3% of patients who received no dose, 1 dose, and 2 doses of the vaccine, respectively (p-value for group comparison < 0.001), after a median of 8.2 ± 1.6 months. Clinical symptoms suggestive of an influenza-like illness were slightly more frequently reported in the unvaccinated group. Vaccinated HIV-infected patients were more likely to be seroprotected at follow-up, but there was no difference comparing those who had received 1 or 2 doses of the vaccine.

Immune response after a single dose of the 2010/11 trivalent, seasonal influenza vaccine in HIV-1-infected patients and healthy controls.

BACKGROUND: Immune response rates following influenza vaccination are often lower in HIV-infected individuals. Low vitamin D levels were correlated with weak immune response in cancer patients and are known to be lower in HIV-infected patients. METHODS: Diagnostic study to determine immune response against the H1N1v component after a single, intramuscular dose of the 2010/11 seasonal, trivalent influenza vaccine (TIV) in adult HIV-infected and healthy controls scheduled for influenza vaccination (ClinicalTrials.gov Identifier: NCT01017172). Influenza A/H1N1 antibody titers (AB) were determined before and 21 days after vaccination by hemagglutination inhibition assay. RESULTS: Immune response was not different between HIV-infected patients (n = 36) and healthy controls (n = 42) who were previously naïve to the H1N1v component of the TIV. Comparing HIV-infected patients (n = 55) and healthy controls (n = 63) who had received 1 or 2 doses of an AS03 adjuvanted H1N1 vaccine in the previous winter season (2009/10), seroconversion rate and the geometric mean AB titer after TIV of the HIV-infected patients were more than twice as high compared to healthy controls. This difference was mainly driven by the 2-dose schedule for HIV patients in 2009/10. Vitamin D levels were lower in HIV patients but did not correlate with immune response. CONCLUSION: HIV-infected patients who had received 1 or 2 doses of an adjuvanted H1N1 vaccine in the previous year (2009/10) had a significant higher seroconversion rate following TIV as compared to healthy controls, indicating a stronger memory cell response due to the 2-dose schedule.

Role of human cytomegalovirus genotype polymorphisms in AIDS patients with cytomegalovirus retinitis.

Although several host factors have been identified to influence the course of HCMV infection, it still remains unclear why in AIDS patients without highly active antiretroviral therapy human cytomegalovirus (HCMV) retinitis is one of the most common opportunistic infections, whereas in other immunosuppressed individuals it has a low incidence. It was suggested that HCMV glycoprotein B strains may be suitable as marker for virulence and HCMV retinitis. Moreover, UL144 ORF, a member of the TNF-α receptor superfamily, may play a crucial role in innate defences and adaptive immune response of HCMV infection. Furthermore, sequence analyses of HCMV genes UL128, UL130, and UL131A as major determinants of virus entry and replication in epithelial and other cell types were performed. To evaluate the association of sequence variability of depicted viral genes with HCMV retinitis and in vitro growth properties in retinal pigment epithelial cells (RPE) and human foreskin fibroblasts (HFF), we compared 14 HCMV isolates obtained from vitreous fluid and urine of AIDS patients with clinically proven HCMV retinitis. Isolates were analyzed by PCR cycle sequencing and phylogenetic analysis. In addition, sequences of HCMV strains AF1, U8, U11, VR1814, and its cell culture adapted derivates were included. Sequence analysis of gB yielded three genetic subtypes (gB type 1 (5 isolates), gB type 2 (12 isolates), and gB type 3 (5 Isolates)), whereas sequence analysis of UL144 showed a greater diversity (7 isolates type 1A, 2 isolates type 1C, 7 isolates type 2, and 3 isolates type 3). In contrast, the UL128, UL130, and UL131A genes of all low-passage isolates were highly conserved and showed no preferential clustering. Moreover, in HFF and RPE cells, all of our HCMV isolates replicated efficiently independently of their genetic subtype. In conclusion, beside a possible link between the gB subtype 2 and HCMV retinitis, our study found no direct evidence for a connection between UL144/UL128/UL130/UL131A genotypes and the incidence of HCMV retinitis in AIDS patients.

