Varicella zoster virus reactivation after autologous SCT is a frequent event and associated with favorable outcome in myeloma patients.

The occurrence of varicella zoster virus (VZV) reactivation is increased after allogeneic transplantation, whereas limited data are available for herpes zoster (HZ) after autologous SCT (ASCT). We determined the incidence and the prognostic significance of HZ and its correlation with VZV serology in 191 consecutive myeloma patients undergoing high-dose melphalan chemotherapy with ASCT. We found that VZV reactivation occurred in 57 (30%) patients, in 8.5% during induction and in 21.5% after ASCT peaking at 8 months after ASCT. Disease burden due to HZ was assessed as high or rather high in 70% of the patients. By immune fluorescence and Serion Elisa VZV IgG assessment, 90.8% of all patients had specific anti-VZV antibodies at ASCT. Lower specific antibody titers at transplantation were observed in patients with HZ after ASCT than in those without reactivation (P=0.009). Finally, OS was better in myeloma patients with HZ after ASCT compared with patients without HZ (P=0.007). Our data indicate that VZV reactivation after ASCT is a frequent event carrying a significant disease burden and it is associated with improved survival. Low levels of specific VZV antibodies at ASCT suggest increased vulnerability for VZV reactivation.Bone Marrow Transplantation advance online publication, 19 January 2015; doi:10.1038/bmt.2014.290.

Reactivated and latent varicella-zoster virus in human dorsal root ganglia.

Ganglia obtained at autopsy were examined by in situ hybridization from one patient with zoster (also called herpes zoster or shingles), two varicella-zoster virus (VZV)-seropositive patients with clinical evidence of zoster, one VZV-seronegative child, and one fetus. Ganglia positive for VZV had a hybridization signal in both neuronal and nonneuronal satellite cells. Ganglia obtained from the fetus and from the seronegative infant were consistently negative for VZV. Two striking observations were evident regarding the presence of VZV DNA in ganglia obtained from the individual with zoster at the time of death. First, ganglia innervating the sites of reactivation and ganglia innervating adjacent sites yielded strongly positive signals in neurons and satellite cells, whereas ganglia from distant sites were rarely positive. Second, VZV DNA was found in both the nuclei and the cytoplasm of neurons innervating areas of zoster. However, in neurons innervating zoster-free areas, VZV DNA was found only in the nucleus of neurons and their supporting satellite cells. Immunohistochemistry with a fluorescent monoclonal antibody to the VZV glycoprotein gpI, a late virus protein, revealed a positive signal in the cytoplasm of ganglia with clinical evidence of reactivation. These results illustrate that both neuronal and satellite cells become latently infected following primary VZV infection. The presence of VZV DNA and gpI in the cytoplasm of neurons demonstrates productive infection following reactivation at the site of latency.

Facial sensibility of patients with trigeminal neuralgias

Objectives: Idiopathic trigeminal neuralgia (ITN) is an excruciating shock-like paroxysmal pain restricted to the trigeminal area of innervation, with discrete loss of sensibility (thermal, tactile and painful). Trigeminal postherpetic neuralgia (PHN) is a neuropathic pain at the trigeminal territory that persists after Herpes zoster infection, which also is associated to sensorial compromise. The objective of this study was to evaluate the somesthetic facial sensibility (pain, thermal and tactile) and to compare the findings between PHN and ITN. Methods: 18 patients with PHN and 26 patients with ITN were diagnosed by the IASP criteria. They were evaluated with a systematic approach, which included mechanical, thermal (cold and warm) and painful stimuli. Results: We found statistical significance at the ophthalmic branch of PHN in pain (p=0.001), tactile (p=0.002), cold (p=0.016) and warm (p=0.013); in ITN, the maxillary branch had higher threshold with pinpricks (p=0.016) and the mandibular branch had higher tactile threshold. Conclusions: The trigeminal area affected by the disease had the higher sensorial losses (ophthalmic branch in PHN and maxillary/mandibular branches in ITN). PHN patients had losses in large and small fibers; therefore, ITN patients had the losses mostly in large fibers, which support different peripheral neural mechanisms for these neuropathic diseases. (C) 2010 Elsevier B.V. All rights reserved.

