1: J Gen Intern Med. 2008 Feb 20 [Epub ahead of print]

Live, Attenuated Varicella Zoster Vaccination of an Immunocompromised Patient.

Curtis KK, Connolly MK, Northfelt DW.

Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ, USA.

A vaccine for the prevention of herpes zoster outbreaks in adults over the age of
60 years has recently been approved. A 76-year-old white female with a history of
recurrent left axillary breast cancer undergoing chemotherapy was given a
Zostavax(R) injection by her primary care physician. Eight days later, the
patient developed a rash. Given the recent administration of live, attenuated
varicella zoster virus (VZV), a diagnosis of disseminated cutaneous herpes zoster
was made. The patient was treated successfully with a course of famciclovir for
10 days and cephalexin for 7 days for a secondary bacterial infection. A review
of the medical literature disclosed no reports of Zostavax(R) given to adult
cancer patients immunocompromised by systemic chemotherapy. Therefore, we believe
this report is the first to describe the consequences of Zostavax(R)
administration to such a host. Clinicians should take care to review
contraindications and precautions prior to administering the Zostavax(R) vaccine.

PMID: 18286341 [PubMed - as supplied by publisher]

2: Br J Dermatol. 2008 Feb 16 [Epub ahead of print]

Primary manifestation of a zosteriform lichen planus: isotopic response following
herpes zoster sine herpete?

Mohrenschlager M, Engst R, Hein R, Ring J.

Department of Dermatology and Allergy Biederstein, Technical University of
Munich, Munich, Germany.

PMID: 18284381 [PubMed - as supplied by publisher]

3: Pharmacoeconomics. 2008;26(3):235-49.

Community and patient values for preventing herpes zoster.

Lieu TA, Ortega-Sanchez I, Ray GT, Rusinak D, Yih WK, Choo PW, Shui I, Kleinman
K, Harpaz R, Prosser LA.

Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and
Harvard Medical School, Boston, Massachusetts, USA.

OBJECTIVES: The US Advisory Committee on Immunization Practices has recently
recommended a new vaccine against herpes zoster (shingles) for routine use in
adults aged >/=60 years. However, estimates of the cost effectiveness of this
vaccine vary widely, in part because of gaps in the data on the value of
preventing herpes zoster. Our aims were to (i) generate comprehensive information
on the value of preventing a range of outcomes of herpes zoster; (ii) compare
these values among community members and patients with shingles and post-herpetic
neuralgia (PHN); and (iii) identify clinical and demographic characteristics that
explain the variation in these values. METHODS: Community members drawn from a
nationally representative survey research panel (n = 527) completed an
Internet-based survey using time trade-off and willingness-to-pay questions to
value a series of scenarios that described cases of herpes zoster with varying
pain intensities (on a scale of 0 to 10, where 0 represents no pain and 10
represents the worst imaginable pain) and duration (30 days to 1 year). Patients 
with shingles (n = 382) or PHN (n = 137) [defined as having symptoms for >/=90
days] from two large healthcare systems completed telephone interviews with
similar questions to the Internet-based survey and also answered questions about 
their current experience with herpes zoster. We constructed generalized linear
mixed models to evaluate the associations between demographic and clinical
characteristics, the length and intensity of the health states and time trade-off
and willingness-to-pay values. RESULTS: In time trade-off questions, community
members offered a mean of 89 (95% CI 24, 182) discounted days to avoid the least 
severe scenario (pain level of 3 for 1 month) and a mean of 162 (95% CI 88, 259) 
discounted days to avoid the most severe scenario (pain level of 8 for 12
months). Compared with patients with shingles, community members traded more days
to avoid low-severity scenarios but similar numbers of days to avoid
high-severity scenarios. Compared with patients with PHN, community members
traded fewer days to avoid high-severity scenarios. In multivariate analyses,
older age was the only characteristic significantly associated with higher time
trade-off values.In willingness-to-pay questions, community members offered a
mean of $US450 (95% CI 203, 893) to avoid pain of level 3 for 1 month and a mean 
of $US1384 (95% CI 873, 2050) [year 2005 values] to avoid pain of level 8 for 12 
months. Community members traded less money than patients with either shingles or
PHN to avoid both low- and high-severity scenarios (p-values <0.05 to <0.001). In
multivariate models, male gender, higher income and having experienced shingles
or PHN were associated with higher willingness to pay to avoid herpes zoster.When
patients were asked to assign a value to avoiding their own case of herpes
zoster, those with shingles assigned a mean of 67 days or $US2319, while those
with PHN assigned a mean of 206 days or $US18 184. Both the time and monetary
value traded were associated with the maximum intensity of the pain the
individual had experienced, but neither was associated with the duration of the
pain. CONCLUSIONS: We believe that this study provides the most comprehensive
information to date on the value individuals place on preventing herpes zoster,
and it includes the only such valuation from nationally representative community 
members as well as patients with herpes zoster. Community members would trade
substantial amounts of time or money to avoid herpes zoster, even in the least
severe scenarios. The time trade-off results in this study may differ from those 
in other studies because of important differences in methods of assessing health 
utilities. Consideration of both community and patient perspectives is crucial to
help decision makers fully determine the implications of their policies now that 
a vaccine against herpes zoster is available.