The multi-targeted kinase inhibitor sorafenib inhibits human cytomegalovirus replication.

Human cytomegalovirus (HCMV) is a major pathogen in immunocompromised individuals. Here, non-toxic concentrations of the anti-cancer kinase inhibitor sorafenib were shown to inhibit replication of different HCMV strains (including a ganciclovir-resistant strain) in different cell types. In contrast to established anti-HCMV drugs, sorafenib inhibited HCMV major immediate early promoter activity and HCMV immediate early antigen (IEA) expression. Sorafenib is known to inhibit Raf. Comparison of sorafenib with the MEK inhibitor U0126 suggested that sorafenib inhibits HCMV IEA expression through inhibition of Raf but independently of signaling through the Raf downstream kinase MEK 1/2. In concordance, siRNA-mediated depletion of Raf but not of MEK-reduced IEA expression. In conclusion, sorafenib diminished HCMV replication in clinically relevant concentrations and inhibited HCMV IEA expression, a pathophysiologically relevant event that is not affected by established anti-HCMV drugs. Moreover, we demonstrated for the first time that Raf activation is involved in HCMV IEA expression.

Oncomodulation by human cytomegalovirus: novel clinical findings open new roads.

The question whether human cytomegalovirus may affect cancer diseases has been discussed (very controversially) for decades. There are convinced believers and strict opponents of the idea that HCMV might be able to play a role in the course of cancer diseases. In parallel, the number of published reports on the topic is growing. Recently published and presented (Ranganathan P, Clark P, Kuo JS, Salamat S, Kalejta RF. A Survey of Human Cytomegalovirus Genomic Loci Present in Glioblastoma Multiforme Tissue Samples. 35th Annual International Herpes Workshop, Salt Lake City, 2010) data on HCMV detection in glioblastoma tissues and colocalisation of HCMV proteins with cellular proteins known to be relevant for glioblastoma progression motivated us to recapitulate the current state of evidence.

Prevalence- and gender-specific immune response to opportunistic infections in HIV-infected patients in Lesotho.

BACKGROUND: The objective of this study was to assess the seroprevalence of coinfecting viruses and Treponema pallidum (T. pallidum) in a cohort of 205 antiretrovirally treated HIV-infected individuals (152 females and 53 males, aged: 19-71 years) in rural Lesotho. Furthermore agent-specific immune responses were investigated by analyzing antibody titers against herpes simplex virus type 2 (HSV-2) and against T. pallidum. METHODS: Serum samples were tested by enzyme-linked immunosorbent assay for antibodies against HSV-2, cytomegalovirus, hepatitis A, B, and C viruses, and T. pallidum. RESULTS: Seroprevalences (95% confidence intervals) were found to be 100% (98.5%-100%) for anti-cytomegalovirus, 98.5% (95.7%-99.7%) for anti-hepatitis A virus, 35.5% (28.9%-42.6%) for anti-HBc, 5.5% (2.8%-9.6%) for hepatitis B surface antigen, and 0.5% (0.0%-2.8%) for anti-hepatitis C virus. Only 78.5% (72.2%-84.0%) were anti-HSV-2 positive and 29.0% (22.8%-35.8%) had antibodies against T. pallidum. Only anti-HSV-2 titers showed gender- and CD4 cell-count dependent differences: females with >500 CD4 cells/microL had an average anti-HSV-2 titer of 446 compared with males of 398 AU/mL (not significant), but in those with 250 to 500 CD4 cells/microL, there was a significant difference with a mean titer of 467 compared to 302 AU/mL in males (P = 0.001). CONCLUSIONS: A high seroprevalence of CMV, HAV, and HBV was found in both genders. One-third of the patients had been exposed to HBV and T. pallidum. The generally high HSV-2 prevalence showed gender- and CD4 cell count-dependent differences in HSV-2 antibody titer.

Hand, foot and mouth disease: seroprevalence of Coxsackie A16 and Enterovirus 71 in Germany.