Wegener`s granulomatosis: experience from a Brazilian tertiary center

Most epidemiological studies with Wegener`s granulomatosis (WG) patients are based on populations from the Northern hemisphere, whereas very few studies have been conducted in Southern hemisphere populations, particularly from South America. The authors performed a large retrospective, demographic study including clinical and laboratory profiles of 134 consecutive WG patients seen at one Brazilian center from 1999 to 2009. Mean age at initial WG diagnosis was 43.4 +/- 15.5 years, and mean disease duration was 8.6 +/- 6.6 years. Sixty-four (47.8%) patients were male and a total of 113 (84.3%) subjects were white. Ear/nose/throat involvement occurred in 85.8%. The classic lung and renal involvement were observed in 77.6% and 75.4%, respectively, followed by ocular (35.8%), musculoskeletal (33.4%), cutaneous (29.1%), neurological (20.1%), cardiac (11.2%), and genitourinary involvement in 2.2% of cases. Cytoplasmic pattern-antineutrophil cytoplasmic antibody was detected in 83 (61.9%) cases. Ten (7.5%) individuals presented limited forms of WG. Classic therapy with corticosteroids and cyclophosphamide was used in 97 cases (72.4%). There were no cases of tuberculosis or Pneumocystis jiroveci pneumonia, but cutaneous herpes zoster occurred in eight (6.0%) individuals. There were 29 deaths (21.6%). Eighteen patients died of septic shock (mainly bacterial pneumonia), whereas four died of alveolar hemorrhage, four of myocardial infarction, and three of other causes. In summary, our data from a very large retrospective and descriptive study mirrored the main clinical features of WG described in other countries, demonstrating that they may serve as a reference for South American populations.

Irreversible blindness in juvenile systemic lupus erythematosus

Blindness caused by severe vasculitis or uveitis is rare in juvenile systemic lupus erythematosus (JSLE) patients. In a 27-year period, 5367 patients were followed at our Paediatric Rheumatology Division and 263 (4.9%) patients had JSLE (American College of Rheumatology criteria). Of note, two (0.8%) of them had irreversible blindness. One of them presented with cutaneous vasculitis and malar rash, associated with pain and redness in both eyes, impairment of visual acuity due to iridocyclitis and severe retinal vasculitis with haemorrhage. Another patient had peripheral polyneuropathy of the four limbs and received immunosuppressive drugs. Three weeks later, she developed diffuse herpes zoster associated with acute blindness due to bilateral retinal necrotizing vasculitis compatible with varicella zoster virus ocular infection. Despite prompt treatment, both patients suffered rapid irreversible blindness. In conclusion, irreversible blindness due to retinal vasculitis and/or uveitis is a rare and severe lupus manifestation, particularly associated with disease activity and viral infection. Lupus (2011) 20, 95-97.

Cost-effectiveness analysis of universal childhood vaccination against varicella in Brazil

This study conducts a cost-effectiveness analysis of a childhood universal varicella vaccination program in Brazil. An age and time-dependent dynamic model was developed to estimate the incidence of varicella for 30 years. Assuming a single-dose schedule; vaccine efficacy of 85% and coverage of 80%, the program could prevent 74,422,058 cases and 2905 deaths. It would cost R$ 3,178,396,110 and save R$ 660,076,410 to the society and R$ 365,602,305 to the healthcare system. The program is cost-effective (R$ 14,749 and R$ 16,582 per life-year saved under the societal and the healthcare system`s perspective, respectively). The program`s cost-effectiveness is highly sensitive to the vaccine price and number of doses. (C) 2008 Elsevier Ltd. All rights reserved.