PMID: 18282017 [PubMed - in process]

4: J Am Acad Dermatol. 2008 Mar;58(3):361-70.

New viral vaccines for dermatologic disease.

Urman CO, Gottlieb AB.

Tufts University School of Medicine, Boston, Massachusetts, USA.
Christine.Orlova@tufts.edu

Two new viral vaccines have recently been approved by the Food and Drug
Administration. Human papillomavirus (HPV) vaccine is intended to reduce
infection with the most common HPV types that cause anogenital disease, including
cervical cancer and genital warts. Herpes zoster (HZ) vaccine is intended to
prevent shingles and its complications. The use of these two vaccines will
immediately begin to impact dermatologic practice throughout the world and will
reduce the healthcare burden associated with the diseases caused by the two
viruses. The following review summarizes the relevant pathophysiology and
epidemiology of genital warts, cervical neoplasia, and herpes zoster and
describes the recent trials that have demonstrated efficacy and safety of the HPV
and HZ vaccines. LEARNING OBJECTIVES: Following the completion of this learning
activity, the participant will be able to describe the mechanisms of HPV and
varicella zoster virus infection as well as pathogenesis, identify key aspects of
the immune system involved in clearing the infection, and prescribe HPV and HZ
vaccines for prevention of disease.

PMID: 18280332 [PubMed - in process]

5: Ophthalmology. 2008 Feb;115(2 Suppl):S35-8.

Preventing herpes zoster through vaccination.

Gelb LD.

Division of Infectious Disease, Washington University School of Medicine,
Department of Internal Medicine, Barnes-Jewish Medical Center, St. Louis,
Missouri 63110, USA. ldgelb@swbell.net

TOPIC: The role of the zoster vaccine in the prevention of herpes zoster and its 
sequelae, including postherpetic neuralgia (PHN) and herpes zoster ophthalmicus. 
CLINICAL RELEVANCE: Wide administration of the herpes zoster vaccine in
accordance with the recommendations of the Centers for Disease Control and
Prevention Advisory Committee on Immunization Practices (ACIP) will lead to a
decline in the incidence and morbidity of herpes zoster and its complications,
including PHN. METHODS: The key study leading to the approval of the zoster
vaccine for use, the Centers for Disease Control and Prevention ACIP's
recommendations for appropriate use of the zoster vaccine, and predictions
regarding the cost efficacy of a zoster vaccination program are reviewed.
RESULTS: The Shingles Prevention Study established that the zoster vaccine was
safe, well tolerated, and effective in reducing the burden of illness due to
herpes zoster and the incidence of PHN. The ACIP recommended that the zoster
vaccine be given to adults 60 and older for the prevention of herpes zoster.
Cost-efficacy analyses suggest that the greatest gain in quality-adjusted
life-years can be gained by vaccinating individuals at the younger end of the
ACIP-recommended age range. CONCLUSION: The zoster vaccine promises to reduce the
morbidity and mortality of herpes zoster. Administering the vaccine at the
younger end of the age range may offer a greater cost benefit.

