A study on viral CNS inflammation beyond herpes encephalitis.

The early diagnosis of herpes simplex virus encephalitis (HSVE) enables induction of antiviral therapy in this potentially life-threatening disease. The study aimed to determine clinical findings including cerebrospinal fluid (CSF) data and MRI imaging in HSVE patients and to identify features distinguishing HSVE from encephalitis of other viral etiologies. We retrospectively reviewed consecutive patients who were diagnosed with viral encephalitis between 2000 and 2014 at the University Hospital Halle. Forty-nine patients with viral encephalitis were identified. A viral etiology could be confirmed by PCR or antibody testing in 22/49 (44.9 %) of patients (15 (30.6 %) HSV, 5 (10.2 %) VZV, 2 (4.1 %) EBV). In HSVE, typical findings were focal slowing in electroencephalophy (EEG) (80 %, p = 0.021) and presence of cortical (86.7 %, p = 0.030) lesions in MRI. Restricted diffusion was particularly helpful in detection of early signal abnormalities in HSVE (p = 0.014). In 27/49 (55.1 %) of patients, no causative agent could be elucidated. In these patients, 15/27 (55.6 %) experienced a rather "benign" disease course with no MRI pathology despite initially HSVE mimicking clinical picture. However, CSF was significantly different showing a higher amount of granulocytes and activated lymphocytes. The remaining 12/27 (44.4 %) patients developed MRI changes consistent with encephalitis, in 4 of these patients, disease course was fatal. Beside PCR-based serology as standard procedure, MRI including diffusion-weighted images and EEG represent additional tools in early HSVE diagnosis. CSF cytology might be particularly supportive in differentiating likely benign forms of encephalitis.

Endovascular treatment using woven stents for ruptured vertebral artery dissecting aneurysm induced by varicella zoster virus: case report.

Subarachnoid hemorrhage with ruptured cerebral artery dissection caused by varicella zoster (VZ) vasculopathy is rare. We report a rare case of vertebral artery (VA) dissection induced by VZ virus, successfully treated with stent-assisted coil embolization and systemic anti viral medication, on six month follow-up cerebral angiography with the review of literatures.

Association between emphysema and other pulmonary computed tomography patterns in primary varicella pneumonia: A retrospective cohort study.

This study aims to evaluate chest computed tomography (CT) findings in hospital patients with primary varicella pneumonia (PVP). We retrospectively analyzed CT images of 77 PVP patients using 3D Slicer, an open-source software, to model lesions and lungs. This retrospective cohort study was approved by the Institutional Review Board (Ethical Committee, Renmin Hospital, Hubei University of Medicine, Shiyan, China) and waived the requirement for written informed consent. The left lung was more frequently and severely affected in PVP, with significant differences between the 2 groups in CT involvement percentage of each lung region, except for total lung inflation. Group A showed higher median percentages of lung collapse compared to Group B. The extent of left lung involvement is a critical predictor of emphysema in PVP patients, highlighting the importance of also monitoring the right lung for more severe cases. Lower emphysema levels correspond to more collapsed and infiltrated lung segments, suggesting a more severe clinical presentation.

Prenatal sonographic diagnosis of congenital varicella syndrome.

Congenital varicella syndrome is a rare disorder occurring in less than 1% of maternal varicella during early pregnancy but is associated with high fetal morbidity and mortality. This case report aimed to describe the sonographic features of congenital varicella syndrome following maternal varicella. Well-documented maternal chicken pox was made at 12 weeks of gestation and prenatal ultrasound was performed at 16 weeks. Striking sonographic features included hydropic changes and disseminated calcifications in multiple organs, especially liver and myocardium. Elective termination of pregnancy was done at 17 weeks. The presence of disseminated calcifications could suggest the diagnosis of congenital varicella syndrome.

Expanding the clinical and neuroimaging features of post-varicella arteriopathy of childhood.