Oral manifestations after immune reconstitution in HIV patients on HAART

In order to verify possible association between immune reconstitution inflammatory syndrome (IRIS) and oral manifestations (OMs), we selected AIDS patients who had low CD4 count before the initiation of highly active antiretroviral therapy (HAART) and who returned three months later for therapy evaluation. The oral lesions observed three months after the initiation of HAART were evaluated and associated with the type of antiretroviral therapy (ART), CD4 count and HIV-RNA load levels (before and three months after HAART initiation). A total of 105 patients matched the selected criteria. Immune reconstitution (IR) was identified in 35.2%. Among these patients, the mean CD4 cell count rose from 105.97 to 330.29 and the mean viral load dropped from 168.005 (log 5.22) to 21.852 (log 4.33). There was no significant difference in age (P=0.78), sex (P=0.41) or previous history of ART (P=0.55) between IR and non-IR patients. In the IR group, the most common OM was. parotid enlargement (57.14%) (P=0.619), whereas in the non-IR group candidiasis (46.15%) was the most common OM. The results of our study suggest that the parotid gland enlargement found in the studied population might be an IRIS event, as it was found in patients with IR three months after the initiation of HAART.

Infection and childhood leukemia: review of evidence

OBJECTIVE : To analyze studies that evaluated the role of infections as well as indirect measures of exposure to infection in the risk of childhood leukemia, particularly acute lymphoblastic leukemia. METHODS : A search in Medline, Lilacs, and SciELO scientific publication databases initially using the descriptors “childhood leukemia” and “infection” and later searching for the words “childhood leukemia” and “maternal infection or disease” or “breastfeeding” or “daycare attendance” or “vaccination” resulted in 62 publications that met the following inclusion criteria: subject aged ≤ 15 years; specific analysis of cases diagnosed with acute lymphoblastic leukemia or total leukemia; exposure assessment of mothers’ or infants’ to infections (or proxy of infection), and risk of leukemia. RESULTS : Overall, 23 studies that assessed infections in children support the hypothesis that occurrence of infection during early childhood reduces the risk of leukemia, but there are disagreements within and between studies. The evaluation of exposure to infection by indirect measures showed evidence of reduced risk of leukemia associated mainly with daycare attendance. More than 50.0% of the 16 studies that assessed maternal exposure to infection observed increased risk of leukemia associated with episodes of influenza, pneumonia, chickenpox, herpes zoster, lower genital tract infection, skin disease, sexually transmitted diseases, Epstein-Barr virus, and Helicobacter pylori . CONCLUSIONS : Although no specific infectious agent has been identified, scientific evidence suggests that exposure to infections has some effect on childhood leukemia etiology.

Alterações nucleares das cellulas do figado nas infecções de Macacus Rhesus e M. Cynomolgus pelo virus da febre amarella

