Herpes Zoster Co-Infection with COVID-19: A Case Series

Clinical presentation of COVID-19 infection can be variable in the current pandemic even in patients presenting to the clinic with a mild history of upper respiratory complaints. Various cutaneous manifestations have been noticed in COVID-19 patients with herpes zoster (HZ) being one among them. HZ is an infection that results when varicella zoster virus reactivates from its latent state in the posterior dorsal root ganglion. Here, we aim to expand our knowledge by reporting three cases of associated zoster infection in COVID-19 patients admitted to our intensive care unit in view of respiratory complaints. All the three patients admitted, had revealed lymphocytopenia at the time of HZ diagnosis, and were managed conservatively throughout the course. In all the cases, acyclovir/valacyclovir led to the resolution of lesions in 10 days. No postherpetic sequelae were observed. We here suggest that the clinical presentation of HZ at the time of the current pandemic should be considered as an alarming sign for a latent subclinical SARS CoV-2 infection and thorough follow-up of such patients be adopted.Copyright © 2021 Bali Journal of Anesthesiology. All rights reserved.

Herpes Gastritis: A Rare Cause of Gastric Outlet Obstruction

Introduction: Gastrointestinal tract involvement from herpes simplex virus is commonly associated with esophagitis. However, herpes simplex infection of the stomach is very rare with only a handful of cases being reported in immunocompromised patients. We present a case of herpes gastritis causing gastric outlet obstruction in an otherwise healthy, immunocompetent individual. Case Description/Methods: A 37-year-old male with a recent past medical history of COVID-19 infection, presented to the hospital with intractable nausea, vomiting, bloating, and early satiety for two days. Upon evaluation, CBC and CMP were remarkable for a WBC of 12.5 k/mm3 and ALT and AST of 124 U/L and 129 U/L, respectively. Lipase was 373 U/L. A CT abdomen/pelvis w/contrast showed circumferential wall thickening with edematous changes in the antrum consistent with localized inflammatory response. There was suspicion for gastric lymphoma and patient was admitted for further workup. An EGD was performed which showed exudative esophagitis and antral wall edema with luminal narrowing of gastric antrum. Endoscopic ultrasound (EUS) showed a 2.5 x 3 cm antral wall lesion worrisome for linitis plastica. Esophageal biopsies showed focal cytologic changes consistent with herpes esophagitis. The FNA of the gastric antral wall showed multinucleation of the basal cell layer with classic ground glass nuclei, consistent with herpes infection. No dysplasia or malignancy was seen. Both HSV1 and HSV2 IgG were elevated. HSV IgM was normal. A HSV PCR was ordered but never resulted. Patient was started on Valacyclovir 1 g PO BID for 10 days. He underwent a follow-up EGD 3 months later which showed complete resolution of the gastric antral changes (Figure). Discussion(s): Herpes gastritis is extremely rare. Literature review has revealed only 3 case reports of herpes gastritis;and all involved immunocompromised patients. To the best of our knowledge, this is the first case of herpes gastritis in an immunocompetent patient. Our patient presented with symptoms of gastric outlet obstruction which was caused by local inflammation from herpes simplex. It is unclear if having a COVID 19 infection altered patient's immunity and lead to herpes gastritis. This may need further investigation. No established guideline exists for treatment duration. Our patient received 10-day course of Valacyclovir, and his symptoms improved. Furthermore, patient had complete resolution of the herpes infection on follow-up EGD, indicating adequate treatment response.

Cytomegalovirus reactivation following COVID-19 vaccination: A case report

Case report Cytomegalovirus (CMV) causes latent asymptomatic infection in most adults worldwide. Immunodeficiency or immune activation can disrupt viral suppression and lead to viral reactivation, occasionally causing a mononucleosis-like illness in otherwise healthy immunocompetent people. A 37-year- old female presented with a 10-day history of fevers, chills, right-sided neck tenderness, rapidly expanding rash, as well as myalgia, arthralgia, and weakness. She had received her first dose of tozinameran (Pfizer-BioNTech COVID-19 mRNA vaccine) 11 days prior to symptom onset. She was admitted to hospital for further investigations, and was seen by an allergy/clinical immunology specialist, with the diagnosis initially felt to be a delayed serum sickness-like reaction to the vaccine. On admission to hospital, the patient was febrile (37.8C) and tachycardic (122 beats/min). Her physical examination was remarkable for right-sided submandibular tenderness, diffuse blanchable, nonpruritic, erythematous, maculopapular rash, and mild facial swelling. There were no effused joints, lymphadenopathy, nor splenomegaly. Bloodwork showed pancytopenia and mild liver transaminase elevation. Blood cultures were negative. Multiple PCR tests for COVID-19 were negative. Monospot and serology for HBV, HIV, and B. burgdorferi were negative. CMV serology was positive, but unavailable until after discharge. ANA and rheumatoid factor were negative. CT head demonstrated nonspecific edema in the right submandibular area without abscess. On outpatient follow-up, the patient reported symptom resolution over two months. Repeat CMV titres two months post hospitalisation showed strongly elevated IgG, which upon consultation with infectious diseases was felt to represent CMV reactivation (Table 1). CMV viral load was negative. Pancytopenia resolved and transaminases normalized. She received her second dose of tozinameran 4 months post first dose with prophylactic valacyclovir 1g once daily for 1 week prior to and 1 week post vaccination as recommended by infectious diseases and remained asymptomatic. This case is the first known description of CMV reactivation secondary to COVID-19 vaccination. It may be underdiagnosed due to nonspecific symptomatology, as CMV seropositivity ranges from 60-100% of all adults. While causality has yet to be established, recognition of this condition may allow appropriate treatment and prophylaxis in order to facilitate safe COVID-19 vaccination in affected individuals. The patient has provided verbal consent through the telephone for the publication of this case report due to the current COVID-19 pandemic, with written consent to follow.