OBJECTIVE: Post-varicella arterial ischemic stroke (AIS) is considered an uncommon cause of pediatric stroke that is considered a self-limiting, monophasic disease. However, in a subset of patients, disease recurs; the prevalence of vasculopathy or AIS recurrence, severity of clinical outcomes, and standardized therapies have not been well characterized. Herein, we determined the clinical-neuroradiological features, long-term evolution, and relationship between acute phase treatment and vasculopathy recurrence in a pediatric population with post-varicella AIS. METHODS: Clinical, laboratory, and neuroradiological features of 22 children with post-varicella AIS between 2010 and 2019 (16 males, mean age at stroke 4 years, range 1.7-10) were reviewed. Statistical analyses were performed using χ2 and Fisher exact tests. RESULTS: Of the 22 cases, mean time from varicella to stroke was 4.5 months with 3 cases presenting more than 12 months after rash; 21 (95%) were not vaccinated for varicella; 3 (13.6%) had posterior circulation involvement; and 5 (22.7%) had AIS or vasculopathy recurrence, of which 4 recurred 6.1 months to 2.8 years after initial clinical onset. Recurrence was associated with lack of antiviral treatment during the first episode (p = 0.02). CONCLUSIONS: Post-varicella AIS can occur months after rash making diagnosis challenging. Because recurrent vasculopathy was seen predominantly in cases not treated with antiviral therapy during initial presentation, it is important to rapidly diagnose post-varicella AIS through clinical criteria and/or virological testing then treat with antivirals to prevent recurrence.

Congenital varicella syndrome: still a problem?

A woman contracted chickenpox in the 12th week of gestation. Her general practitioner and later the consultant obstetrician warned her about the small risk of giving birth to a disabled child. She decided to continue the pregnancy without undergoing invasive tests to diagnose fetal intrauterine infection. Symptoms of congenital varicella syndrome (CVS) were detected by ultrasound in the 29th and 34th weeks of gestation. On admission to hospital, the baby was not considered infectious and was not isolated because polymerase chain reaction analysis to detect varicella zoster virus (VZV) DNA in the blood, cerebrospinal fluid, saliva, skin scrapings and feces gave negative results. He was also not separated from his mother. The mother was without clinical complications. Varicella during pregnancy may result in VZV transmission to the fetus or newborn. Intrauterine VZV infection in the first 28 weeks of gestation may result in CVS with limb deformities, brain abnormalities and mental retardation. Usually the newborn is not infectious, and therapy and isolation are unnecessary. When the mother catches the infection in the second trimester, the newborn may manifest shingles in the first 2 years of life. A maternal rash erupting 5 days before to 2 days after delivery is frequently associated with clinically severe varicella in the newborn, leading to high mortality if untreated. Then the newborn is infectious and must be isolated. This case report underlines the need for expert medical counseling for women who contract chickenpox at any time during pregnancy. It also underlines the importance of immunizing susceptible women of childbearing age before they become pregnant.

[Radiograph patterns in herpes simples virus I pneumonia in the adult]. / Hallazgos radiológicos de la neumonía por virus herpes simple I en el adulto.

The aim of this study is to describe epidemiology, patogénesis, pulmonary manifestations and Rx findings in adult patients with varicella pneumonia (VP). Four patients were studied. The diagnosis was established by clinical and radiologic criteria. All had fever , esanthem, 3 cough, 2 dyspnea. Chest X-ray showed interstitial micronodular pattern at bases. 1 case developed airspace consolidation by Staphylococcus aureus. 2 were admitted to ICU. The four received IV acyclovir. We concluded that adults patients with VP usually show nodular infiltrates, with favourable course.

CT appearance of Varicella Zoster lesions in liver and spleen in an immunocompetent patient.

An adult patient presented with vesicular rash and abdominal pain of 5 days duration. His initial laboratory results showed elevated liver enzymes. A contrast enhanced CT scan demonstrated multiple small hypodense nodules in liver and spleen. His serum was reactive for Varicella Zoster IgM. Patient was treated with intravenous Acyclovir for 5 days and followed up with oral tablets for 2 weeks. At 3 weeks, CT scan showed resolution of hypodense nodules and his serum liver enzymes returned to normal at 6 weeks. Patient is on follow up and asymptomatic for 2 years. The CT appearances of nodules and their resolution following specific antiviral therapy are useful in diagnosis and in follow up of disseminated Varicella Zoster.

Varicella pneumonia in immunocompetent adults: report of two cases, with emphasis on high-resolution computed tomography findings.

We report two cases of varicella pneumonia in immunocompetent patients, with emphasis on high-resolution computer tomography manifestations. The predominant findings consisted of multiple bilateral nodules, ranging from 1-10 mm in diameter, with or without a surrounding halo of ground-glass attenuation. Other findings include ground-glass opacities, focal areas of consolidation and small pleural effusions.