No figado de um Macacus rhesus inoculado por BEAUREPAIRE ARAGÃO com sangue deum caso benigno de febre amarella e no qual elle descreveu symptomas e lesões typicas semelhantes ás obidas por STOKES, BAUER e HUDSON pela inoculação com o virus africano no mesmo animal, encontrámos alterações nucleares da mesma natureza das assignaladas, no herpes zoster, herpes symptomatico, varicella e virus III do coelho e descriptas ora sob o nome de "inclusões acidophilas intranucleares" (LIPSCHÜTZ, GOODPASTURE), ora sob o de "degeneração oxychromatica" (LAUDA e LUGER). Alterações nucleares semelhantes da cellula hepatica encontrámos, posteriormente em 13 M. rhesus e 2 M. cynomolgus inoculados com e virus brasileiro da febre amarella o qual fôra isolado independentemente por BEAUREPAIRE ARAGÂO e depois por A. MARQUES DA CUNHA e J. MUNIZ de dois casos benignos de febre amarella, tendo sido um dos macacos injectado directamente com o sangue do doente; dois macacos foram inoculados com Aedes aegypti infectados em homem e em macaco; os animais foram anímaes empregados em passagens em serie do virus pelo macaco, e talvez esse facto explique até certo ponto, as notaveis differenças por vezes encontradas nas alterações histopathologicas do figado, visto como, em condições naturaes, o virus nunca passa directamente de homem para homem. A intensidade com que se apresenta a degeneração oxychromatica de modo algum está na dependencia das alterações do conteúdo gorduroso, necrose e necrobiose encontradas; em um caso, ella era a unica alteração presente no figado, sendo então particularmente intensa. As inclusões acidophilas intranucleares (degeneração oxychromatica) não foram encontradas em diversos M. rhesus não inoculados e mortos por causas obscuras; no entanto, em taes figados eram presentes infiltração e degeneração gordurosas associadas a alterações de necrose e necrobiose. Alguns estadios (figuras intranucleares "em borboleta" e "em ameba", v. fig. g e h, Est. colorida) sendo abundantes, facilitam, em virtude de sua configuração especial, o reconhecimento da degeneração oxychromatica em córtes feitos segundo uma technica rapida (pequenos fragmentos de figado fixados em formol aquecido a 60°C.-trinta minutos, córtes em congelação, hematoxylina, eosina, alcool absoluto, phenol-xylol-creosoto, xylol, balsamo), não tendo, afóra isso, importancia especial. Ao passo que a degeneração e infiltração gordurosa, bem como a necrose e a necrobiose da cellula hepatica apresentam variações consideraveis em sua intensidade de um para outro animal em uma passagem em serie não interrompida do virus pelo M. rhesus, chegando mesmo a faltar interamente em dois animaes cujo figado, no entanto, mostrou-se capaz de reproduzir symptomas e lesões typicas na passagem seguinte, as inclusões acidophilas intranucleares (degeneração oxychromatica), de regra, se encontram com muito maior regularidade...

Intraocular penetration of penciclovir after oral administration of famciclovir: a population pharmacokinetic model.

OBJECTIVES: We developed a population model that describes the ocular penetration and pharmacokinetics of penciclovir in human aqueous humour and plasma after oral administration of famciclovir. METHODS: Fifty-three patients undergoing cataract surgery received a single oral dose of 500 mg of famciclovir prior to surgery. Concentrations of penciclovir in both plasma and aqueous humour were measured by HPLC with fluorescence detection. Concentrations in plasma and aqueous humour were fitted using a two-compartment model (NONMEM software). Inter-individual and intra-individual variabilities were quantified and the influence of demographics and physiopathological and environmental variables on penciclovir pharmacokinetics was explored. RESULTS: Drug concentrations were fitted using a two-compartment, open model with first-order transfer rates between plasma and aqueous humour compartments. Among tested covariates, creatinine clearance, co-intake of angiotensin-converting enzyme inhibitors and body weight significantly influenced penciclovir pharmacokinetics. Plasma clearance was 22.8 ± 9.1 L/h and clearance from the aqueous humour was 8.2 × 10(-5) L/h. AUCs were 25.4 ± 10.2 and 6.6 ± 1.8 μg · h/mL in plasma and aqueous humour, respectively, yielding a penetration ratio of 0.28 ± 0.06. Simulated concentrations in the aqueous humour after administration of 500 mg of famciclovir three times daily were in the range of values required for 50% growth inhibition of non-resistant strains of the herpes zoster virus family. CONCLUSIONS: Plasma and aqueous penciclovir concentrations showed significant variability that could only be partially explained by renal function, body weight and comedication. Concentrations in the aqueous humour were much lower than in plasma, suggesting that factors in the blood-aqueous humour barrier might prevent its ocular penetration or that redistribution occurs in other ocular compartments.

Epidemiology of uveitis in Switzerland.