A Review: Zinc as an Antivirus Alternative Treatment for Herpes Simplex Virus Infection

This study aimed to review zinc's effectiveness as an antivirus in treating herpes simplex virus infection. The authors use international journals published from 2000-2022, and use search engines such as Google Scholar, PubMed, and Science Direct with the keywords "zinc and herpes simplex virus". The herpes simplex virus that often causes symptoms in humans are HSV type 1 and type 2. The lesions appear as vesicles which then rupture into ulcers. Zinc is one of the most abundant nutrients or metals in the human body besides iron. Studies about the effects of zinc on HSV have shown that it has the function of inhibiting the viral life cycle. HSV attaches to the host cells to replicate and synthesize new viral proteins. Zinc can inhibit this process by depositing on the surface of the virion and inactivating the enzymatic function which is required for the attachment to the host cell, disrupting the surface glycoprotein of the viral membrane so it could not adhere and carry out the next life cycle, it can also inhibit the function of DNA polymerase that works for viral replication in the host cell. This article showed that zinc has effectiveness as an antivirus against the herpes simplex virus, therefore, patients infected with HSV can be treated with zinc as an alternative to an antivirus drug.Copyright © 2022 The Authors. Published by Innovare Academic Sciences Pvt Ltd.

Facial herpes zoster associated with disease reactivation in a patient with multiple sclerosis under dimethyl fumarate treatment

Background: Dimethyl fumarate (DMF) is an approved treatment for multiple sclerosis (MS). Due to its efficacy and safety profile, DMF is the most prescribed oral medication for relapsing remitting (RR) MS. Given the long-term course of treatment with DMF in MS, continuous surveillance of opportunistic infections is fundamental. Case presentation: We report the occurrence of facial herpes zoster (HZ) associated with MS disease reactivation in a person with RRMS after 6 years of DMF therapy. Case report: A 44-year-old woman with RRMS developed right temple pain and blisters over the right cheek, suggestive of facial HZ. A normal lymphocyte count with however relatively lower proportions of CD8+ T cells and higher percentages of natural killer cells were detected in blood. The patient failed oral treatment and required hospitalization for intravenous acyclovir. She eventually developed symptoms of an MS exacerbation featured by lower extremities weakness and urinary retention. Conclusion(s): Our case highlights the importance of counseling patients on the possibility of HZ reactivation even in the setting of a normal lymphocyte count, the risk of MS exacerbation possibly associated with HZ occurrence and the importance of timely vaccination.Copyright © 2022

Molecularly imprinted polymer-modified carbon paste electrodes (MIP-CPE): A review on sensitive electrochemical sensors for pharmaceutical determinations

Recent years have been associated with the development of various sensor-based technologies in response to the undeniable need for the rapid and precise analysis of an immense variety of pharmaceuticals. In this regard, special attention has been paid to the design and fabrication of sensing platforms based on electrochemical detection methods as they can offer many advantages, such as portability, ease of use, relatively cheap instruments, and fast response times. Carbon paste electrodes (CPEs) are among the most promising conductive electrodes due to their beneficial properties, including ease of electrode modification, facile surface renewability, low background currents, and the ability to modify with different analytes. However, their widespread use is affected by the lack of sufficient selectivity of CPEs. Molecularly imprinted polymers (MIPs) composed of tailor-made cavities for specific target molecules are appealing complementary additives that can overcome this limitation. Accordingly, adding MIP to the carbon paste matrix can contribute to the required selectivity of sensing platforms. This review aims to present a categorized report on the recent research and the outcomes in the combinatory fields of MIPs and CPEs for determining pharmaceuticals in complex and simple matrices. CPEs modified with MIPs of various pharmaceutical compounds, including analgesic drugs, antibiotics, antivirals, cardiovascular drugs, as well as therapeutic agents affecting the central nervous system (CNS), will be addressed in detail.Copyright © 2023 Elsevier B.V.