[Congenital varicella: limits of prenatal diagnosis]. / La varicelle congénitale: les limites du diagnostic prénatal.

INTRODUCTION: Primary varicella infection during pregnancy is uncommon. Fetal varicella syndrome is unusual when varicella occurs after 20 weeks of gestation. CASE REPORT: A mother contracted chicken pox at 21 weeks and 3 days of gestation. Monthly monitoring was assured by the center for prenatal diagnosis, starting from 23 weeks. At 36 weeks, foetal echography detected liver calcifications, without other lesions. At 38 weeks, the patient went into spontaneous labour and delivered a male baby. The baby presented cicatricial skin lesions all over the body and scalp. The cerebral scan detected calcifications and a bilateral chorioretinitis was noticed. At 12 months, the infant had delayed psychomotor acquisitions, a cerebral cortical atrophy and blindness. CONCLUSION: The presence of fetal liver calcifications after chicken pox in the mother is a seldom reported sign. In our observation, liver calcifications were the single sign of a severe fetal damage.

Corticosteroids in life-threatening varicella pneumonia.

BACKGROUND: Varicella pneumonia that results in respiratory failure or progresses to the institution of mechanical ventilation carries a significant morbidity and mortality despite intensive respiratory support and antiviral therapy. There has been no reported study of the role of corticosteroids in life-threatening varicella pneumonia. DESIGN AND METHODS: This was an uncontrolled retrospective and prospective study of all adult patients with a diagnosis of varicella pneumonia who were admitted to the ICUs of the Johannesburg group of academic hospitals in South Africa between 1980 and 1996. Patient demographics, clinical and laboratory features, necessity for mechanical ventilation, and complications were reviewed. The outcome and therapy of varicella pneumonia was evaluated with particular reference to the use of corticosteroids. Patients with comorbid disease and those already taking immunosuppressive agents were excluded. Key endpoints included length of ICU and hospital stay and mortality. MEASUREMENTS AND RESULTS: Fifteen adult patients were evaluated, six of whom received corticosteroids in addition to antiviral and supportive therapy. These six patients demonstrated a clinically significant therapeutic response. They had significantly shorter hospital (median difference, 10 days; p<0.006) and ICU (median difference, 8 days; p=0.008) stays and there was no mortality, despite the fact that they were admitted to the ICU with significantly lower median ratios between PaO2 and fraction of inspired oxygen than those patients (n=9) who did not receive corticosteroid therapy (86.5 vs 129.5; p=0.045). CONCLUSION: When used in addition to appropriate supportive care and early institution of antiviral therapy, corticosteroids appear to be of value in the treatment of previously well patients with life-threatening varicella pneumonia. The observations presented in this study are important and should form the basis for a randomized controlled trial, as no other relevant studies or guidelines are available.

Varicella pneumonitis: clinical presentation and experience with acyclovir treatment in immunocompetent adults.

OBJECTIVE: Cases of varicella pneumonitis were reviewed to examine the effects of acyclovir therapy on outcome. METHODS: A retrospective chart review was done of all admissions of adults to two hospitals, between 1985 and 1995, because of complications of chickenpox. RESULTS: Fifteen patients were hospitalized for varicella pneumonitis during this period. No patient had a history of chickenpox as a child; all had a recent history (within 2-4 weeks prior to admission) of exposure to chickenpox in their family or neighborhood and developed respiratory symptoms 1 to 4 days after the appearance of the rash. Twelve patients (80%) had a history of cigarette smoking, and seven patients had a platelet count below the normal range. All patients were treated with intravenous acyclovir within 24 hours of admission, and all but one survived and were discharged from the hospital without comorbid conditions. The one mortality was attributed to bacterial superinfection. CONCLUSIONS: Acyclovir treatment may be of benefit for varicella pneumonitis, but no controlled trial has been performed to definitively answer this question.

Varicella with delayed hemiplegia.

We report 4 children who developed acute hemiplegia 7 weeks to 4 months after varicella infection. In 2 patients, carotid angiography demonstrated segmental narrowing and occlusion of the middle cerebral artery. Their clinical and angiographic features were similar to those associated with contralateral hemiplegia after herpes zoster ophthalmicus, the pathogenesis of which comprises cerebral angiitis due to varicella zoster viral infection. We believe that our patients had the same pathogenesis. In a survey of infectious diseases in our region, the frequency of varicella with delayed hemiparesis was roughly 1:6,500 varicella patients.