Publication Types: 
    Review

PMID: 18243932 [PubMed - indexed for MEDLINE]

6: Ophthalmology. 2008 Feb;115(2 Suppl):S33-4.

Use of photorefractive keratectomy in a patient with a corneal scar secondary to 
herpes zoster ophthalmicus.

Kaufman SC.

Department of Ophthalmology, University of Minnesota, Minneapolis, Minnesota
55455, USA. corneamd2000@yahoo.com

TOPIC: The use of LASIK surgery to correct vision in a patient with postzoster
corneal scarring. CLINICAL RELEVANCE: The cornea is commonly involved in cases of
herpes zoster ophthalmicus, and as a result, corneal scarring after a
varicella-zoster virus corneal infection is common. Corneal scars can be treated 
by lamellar keratoplasty or keratectomy, which may be performed using a
microkeratome or excimer laser phototherapeutic keratectomy (PTK). However,
articles on studies concerning the treatment of postherpetic scars by PTK have
been published, offering conflicting results. LASIK surgery may offer an
additional therapeutic approach to corneal scarring. METHODS: A patient seeking
corrective surgery to improve vision was found to have corneal scarring. RESULTS:
The patient experienced successful vision correction. CONCLUSION: LASIK surgery
can be conducted even in a patient with postzoster corneal scarring. No
complications were apparent in this case.

Publication Types: 
    Case Reports

PMID: 18243931 [PubMed - indexed for MEDLINE]

7: Ophthalmology. 2008 Feb;115(2 Suppl):S3-12.

Herpes zoster ophthalmicus natural history, risk factors, clinical presentation, 
and morbidity.

Liesegang TJ.

Mayo Clinic College of Medicine, Jacksonville, Florida 32224, USA.
tliesegang@mayo.edu

TOPIC: The incidence and morbidity of herpes zoster (HZ) and HZ ophthalmicus
(HZO), and the potential impact of varicella vaccine on their epidemiology.
CLINICAL RELEVANCE: Herpes zoster affects 20% to 30% of the population at some
point in their lifetime; approximately 10% to 20% of these individuals will have 
HZO. METHODS: The peer-reviewed literature published from 1865 to the present was
reviewed. RESULTS: Herpes zoster is the second clinical manifestation of
varicella-zoster virus (VZV). The incidence and severity of HZ increase with
advancing age. Varicella-zoster virus-specific cell-mediated immunity, which
keeps latent VZV in check and is boosted by periodic reexposure to VZV, is an
important mechanism in preventing VZV reactivation as zoster. Thus, widespread
varicella vaccination may change the epidemiology of HZ. Herpes zoster
ophthalmicus occurs when HZ presents in the ophthalmic division of the fifth
cranial nerve. Ocular involvement occurs in approximately 50% of HZ patients
without the use of antiviral therapy. There is a long list of complications from 
HZ, including those that involve the optic nerve and retina in HZO, but the most 
frequent and debilitating complication of HZ regardless of dermatomal
distribution is postherpetic neuralgia (PHN), a neuropathic pain syndrome that
persists or develops after the zoster rash has resolved. The main risk factor for
PHN is advancing age; other risk factors include severe acute zoster pain and
rash, a painful prodrome, and ocular involvement. Many cases of HZ, HZO, and PHN 
can be prevented with the zoster vaccine. CONCLUSION: Vaccination is key to
preventing HZ, HZO, and PHN, but strategies for both varicella and HZ vaccines
will need to be evaluated and adjusted periodically as changes in the
epidemiology of these VZV diseases become more evident.

Publication Types: 
    Review

PMID: 18243930 [PubMed - indexed for MEDLINE]

8: Ophthalmology. 2008 Feb;115(2 Suppl):S24-32.

Anterior segment complications of herpes zoster ophthalmicus.

Kaufman SC.