Coxsackie A16 (CA16) and Enterovirus 71 (EV71) are members of the picornaviridae family and are associated with hand, foot and mouth disease (HFMD), in rare cases also to acute neurological diseases. HFMD outbreaks have been reported from many parts of the world, especially Southeast Asia. The objective of the study was to analyze CA16 and EV71 seroepidemiologically in the population of Frankfurt/M., Germany. A total of 696 individuals (349 males and 347 females, divided into seven different age groups, 1-4, 5-9, 10-14, 15-19, 20-39, 40-59 and >60 years) were tested for serum antibodies against CA16 and EV71 by the use of a microneutralization test. Sera were collected at the Frankfurt university hospital from patients suffering from other diseases between March and September 2006. CA16 and EV71 infections were observed to be widely present in the population. The age-adjusted seroprevalence for individuals >or=1 year was found to be 62.9% for CA16 and 42.8% for EV71 without a gender-specific significant difference. Only 12.0 and 27.0% of the children aged 1-4 had antibodies to EV71 and CA16, respectively - indicating that 88 and 73% of the children in this age group were susceptible to the infection. A total of 213 individuals (30.6%) was seropositive for both viruses, 303 (43.5%) showed neutralizing antibodies (NtAb) to at least one of the two viruses. A total of 180 individuals (25.9%) revealed no antibodies. High CA16 and EV71 antibody titers were found especially in the age group of the 10- to 14-year-olds, without gender-specific difference. The seroprevalence study demonstrates a common spread of CA16 and EV71 in Germany, but a relatively high susceptibility of the younger population to CA16 and EV71. Obviously, the manifestation rate, i.e., distinct disease of these infections is low.

Epidemiology of human cytomegalovirus (HCMV) in an urban region of Germany: what has changed?

Since the dynamics of transmission of human cytomegalovirus (HCMV) have not been clarified yet, we assessed a possible change in HCMV seroprevalence in Frankfurt am Main, Germany during the past twenty years and tried to detect variables with an impact on epidemiology. Between 1/1/1988 and 10/15/2008, a total of 54443 serum samples were collected for routine diagnostics and analyzed using Enzygnost Anti HCMV-IgG enzyme immunoassay (Siemens/Dade Behring, Marburg, Germany). Two decades, 1/1/1988-12/31/1997 and 1/1/1998-10/15/2008, and several groups (type of health insurance, gender, age, HIV-status) were evaluated to assess changes in seroprevalence. Regarding both decades, the overall age-adjusted prevalence of HIV-negative patients dropped from 63.70% (confidence interval (CI) 95% 63.15-64.25) to 57.25% (CI 95% 56.57-57.93; P < 0.0001). Private health insurance (PHI) patients showed significant lower HCMV seroprevalences than members of obligatory health insurances (OHI) in both decades (1988-1997: PHI = 55.79%, OHI = 64.27%; P < 0.0001; 1998-1908: PHI = 47.02%, OHI = 58.74%; P < 0.0001). Furthermore, comparing the two decades, there was generally a gender-specific statistically significant decrease in HCMV seroprevalence for males (63.54-55.54%) and females (63.83-58.73%) as well as for members of PHI and OHI (PHI males: 57.59% to 47.19%, PHI females 54.10-46.80%; OHI males: 64.00-57.06%, OHI females 64.50-60.11%). Also, while female HIV-positive patients showed significant difference in HCMV seroprevalence between the two decades (83.17 and 87.80%, P = 0.023), there was no significant difference in male patients with HIV (88.76 and 87.32% in the first and second decade, respectively (P = 0.196). The cumulative HCMV prevalence of all HIV-negative patients tested in the past 20 years demonstrates a biphasic, age-related rise of HCMV seroprevalence throughout all age-groups. The seroprevalence of HCMV has declined between 1988-1997 and 1998-2008 in Frankfurt am Main, Germany. The decline varied between different age-groups. HCMV prevalence correlates with the type of health insurance, gender, age, and HIV-status.

Tumor cells infected with oncolytic influenza A virus prime natural killer cells for lysis of resistant tumor cells.