During the period from January 1990 to December 1993, 558 new patients (250 female and 308 male, mean age 44 years; range 5-92) were seen at the Uveitis Clinic of the Hopital Jules Gonin. These 558 patients (740 eyes) were subdivided into anterior uveitis (343 patients-61%), intermediate uveitis (57 patients-10%), posterior uveitis (118 patients-21 %) and panuveitis (40 patients-7%). The incidence of uveitis for the referral area considered was calculated to be 17.5 per 100,000 inhabitants per year. A specific diagnosis was found in 386 cases (69%). The most frequently diagnosed entities were HLA-B27-associated acute anterior uveitis (89 cases-15.9%), uveitis associated with acute herpes zoster ophthalmicus (54 cases-9.7%), toxoplasmosis (53 cases-9.5%), sarcoidosis (33 cases-5.9%), typical pars planitis (31 cases-5.6%), Fuchs' heterochromic cyclitis (30 cases-5.4%), herpetic anterior uveitis (23 cases-4.1 %) and acute retinal necrosis (13 cases-2.3%). Incidence and distribution of most disease entities correspond to those of other European and American series.

Gériatrie [Review in geriatric medicine].

In 2010, a study emphasizes the difficulty to predict disability trajectories in the last year of life. A meta analysis shows the effectiveness of post-acute geriatric rehabilitation in reducing functional decline after hospitalisation. Several studies evaluated pneumococcal and herpes zoster vaccines' efficacy. A short and simple intervention is effective in reducing benzodiazepine use. The effect of vitamine D on falls and fractures has been further evaluated in several studies. Diagnostic criteria for dementias, including Alzheimer's disease, are moving to better acknowledge their preclinical stages.

Étude de l’immunité antivaricelleuse chez l’enfant transplanté au moyen de moelle osseuse ou de sang de cordon ombilical

L’infection primaire au VZV et la réactivation du VZV latent sont fréquemment observées à la suite d’une GMO ou d’une GSCO, ce qui cause de sérieuses complications chez le patient. Pour prévenir ces infections, une prophylaxie antivirale est administrée systématiquement chez tous les greffés de MO ou de SCO, alors qu’il n’existe aucun consensus sur la durée optimale d’une telle prophylaxie. Pour résoudre ce problème, notre objectif est de développer et valider une méthode ELISpot-VZV-IFN- qui permettra de suivre la reconstitution de l’immunité à médiation cellulaire anti-VZV chez les receveurs de GMO ou de GSCO et ainsi déterminer le moment opportun pour réduire ou interrompe la prophylaxie chez les receveurs de greffes de CSH. Dans un premier temps, des valeurs-seuil de la réponse à médiation cellulaire anti-VZV chez la population pédiatrique saine ont dû être générées. À la lumière de nos résultats, un enfant avec un résultat ELISpot-VZV-IFN- > 190.0 SFU/106 PBMC devrait être protégé contre une possible infection à VZV. Pour valider cette étude, une étude prospective de la reconstitution immunitaire anti-VZV a été effectuée chez 9 enfants greffés de MO ou de SCO. Nos résultats préliminaires ont montré qu’il n’y avait eu aucune reconstitution significative de l’immunité à médiation cellulaire anti-VZV dans les 18 premiers mois post-transplantation chez 8 de ces 9 enfants. Les résultats de ces expériences vont fournir d’importantes informations quant à la reconstitution de l’immunité anti-VZV à la suite d’une GMO ou d’une GSCO et pourraient permettre l’amélioration des soins apportés aux receveurs de GMO ou de GSCO.

Intercostal nerve mononeuropathy: study of 14 cases

Este trabalho apresenta estudo retrospectivo de 14 pacientes com mononeuropatia de nervo intercostal (MNI), obtidos dentre 5.560 exames eletromiográficos, realizados de janeiro de 1991 até junho de 2004, em nosso Hospital Universitário. MNI foi encontrada em 14 pacientes, tendo como causas prováveis intervenções cirúrgicas torácicas em 6 (43%), neuropatia por herpes-zoster em 4 (28%), provável neurite de nervo intercostal em 2 (14%), neoplasia pulmonar em 1 (7%) e radiculopatia em 1 (7%). As principais causas de MNI de nosso Serviço são similares às da literatura. Os antidepressivos tricíclicos e anticonvulsivantes foram os fármacos mais utilizados no controle da dor.

Topical (S)-ketamine for pain management of postherpetic neuralgia

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)