Department of Ophthalmology, University of Minnesota, Minneapolis, Minnesota
55455, USA. corneamd2000@yahoo.com

TOPIC: The clinical features and management strategies for varicella-zoster virus
(VZV) infections of the cornea, lids, and adnexa. CLINICAL RELEVANCE: Herpes
zoster ophthalmicus (HZO) can result in a myriad of chronic and recurrent
complications that may be sight threatening. Surgical intervention is the
mainstay of treatment, and advancements in this area may lessen the complications
of HZO if correctly implemented. METHODS: Literature review of pertinent topics, 
authors, and journals utilizing the National Institutes of Health PubMed service.
RESULTS: A higher rate of treatment success for VZV-related complications was
obtained when any preexisting ocular inflammation, increased intraocular
pressure, lagophthalmos, dry eye, exposure, or neurotrophic keratitis was treated
and under control before attempting ocular surgery. CONCLUSION: Options are
available to manage ophthalmic complications of HZO and reduce the risk of
treatment failure.

Publication Types: 
    Review

PMID: 18243929 [PubMed - indexed for MEDLINE]

9: Ophthalmology. 2008 Feb;115(2 Suppl):S21-3.

Boston keratoprosthesis treatment of herpes zoster neurotrophic keratopathy.

Pavan-Langston D, Dohlman CH.

Massachusetts Eye And Ear Infirmary, Harvard Medical School, Boston,
Massachusetts 02114, USA. deborah.langston@schepens.harvard.edu

TOPIC: The successful use of the Boston keratoprosthesis in a severely inflamed
ulcer in herpes zoster neurotrophic keratopathy. CLINICAL RELEVANCE:
Approximately 10% to 20% of patients with herpes zoster will develop herpes
zoster ophthalmicus (HZO). Antiviral medication forms the foundation of
pharmacologic treatment for acute herpes zoster, but management of HZO is
supplemented with topical and systemic antimicrobials and corticosteroid agents
as well as surgical interventions. However, HZO is associated with poor healing, 
as evidenced by a high occurrence of ulceration, superinfection, and surgical
failure. METHODS: A 95-year-old man was referred for corneal edema in the right
eye. There was a history of acute herpes zoster in the right eye 10 months
previously. Slit-lamp examination revealed lagophthalmos, ectropion, total
corneal anesthesia, and marked inferior corneal edema. Despite surgical repair of
all lid abnormalities and aggressive lubrication and management of rosacea
blepharitis, the corneal surface remained unhealthy. Four months later, the
patient presented with an inflamed hypopyon ulcer, culture positive for abundant 
Pseudomonas and Candida albicans. The ulcer progressed to descemetocele in the
face of aggressive antimicrobial therapy, vision was light perception (LP), and
perforation became imminent. A Boston keratoprosthesis was used to replace the
severely damaged cornea, and extracapsular cataract extraction of a mature
cataract was also performed. RESULTS: One week after surgery, the inflammation
was almost entirely resolved, and cultures of the host button were negative for
any organisms. Vision gradually increased from LP to 20/60 over the ensuing 4
months. CONCLUSION: The Boston keratoprosthesis procedure successfully salvaged
and restored vision in this high-risk herpes zoster eye in which standard
keratoplasty would almost certainly have failed.

Publication Types: 
    Case Reports

PMID: 18243928 [PubMed - indexed for MEDLINE]

10: Ophthalmology. 2008 Feb;115(2 Suppl):S13-20.

Herpes zoster antivirals and pain management.

Pavan-Langston D.

Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston,
Massachusetts 02114, USA. deborah.langston@meei.harvard.edu

TOPIC: Evaluation of evidence-based strategies for managing herpes zoster (HZ)
and the pain of postherpetic neuralgia (PHN). CLINICAL RELEVANCE: Approximately
20% of the world's population suffers from herpes zoster at least once in a
lifetime, with 10% to 20% having ophthalmic involvement. Treatment of the acute
disease with oral antivirals may reduce the incidence and severity of
complications but does not reliably prevent PHN or postherpetic itch (PHI). The
acute pain abates as the acute phase resolves; the long-term pain of PHN or PHI
may be severe and difficult to manage. Although many therapeutic agents have
efficacy in the management of these complications, relief is frequently partial
for months to the remainder of the lifetime. METHODS: Literature review was
performed using the resources of the Harvard Medical School/Massachusetts Eye and
Ear Infirmary Ophthalmic library as well as the National Library of Medicine and 
the National Institutes of Health PubMed service searching by pertinent topics,
authors, and journals. RESULTS: If started within 72 hours of the onset of the
acute HZ rash, the oral antiviral agents acyclovir, valacyclovir, and famciclovir
significantly shorten the periods of acute pain, virus shedding, rash, acute and 
late-onset anterior segment complications, and, in the case of valacyclovir and
famciclovir, the incidence and severity of PHN. However, these medications do not
prevent PHN, which remains a common and debilitating complication of HZ in older 
patients, requiring assiduous pain management. Tricyclic antidepressants,
antiseizure drugs, opioids, and topical analgesics all offer some pain relief,
and may be combined. CONCLUSION: Options are available to manage HZ and reduce
the pain of PHN. However, prevention, now possible with the HZ vaccine, is
preferable to treatment.

Publication Types: 
    Review

PMID: 18243927 [PubMed - indexed for MEDLINE]

11: J Infect Dis. 2008 Feb 8 [Epub ahead of print]

Varicella-Zoster Virus in the Saliva of Patients with Herpes Zoster.

Mehta SK, Tyring SK, Gilden DH, Cohrs RJ, Leal MJ, Castro VA, Feiveson AH, Ott
CM, Pierson DL.

1Enterprise Advisory Services, Inc., 2Space Life Sciences, National Aeronautics
and Space Administration, Lyndon B. Johnson Space Center, and 3University of
Texas Health Science Center, Houston; Departments of 4Neurology and
5Microbiology, University of Colorado Health Sciences Center, Denver.

Fifty-four patients with herpes zoster were treated with valacyclovir. On
treatment days 1, 8, and 15, pain was scored and saliva examined for
varicella-zoster virus (VZV) DNA. VZV DNA was found in every patient the day
treatment was started and later disappeared in 82%. There was a positive
correlation between the presence of VZV DNA and pain and between VZV DNA copy
number and pain ([Formula: see text]). VZV DNA was present in 1 patient before
rash and in 4 after pain resolved and was not present in any of 6 subjects with
chronic pain or in 14 healthy subjects. Analysis of human saliva has potential
usefulness in the diagnosis of neurological disease produced by VZV without rash.

PMID: 18260763 [PubMed - as supplied by publisher]

12: J Infect Dis. 2008 Feb 8 [Epub ahead of print]

Herpes Zoster: New Insights Provide an Important Wake-Up Call for Management of
Nosocomial Transmission.

Breuer J.

Barts and The London School of Medicine and Dentistry, London, United Kingdom.

PMID: 18260760 [PubMed - as supplied by publisher]

13: J Infect Dis. 2008 Feb 8 [Epub ahead of print]

Transmission of a Newly Characterized Strain of Varicella-Zoster Virus from a
Patient with Herpes Zoster in a Long-Term-Care Facility, West Virginia, 2004.

Lopez AS, Burnett-Hartman A, Nambiar R, Ritz L, Owens P, Loparev VN, Guris D,
Schmid DS.

1Division of Viral Diseases, National Center for Immunizations and Respiratory
Diseases, and 2Biotechnology Core Facility, Coordinating Center for Infectious
Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; 3Division
of Surveillance and Disease Control, Infectious Disease Epidemiology Program,
West Virginia Department of Health and Human Resources, Charleston, and 4Marshall
County Health Department, Moundsville, West Virginia.