DISSEMINATED HERPES ZOSTER VIRUS INFECTION FOLLOWING BARICITINIB IN COVID-19

SESSION TITLE: COVID-19 Co-Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Baricitinib with Remdesivir has been Food and Drug Administration (FDA) approved for hospitalized COVID-19 pneumonia patients requiring supplemental oxygen and is used across the United States. However, limited post-marketing surveillance data is currently available for these drugs. We present a case of an unvaccinated, immunocompetent patient with Herpes-Zoster virus (HZV) infection following baricitinib administration. CASE PRESENTATION: A 66-year-old African-American male with unknown vaccination status for Herpes zoster presented with worsening shortness of breath for 1 week. He had an SpO2 85% on presentation however had to be subsequently intubated due to worsening hypoxia in the ER. Cardiorespiratory exam was remarkable for diminished bibasilar breath sounds. Lab work was significant for positive COVID-19, elevated leukocytes and deranged inflammatory markers. CT chest showed bilateral ground glass opacities. He received a 14 day course of baricitinib, 10 days of dexamethasone and 5 days of remdesivir during his hospital stay. Tracheostomy and percutaneous endoscopic gastrostomy were performed due to prolonged vent dependence. On day 37 of hospitalization, the patient developed vesicular rashes over his left shoulder and anterior chest. Disseminated HZV infection was confirmed based on serologic testing. Patient received 7 days of valacyclovir with complete resolution. He was eventually discharged to a pulmonary rehabilitation center. DISCUSSION: Baricitinib was first developed for patients with rheumatoid arthritis and has been used in the treatment of rheumatoid arthritis and acts by reversible inhibition of JAK1 and JAK2. These proteins have been implicated in COVID-19 pathophysiology;promoting intracellular assembly of SARS-CoV-2 and subsequent cytokine release. Baricitinib in COVID-19 leads to the inhibition of proinflammatory cytokine release, antibody production, monocyte activation and viral proliferation. [1] There have been several studies published in support of Baricitinib induced HZV infection in rheumatoid arthritis patients, however there is little data available in COVID patients. Nonetheless, immunomodulatory action is the same. A study comparing the incidence rate (IR) of Baricitinib emergent HZV infection per 100 patient years (PY) vs placebo found IR/100PY 4.3 (p<_0.01) vs 3.1 (p not significant) [2]. Another study found the HZV IR vs placebo of 4.3 vs 1.0, with all-bari-RA IR was 3.2 (95% CI 2.8-3.7) [3]. In our case, the patient developed HZV infection after baricitinib treatment, demonstrating its immunomodulatory effects. CONCLUSIONS: This case demonstrates the ability of baricitinib to cause immunosuppression and hence causing HZV infection in COVID-19 affected patients. Reference #1: Schwartz DM, Bonelli M, Gadina M, O'shea JJ. Type I/II cytokines, JAKs, and new strategies for treating autoimmune diseases. Nat Rev Rheumatol. 2016;12(1):25. Reference #2: Kevin L, Masayoshi H, Mark C et al. Infections in baricitinib clinical trials for patients with active rheumatoid arthritis. Ann Rheum Dis.2020 Oct;79(10):1290-1297. Reference #3: Joseph S, Mark C, Tsutomu T et al. Safety profile of Baricitinib in patients with active rheumatoid arthritis with over 2 years median time in treatment. The Journal of Rheumatology January 2019, 46 (1) 7-18;DOI: https://doi.org/10.3899/jrheum.171361 DISCLOSURES: No relevant relationships by Mark Aloysius No relevant relationships by Gursharan Kaur No relevant relationships by Mohammed Musa Najmuddin No relevant relationships by mashu shrivastava

BUT WHAT ABOUT THE RASH?