Tumor resistance to lysis by resting natural killer (NK) cells may be overcome by priming of NK cells with cytokines or by binding of NK activating receptors to ligands expressed on target cells. In this study, major histocompatibility complex class I (MHC-I)-negative LNCaP and MHC-I-positive DU145 cells were infected with genetically modified influenza A virus lacking the non-structural gene 1 (NS1 IAV). The cells were used to investigate the influence of NS1 IAV infection on NK cell lysis of tumor cells as well as to prime NK cells for lysis of LNCaP and DU145 cells. While LNCaP cells infected with DeltaNS1 IAV showed enhanced lysis when compared with mock-infected cells (93% +/- 1.47 vs. 52% +/- 0.74), both mock-infected and DeltaNS1 IAV-infected DU145 cells were resistant to NK cell lysis. Moreover, NK cells primed with DeltaNS1 IAV-infected LNCaP/DU145 cells effectively lysed resistant DU145 and sensitive LNCaP cells to a greater extent than NK cells primed with mock-infected LNCaP/DU145 or non-primed NK cells. Also, NK cell priming with DeltaNS1 IAV-infected tumor cells enhanced extracellular signal-regulated kinase phosphorylation and increased granule release in NK cells. The increased granule release was specifically mediated by NKp46, which eventually potentiated NK cells primed with DeltaNS1 IAV-infected tumor cells to overcome the inhibitory effects posed by MHC-I expression on DU145 cells. These findings show that in addition to direct lytic activity of NK cells, DeltaNS1 IAV may influence anti-tumoral responses by priming NK cells.

Glycyrrhizin inhibits highly pathogenic H5N1 influenza A virus-induced pro-inflammatory cytokine and chemokine expression in human macrophages.

Hypercytokinaemia is thought to contribute to highly pathogenic H5N1 influenza A virus disease. Glycyrrhizin is known to exert immunomodulatory and anti-inflammatory effects and therefore a candidate drug for the control of H5N1-induced pro-inflammatory gene expression. Here, the effects of an approved parenteral glycyrrhizin preparation were investigated on H5N1 virus replication, H5N1-induced pro-inflammatory responses, and H5N1-induced apoptosis in human monocyte-derived macrophages. Glycyrrhizin 100 µg/ml, a therapeutically achievable concentration, impaired H5N1-induced production of CXCL10, interleukin 6, and CCL5 and inhibited H5N1-induced apoptosis but did not interfere with H5N1 replication. Global inhibition of immune responses may result in the loss of control of virus replication by cytotoxic immune cells including natural killer cells and cytotoxic CD8(+) T-lymphocytes. Notably, glycyrrhizin concentrations that inhibited H5N1-induced pro-inflammatory gene expression did not affect cytolytic activity of natural killer cells. Since H5N1-induced hypercytokinaemia is considered to play an important role within H5N1 pathogenesis, glycyrrhizin may complement the arsenal of potential drugs for the treatment of H5N1 disease.

Of chickens and men: avian influenza in humans.

Highly pathogenic H5N1 avian influenza virus can infect humans and is currently the most deadly influenza virus that has crossed the species barrier. As of December 2007, the spread of H5N1 virus from human to human has been rare. Nobody can predict if H5N1 may cause a pandemic. However, the number of human cases is continuously increasing and changes in virulence and epidemiology have been detected. There are specific pathogenic features of H5N1 infection. In contrast to human-adapted influenza A strains, H5N1 preferentially infects cells of the lower respiratory tract and may spread to tissues outside the respiratory tract in humans. Moreover, H5N1 replication is prolonged in target organs and results in higher viral loads and increased tissue damage. These features will have to be considered for therapeutic protocols for H5N1 infection in humans. Rapid genetic and antigenic changes observed in H5N1 virus isolates represent a challenge for the development of vaccines. In the present review, current knowledge about epidemiology, virulence factors and pathology of H5N1 infections in humans are summarised and discussed. Moreover, the possible roles of anti-influenza drugs in the pandemic situation as well as the development of effective vaccines are subject of this overview.