We investigated a small outbreak of varicella in a long-term-care facility after 
a case of herpes zoster. Clinical specimens and environmental samples were
collected from all case patients and from surfaces in the case patients' rooms
and other common-use areas. Wild-type varicella-zoster virus (VZV) DNA was
identified in all 3 varicella case patients, and high concentrations of VZV DNA
were detected in environmental samples from the room of the herpes zoster case
patient. Genotypic analysis showed that the identical VZV strain was present in
all samples; moreover, the strain was a unique Mosaic genotype isolate that
included a stable Oka vaccine marker that had hitherto never been observed in a
wild-type strain of VZV. This study provides evidence for the value of including 
environmental sampling during the investigation of varicella outbreaks and
illustrates the importance of evaluating multiple vaccine-associated markers for 
the discrimination of vaccine virus from wild-type VZV.

PMID: 18260757 [PubMed - as supplied by publisher]

14: Zhongguo Zhen Jiu. 2007 Oct;27(10):729-30.

[Observation on therapeutic effect of pricking blood therapy combined with
acupuncture on herpes zoster]

[Article in Chinese]

Huo HM, Yang XP.

Department of Dermatology, Jimo Third People's Hospital, Shandong 266200, China.

OBJECTIVE: To compare the therapeutic effects of pricking blood therapy combined 
with acupuncture and routine western medicine on herpes zoster. METHODS: Two
hundred and forty cases were randomly divided into 2 groups, 120 cases in each
group. The treatment group were treated with acupuncture combined with pricking
blood therapy on the point with the most pain, and cupping and surround needling;
the control group with external application and oral administration of Aciclovir 
plaster and Aciclovir tablets, respectively. Their therapeutic effects were
compared. RESULTS: The total effective rate was 92.5% in the treatment group and 
55.8% in the control group with a very significant difference between the two
groups (P < 0.01). The time of producing killing pain, stopping vesication and
scabbing in the treatment group was shorter than that in the control group.
CONCLUSION: The pricking blood therapy combined with acupuncture is an effective 
therapy for herpes zoster.

Publication Types: 
    English Abstract

PMID: 18257346 [PubMed - in process]

15: Drug Ther Bull. 2008 Feb;46(2):14-6.

Lidocaine plasters for postherpetic neuralgia?

[No authors listed]

Each year in the UK, about 1 in 2,500 people experiences neuropathic pain that is
still present 3-6 months after acute herpes zoster (shingles).1 This condition,
known as postherpetic neuralgia, is the most common complication of herpes zoster
and can be chronic, intractable and distressing. Treatments used in an attempt to
reduce postherpetic neuralgia include tricyclic antidepressants (e.g.
amitriptyline - an unlicensed indication), antiepileptics (e.g. gabapentin) and
opioid analgesics, as well as topical treatments such as capsaicin.2 However,
such treatments may only provide partial pain relief, and tolerability can be a
problem, particularly in older patients.2 Versatis (Grunenthal Ltd), a topical
preparation of lidocaine formulated in a plaster, has recently been licensed for 
treating patients with postherpetic neuralgia.3 Does it offer useful benefit?

PMID: 18256177 [PubMed - in process]

16: J Virol. 2008 Feb 6 [Epub ahead of print]

Mechanisms of Varicella-Zoster Virus Neuropathogenesis in Human Dorsal Root
Ganglia.

Reichelt M, Zerboni L, Arvin AM.

Departments of Pediatrics and Microbiology & Immunology, Stanford University
School of Medicine, Stanford, CA, 94305.

Varicella-zoster virus (VZV) is a human alphaherpesvirus that infects sensory
ganglia and reactivates from latency to cause herpes zoster. VZV replication was 
examined in human dorsal root ganglia (DRG) xenografts in mice with severe
combined immunodeficiency using multiscale correlative immunofluorescence and
electron microscopy (IF-EM). These experiments showed the presence of VZV genomic
DNA, viral proteins and virion production in both neurons and satellite cells
within DRG. Furthermore, the multiscale analysis of VZV-host cell interactions
revealed virus-induced cell-cell fusion and polykaryon formation between neurons 
and satellite cells during VZV replication in DRG in vivo. Satellite cell
infection and polykaryon formation in neuron-satellite cell complexes provide
mechanisms to amplify VZV entry into neuronal cell bodies, which is necessary for
VZV transfer to skin in the affected dermatome during herpes zoster. These
mechanisms of VZV neuropathogenesis help to account for the often severe
neurologic consequences of herpes zoster.

