Varicella-Zoster Virus: Atypical Presentations and Unusual Complications

Journal of Infectious Diseases, Oct 2002

Varicella-zoster virus (VZV) is the etiologic agent of varicella (primary infection) and herpes zoster (reactivation of latent infection). Although varicella is most often a relatively benign and self-limited childhood illness, the disease can be associated with a variety of serious and potentially lethal complications in both immunocompetent and immunocompromised persons. One complication of varicella that appears to be increasing in frequency is serious bacterial soft tissue infections caused by group A streptococci. Issues related to management of varicella become especially complex when varicella involves pregnant women or susceptible neonates. Herpes zoster can be associated with a variety of neurologic complications, including a syndrome of delayed contralateral hemiparesis. Neurologic complications of herpes zoster, including chronic encephalitis, occur with increased frequency in AIDS patients. VZV retinitis is a potentially sight-threatening complication that occurs in both immunocompetent and immunocompromised persons. Current knowledge regarding pathogenesis and antiviral therapy is reviewed

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Varicella-Zoster Virus: Atypical Presentations and Unusual Complications

John W. Gnann 0 1 Jr. 0 1 0 Financial support: GlaxoSmithKline (honoraria and research funding). abama at Birmingham, Div. of Infectious Diseases , 845 S. 19th St., BBRB 220, Birmingham, AL 35294-2170 1 University of Alabama at Birmingham and Birmingham VA Medical Center , Birmingham, Alabama Varicella-zoster virus (VZV) is the etiologic agent of varicella (primary infection) and herpes zoster (reactivation of latent infection). Although varicella is most often a relatively benign and self-limited childhood illness, the disease can be associated with a variety of serious and potentially lethal complications in both immunocompetent and immunocompromised persons. One complication of varicella that appears to be increasing in frequency is serious bacterial soft tissue infections caused by group A streptococci. Issues related to management of varicella become especially complex when varicella involves pregnant women or susceptible neonates. Herpes zoster can be associated with a variety of neurologic complications, including a syndrome of delayed contralateral hemiparesis. Neurologic complications of herpes zoster, including chronic encephalitis, occur with increased frequency in AIDS patients. VZV retinitis is a potentially sight-threatening complication that occurs in both immunocompetent and immunocompromised persons. Current knowledge regarding pathogenesis and antiviral therapy is reviewed. - Varicella-zoster virus (VZV) causes two clinically distinct diseases. Primary infection results in varicella (chickenpox), a common and extremely contagious acute infection that occurs in epidemics among preschool and school-aged children, is characterized by generalized vesicular rash. Like other a-herpesviruses, VZV establishes latency in neural tissue following primary infection. Reactivation of latent VZV from dorsal root ganglia results in herpes zoster (shingles), a localized cutaneous eruption accompanied by neuralgic pain that occurs most commonly in older persons. The typical clinical presentations of varicella and herpes zoster are distinctive and readily recognized by most experienced clinicians. However, atypical clinical presentations and uncommon complications of these diseases can pose diagnostic and therapeutic challenges. This review will address some less common manifestations of VZV infection that can occur in otherwise healthy immunocompetent persons and in special populations. Varicella Pneumonitis as a complication of varicella is rare in healthy children but occurs with increased frequency in immunocompromised persons of all ages and in immunocompetent adolescents and adults [1, 2]. Among otherwise healthy adults with varicella, 2.7%16.3% will have radiographic evidence of VZV pneumonitis, but only about one-third of those with abnormal chest radiographs will have respiratory symptoms [36]. As discussed below, varicella pneumonia appears to be more frequent and more severe in pregnant women [7]. The onset of respiratory symptoms (including cough, dyspnea, and sometimes hemoptysis) usually occurs within a few days of development of the varicella rash. The chest radiograph reveals a diffuse interstitial nodular infiltrate [2, 8]. Prior to the availability of antiviral therapy, mortality rates of up to 30% were reported for varicella pneumonia. However, with the advent of antiviral treatment and intensive supportive care, the mortality rate is now probably less than 10%. Although intravenous acyclovir has not been evaluated in controlled trials for treatment of varicella pneumonia, abundant clinical experience and anecdotal reports indicate the drug is effective in this setting [911]. Neurologic Complications The incidence of neurologic complications associated with varicella is estimated to be 13 per 10,000 cases [12]. The central nervous system (CNS) manifestations that occur most frequently with varicella are cerebellar ataxia and encephalitis [1315]. Other rare neurologic complications include transverse myelitis, aseptic meningitis, and Guillain-Barre syndrome [1618]. Few data exist to help define the role of antiviral therapy for neurologic complications of varicella. Varicella with cerebellar ataxia. Symptomatic cerebellar ataxia occurs in about 1 in 4000 varicella cases [12]. The pathogenesis of this syndrome is incompletely understood, partly because the illness is rarely fatal and few pathologic studies have been reported. Possible mechanisms are direct viral infection of the cerebellum or a parainfectious immunologically mediated demyelinating process. VZV-specific antibodies and antigens have been found in cerebrospinal fluid (CSF) of patients with varicella-associated cerebellar ataxia, suggesting that VZV replicates within the CNS [1921]. Ataxia may develop from several days before to 2 weeks after the onset of varicella, although the neurologic symptoms most often occur simultaneously with rash [16]. Ataxia is usually accompanied by vomiting, headache, and lethargy; nuchal r (...truncated)


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John W. Gnann Jr.. Varicella-Zoster Virus: Atypical Presentations and Unusual Complications, Journal of Infectious Diseases, 2002, pp. S91-S98, 186/Supplement 1, DOI: 10.1086/342963