Case report: the pulmonary lesions of chickenpox pneumonia--revisited.

Infection with the varicella zoster virus can include pulmonary complications. These may cause such minor symptomatology as to go unrecognized and unimaged. We describe a case of active chickenpox pneumonia that mimicked pulmonary metastases and was detected incidentally by means of computed tomography in a man with a past history of testicular teratoma.

[Fatal varicella pneumonia unresponsive to acyclovir therapy in a child with a malignancy]. / Malignansili bir çocukta acyclovir tedavisine cevap vermeyen fatal su çiçegi pnömonisi.

Acyclovir has become the drug of choice for prevention of visceral dissemination of Varicella-zoster virus infections in immunocompromised individuals. This article describes a 6-year-old girl taking cytotoxic therapy and radiotherapy for treatment of Hodgkin lymphoma who developed cutaneous varicella infection. Despite the early administration of acyclovir a fatal varicella pneumonia occurred and she died on the 4th day of hospitalization. Since the resistance is inducible, the increase of unresponsiveness to acyclovir in immunocompromised hosts with varicella infection is a potential risk that can cause to increase in fatalities in these patients.

[Varicella pneumonia with multiple nodular shadows after allogeneic bone marrow transplantation in chronic myeloid leukemia].

A 30-year-female with chronic myelogenous leukemia received allogeneic bone marrow transplantation (BMT). On day 104, low-grade fever, cough, and general malaise developed, resulting in hospitalization 10 days later. Chest X ray revealed diffuse infitrates, suggesting cytomegalovirus interstitial pneumonia. Ganciclovir (DHPG) was given daily and all symptoms disappeared three days later. However, a very few vesicular lesions appeared on her trunk and her two children had chickenpox at that time. Chest CT was taken and disclosed diffuse nodular shadows. Clinical course and chest CT suggested varicella pneumonia. DHPG administration was stopped and acyclovir PO started to be given. She was discharged in excellent condition. In this report, we show a rare case of varicella pneumonia after allogeneic BMT and efficacy of DHPG for the treatment of varicella pneumonia.

[Abnormal fetal ultrasound findings after maternal chickenpox infection]. / Abnorme UL-fund hos fosteret efter maternel skoldkoppeinfektion.

Chicken pox infection in the first and early in the second trimester can lead to intrauterine infection and a 2% risk of developing congenital varicella syndrome (CVS). CVS is characterized by one or more of the following malformations: hypoplasia of a limb, scarring of the skin, microcephaly, cataract, microophthalmia, cerebellar dysplasia, gastrointestinal malformations and urogenital malformations. Most of these malformations can be seen by ultrasound. Foetal viral infection can also lead to intrauterine growth retardation, polyhydramnios and hydrops foetalis. This paper is a review of the literature with the focus on ultrasound findings in CVS. The options for performing prenatal diagnostic tests and the consequences of maternal varicella zoster (chickenpox) for prenatal care are discussed.

[Three adults with mild varicella and bronchial mucosal lesions].

We encountered three adults with varicella and bronchial mucosal lesions. Respiratory symptoms were minimal in all three. Chest X-ray films showed bilateral, diffuse, small, nodular shadows. Small, elevated lesions with white plaque's were seen on the bronchial mucosa bronchoscopically. Transbronchial lung biopsy, bronchial mucosal biopsy, and bronchoalveolar lavage were also done. The lung-biopsy specimen showed infiltration of lymphocytes into the interstitial space: VZV antigen was found by immunohistochemical staining of the lesion in one case. Analysis of bronchoalveolar lavage fluid revealed abnormally low CD 4/8 ratios in three cases. These findings suggest a high incidence of respiratory complications, especially bronchial lesions, despite the lack of respiratory symptoms, in adults with varicella.

[Can outcome of varicella pneumonia be predicted in a non-immunosuppressed patient?]. / Peut-on prévoir l'évolution d'une pneumopathie varicelleuse chez un sujet non-immunodéprimé?

Varicella rarely occurs in the adult but can cause multi-organ complications. The most frequent (15 to 30% involve varicella pneumonia of unpredictable outcome. In the healthy adult, outcome can be favourable in 5 days or inversely lead to respiratory distress and death in 10 to 20% of the cases. An analysis of the published cases does not reveal any factor predicting unfavourable outcome. A register of varicella pneumonia would help identify potential predictive factors.