PMID: 18256143 [PubMed - as supplied by publisher]

17: Cochrane Database Syst Rev. 2008 Jan 23;(1):CD005582.

Corticosteroids for preventing postherpetic neuralgia.

He L, Zhang D, Zhou M, Zhu C.

BACKGROUND: Postherpetic neuralgia is a common serious complication of herpes
zoster. Corticosteroids are anti-inflammatory and might be beneficial.
OBJECTIVES: To examine the efficacy of corticosteroids in preventing postherpetic
neuralgia. SEARCH STRATEGY: Search for randomised or quasi-randomised controlled 
trials for corticosteroids for preventing postherpetic neuralgia in MEDLINE (1950
to 2006), EMBASE (1980 to 2006), LILACS (1982 to 2005), the Chinese Biomedical
Retrieval System (1978 to 2006) and the Cochrane Register of Controlled Trials
(CENTRAL) (Cochrane Library Issue 3, 2006). Date of most recent search: September
2006. SELECTION CRITERIA: Types of studies: quasi-randomised or randomised
controlled trialsTypes of participants: people of all ages with herpes zoster of 
all degrees of severity within seven days after onset.Types of interventions: all
kinds of corticosteroids given by oral, intramuscular or intravenous routes
during the acute stage (starting within one week of onset of the rash) compared
with no treatment or placebo, but not with other treatments. We also included
trials which compared corticosteroids plus routine treatment with placebo plus
routine treatment.Types of outcome measures:Primary: the presence of postherpetic
neuralgia six months after the onset of the acute herpetic rash.Secondary: pain
severity measured by a validated visual analogue scale or numerical descriptive
scale after three, six and 12 months; quality of life measured with the short
form 36 questionnaire after six months; adverse events during or within two weeks
after stopping treatment. DATA COLLECTION AND ANALYSIS: Data were extracted by
two independent reviewers. MAIN RESULTS: Five trials were included with
altogether 787 participants. All were randomised, double-blind,
placebo-controlled parallel group studies. Our primary outcome measure was the
presence of postherpetic neuralgia six months after the onset of the acute
herpetic rash. There was no significant difference between the corticosteroid and
control groups for the primary outcome (RR 1.27, 95% CI 0.20 to 7.97). There was 
also no significant difference between the corticosteroid plus antiviral agents
and placebo plus antiviral agents groups for the primary outcome (RR 0.90, 95% CI
0.40 to 2.03). No included trials evaluated pain severity with a validated visual
analogue scale or numerical descriptive scale and also no trials measured quality
of life with the Short Form 36 questionnaire. Adverse events during or within two
weeks after stopping treatment were reported by all five included trials, but
after meta-analysis, there was no significant difference in any serious adverse
event (death, acute cardiac insufficiency, rash dissemination, bacterial
pneumonia or haematemesis) or non serious adverse event (dizziness, nausea,
vomiting, hypertension or hyperglycaemia). AUTHORS' CONCLUSIONS: There was
insufficient evidence to conclude that corticosteroids are safe or effective in
the prevention of postherpetic neuralgia. More randomised controlled trials with 
a greater number of participants are needed to determine reliably whether there
is real benefit (or harm) from the use of corticosteroid therapy to prevent
postherpetic neuralgia. Future trials should measure function and quality of
life.

PMID: 18254083 [PubMed - in process]

18: Emerg Med Clin North Am. 2008 Feb;26(1):217-31.

Ophthalmologic complications of systemic disease.

Klig JE.

Division of Pediatric Emergency Medicine, Boston University School of Medicine,
Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, USA.

The human eye, as an organ, can offer critical clues to the presence of systemic 
disease. This article discusses the various ophthalmologic manifestations of
systemic disease that can be evident on examination by an emergency department
provider, as well as some findings that can be discerned with specialty
consultation. The following topics are reviewed with respect to potential ocular 
signs and complications: syphilis, herpes zoster, Lyme disease, acquired
immunodeficiency syndrome, Reiter's syndrome, Kawasaki's disease, temporal
arteritis, endocarditis, hypertension, and diabetes mellitus. Indications for
emergent ophthalmologic consultation are also emphasized.