[S2k guideline for the diagnosis and therapy of zoster and post-zoster neuralgia]. / S2k-Leitlinie zur Diagnostik und Therapie des Zoster und der Postzosterneuralgie.

This guideline is aimed at registrars and consultants in dermatology, ophthalmology, ENT, pediatrics, neurology, virology as well as infectiology, anaesthesia and generell medicine as well as policymakers and payers and purchasers of care. It was developed by dermatologists, virologists, ophthalmologists, ENT physicians, neurologists, pediatrician and anesthetists using a formal consensus process (S2k).The guideline provides an overview of clinical and molecular diagnostics as well as antigen detection, antibody culture and viral culture. Diagnostic special situations and complicated courses of the disease are also considered. The antiviral therapy of zoster and postzoster neuralgia is presented in general and for special situations. Detailed information on the treatment of pain is mentioned and presented in an overview. Likewise, the local therapeutic measures are discussed.

First transmission of human immunodeficiency virus Type 1 by a cellular blood product after mandatory nucleic acid screening in Germany.

BACKGROUND: In February 2007, a 63-year-old man underwent surgery. Retrospective testing with nucleic acid testing (NAT) showed that the patient was human immunodeficiency virus Type 1 (HIV-1) positive 10 days after transfusion. The transfusion-transmitted infection had been identified by a donor-related lookback started in April 2007 after anti-HIV seroconversion. METHODS: Sequence analysis was performed in the gag-pol region as well as in the V3 loop env region. Archived plasma from the transmitting donation was investigated for the individual-donation NAT with the Roche COBAS AmpliPrep/COBAS TaqMan HIV-1 test (Roche CAP/CTM HIV-1 test) and for HIV antigen/antibody combination testing (Abbott Architect). Additional testing was done on the donor's follow-up sample and on the recipient's sample. RESULTS: The Roche CAP/CTM HIV-1 test failed to detect viral RNA by minipool NAT in the index donation (April 2007) as well as in the donation that caused the infection (January 2007). Phylogenetic analysis showed a very high genetic similarity among viral sequences from both donor and recipient, proving the HIV-1 transmission by sequence data. CONCLUSION: This case represents the first documented HIV-1 transmission by transfusion of red blood cells after mandatory introduction of HIV-1 NAT for blood screening in Germany. Low viral load and mismatches in the primer/probe region might explain the detection failure of the NAT screening assay. A certain risk remains that new virus variants contain mutations at positions critical for amplification or detection of viral genomes. An option to reduce the risk of a detection failure by NAT is the simultaneous use of several conserved regions as amplification targets.

Human immunodeficiency virus: 25 years of diagnostic and therapeutic strategies and their impact on hepatitis B and C virus.

The human immunodeficiency virus (HIV) had spread unrecognized in the human population as sexually transmitted disease and was finally identified by its disease AIDS in 1981. Even after the isolation of the causative agent in 1983, the burden and death rate of AIDS accelerated worldwide especially in young people despite the confection of new drugs capable to inhibit virus replication since 1997. However, at least in industrialised countries, this trend could be reversed by the introduction of combination therapy strategies. The design of new drugs is on going; besides the inhibition of the three enzymes of HIV for replication and maturation (reverse transcriptase, integrase and protease), further drugs inhibits fusion of viral and cellular membranes and virus maturation. On the other hand, viral diagnostics had been considerably improved since the emergence of HIV. There was a need to identify infected people correctly, to follow up the course of immune reconstitution of patients by measuring viral load and CD4 cells, and to analyse drug escape mutations leading to drug resistance. Both the development of drugs and the refined diagnostics have been transferred to the treatment of patients infected with hepatitis B virus (HBV) and hepatitis C virus (HCV). This progress is not completed; there are beneficial aspects in the response of the scientific community to the HIV burden for the management of other viral diseases. These aspects are described in this contribution. Further aspects as handling a stigmatising disease, education of self-responsiveness within sexual relationships, and ways for confection of a protective vaccine are not covered.