PMID: 18249264 [PubMed - in process]

19: Br J Ophthalmol. 2008 Feb 1 [Epub ahead of print]

Association of varicella-zoster virus (VZV) load in the aqueous humor with
clinical manifestations of anterior uveitis in herpes zoster ophthalmicus and
zoster sine herpete.

Kido S, Sugita S, Horie S, Miyanaga M, Miyata K, Shimizu N, Morio T, Mochizuki M.

Japan.

Aim: To investigative whether clinical manifestations of anterior uveitis is
associated with the viral load of varicella-zoster virus (VZV) in the aqueous
humor in patients with herpes zoster ophthalmicus (HZO) and zoster sine herpete
(ZSH). Methods: After informed consent was given, an aliquot of aqueous humor was
collected from patients with VZV anterior uveitis (n=8). Using the aqueous humor,
genomic DNAs of the human herpes viruses were measured through the use of two
polymerase chain reaction (PCR) assays: (1) a qualitative multiplex PCR and (2) a
quantitative real-time PCR. Results: All patients had unilateral acute anterior
uveitis with high intraocular pressure, mutton fat keratic precipitates with some
pigmentation, and trabecular meshwork pigmentation. Multiplex PCR demonstrated
VZV genomic DNA in all of the samples, but not in other human herpes virus
samples (HSV-1, HSV-2, EBV, CMV, HHV-6, HHV-7, and HHV-8). Real-time PCR revealed
a high copy number of VZV DNA in the aqueous humor. During the time after the
initial onset of the anterior uveitis, iris atrophy and a distorted pupil with
paralytic mydriasis developed in the patients. The intensity of the iris atrophy 
and pupil distortion, but not the ocular hypertension, was correlated with the
viral load of VZV in the aqueous humor. Conclusion: Viral load of VZV in the
aqueous humor was well correlated with the tissue damage of the iris (iris
atrophy and pupil distortion) in patients with HZO and ZSH.

PMID: 18245272 [PubMed - as supplied by publisher]

20: Med J Aust. 2008 Feb 4;188(3):171-6.

The prevention and management of herpes zoster.

Cunningham AL, Breuer J, Dwyer DE, Gronow DW, Helme RD, Litt JC, Levin MJ,
Macintyre CR.

Westmead Millennium Institute for Medical Research and University of Sydney,
Sydney, NSW, Australia. tony_cunningham@wmi.usyd.edu.au.

The burden of illness from herpes zoster (HZ) and postherpetic neuralgia (PHN) in
the Australian community is high. The incidence and severity of HZ and PHN
increase with age in association with a progressive decline in cell-mediated
immunity to varicella-zoster virus (VZV). Antiviral medications (valaciclovir,
famciclovir, aciclovir) have been shown to be effective in reducing much but not 
all of the morbidity associated with HZ and PHN, but are consistently
underprescribed in Australia. Zoster-associated pain should be treated early and 
aggressively, as it is more difficult to treat once established. Clinicians
should be proactive in their follow-up of individuals at high risk of developing 
PHN, and refer patients to a specialist pain clinic earlier, rather than later. A
live, attenuated VZV vaccine (Oka/Merck strain, Zostavax [Merck Sharp & Dohme])
has proven to be efficacious in reducing the incidence of and morbidity
associated with HZ and PHN in older adults. The vaccine's efficacy has been shown
to persist for at least 4 years, but is likely to last a lot longer. Ongoing
surveillance will determine the duration of protection and whether a booster dose
is required. Clinicians should consider recommending the vaccine, which can be
safely administered at the same time as the inactivated influenza vaccine, to all
immunocompetent patients aged 60 years or older. Clinicians should refer to the
Australian immunisation handbook for advice on the use of the live vaccine in
immunosuppressed individuals.

PMID: 18241179 [PubMed - in process]
as