SESSION TITLE: Severe and Unusual Blastomycosis Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: This is a case of a patient 74-year-old immunosuppressed woman presenting with a one-week history of skin lesions. CASE PRESENTATION: A 74-year-old woman with Crohn's disease (on weekly adalimumab);pulmonary hypertension (RVSP 76 mmHg);OHS/OSA, on home BPAP 17/7 cmH2O;and morbid obesity presented with a one-week history of skin lesions. She was seen by her primary care physician two days prior with skin lesions, shortness of breath, and decreased vision. She was hypoxic during the visit and given doxycycline for empiric treatment of pneumonia. She denied recent travel or exposure to animals. On admission, she was afebrile (36.9C) and saturating 98% on 2 L nasal cannula. She appeared chronically ill with mouth ulcers and an eroded nodule with overlying hemorrhagic crusting and peripheral pustular area above her right eyebrow (figure 1). Throughout her skin, she had multiple erythematous papules, some with overlying vesicles/pustules. Labs were significant for a leukocytosis of 19.3 with left shift, lactate of 3.5, serum creatinine of 1.9 (likely higher than patient's previous baseline of 1.7 with previous history of recurrent AKIs on CKD), elevated inflammatory markers, and normal ALT/AST. Influenza and COVID were negative. A CT chest showed consolidations and numerous pulmonary nodules highly suspicious for an infectious or inflammatory process (figure 2). She was treated empirically with vancomycin, piperacillin-tazobactam, valacyclovir, and amphotericin B, the latter given the concern of blastomycosis. During her hospitalization, she had further respiratory failure requiring intubation and multiorgan failure. Disseminated blastomycosis was confirmed via a skin biopsy which demonstrated pyogranulomatous inflammation with numerous broad-based budding yeasts (figure 3) and supported with a bronchoalveolar lavage (BAL) culture growing the same. Given her continued decline, her medical decision maker decided to transition the patient to hospice care. DISCUSSION: Blastomycosis is a systemic pyogranulomatous infection that is caused from the inhalation of the conidia form of the dimorphic fungus. It can manifest as asymptomatic infection, acute or chronic pneumonia, or extrapulmonary disease. BAL yields a positive diagnosis in 92% of patients and definitive diagnosis requires growth of the organism from a clinical specimen. Without appropriate treatment of amphotericin B or one of the azole antifungals, the disease had a 90% mortality rate. CONCLUSIONS: Prompt recognition of multiorgan failure secondary to blastomycosis is important for early treatment and improved survival in immunocompromised patients Reference #1: 1)Chapman, S W et al. "Endemic blastomycosis in Mississippi: epidemiological and clinical studies.” Seminars in respiratory infections vol. 12,3 (1997): 219-28. Reference #2: 2)Saccente, Michael, and Gail L Woods. "Clinical and laboratory update on blastomycosis.” Clinical microbiology reviews vol. 23,2 (2010): 367-81. doi:10.1128/CMR.00056-09 Reference #3: 3)Chapman, Stanley W et al. "Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America.” Clinical infectious diseases : an official publication of the Infectious Diseases Society of America vol. 46,12 (2008): 1801-12. doi:10.1086/588300 DISCLOSURES: No relevant relationships by Jennifer Duke No relevant relationships by Ashley Egan

Viral exanthems Unravelling viral rashes

Common causes of viral exanthems in Australia include herpesviruses, enteroviruses, parvovirus B19, varicella, measles and rubella viruses and mosquito-borne alphaviruses. The cause can often be diagnosed clinically from the rash distribution and morphology, confirmed only when necessary with serological or PCR tests. Most viral exanthems are self-limiting, requiring supportive care alone.

A Case of Hydroxyurea-Induced Interstitial Pneumonitis

Introduction: First synthesized in 1869, Hydroxyurea is known for its efficacy in treating myeloproliferative disorders, cervical cancer, and sickle cell disease. Usually well-tolerated, Hydroxyurea has numerous documented adverse effects, including bone marrow suppression, fevers, gastrointestinal upset, anorexia, and maculopapular rash. In addition, one rare side effect is interstitial pneumonitis, a potentially devastating complication if overlooked. We present one such case of Hydroxyurea-induced interstitial pneumonitis. Case Description: A 65-year-old man with a six-month diagnosis of Chronic Granulocytic Leukemia (CGL) on Hydroxyurea developed acute hypoxemic respiratory failure saturating 80% on room air with HR 102, RR 24, and increasing oxygen requirements (10 Lpm) after being admitted with complaints of worsening dyspnea, fatigue, and productive cough with yellow/green sputum. Physical examination was notable for cachexia, ill appearance, generalized weakness, hoarse voice, tachycardia, tachypnea, diffusely diminished breath sounds, and scattered rales on auscultation of lung fields. Initial imaging was notable for bilateral airspace disease and pulmonary opacities on chest radiography and bilateral pneumonia (concerning for COVID-19 pneumonia), mediastinal adenopathy, and splenomegaly on chest computed tomography. Initial laboratory results were notable for leukocytosis 62.5 th/uL, lactic acidosis 2.5 mmol/L, procalcitonin level 4.95 ng/mL, and negative COVID-19 PCR test. Prompt initiation of Vancomycin/Cefepime therapy ensued upon collection of blood cultures in light of possible sepsis. Flagyl, Valacyclovir, and Posaconazole were added to antimicrobial coverage, along with steroid therapy, due to minimal clinical improvement. Tachycardia with significant oxygen requirements alternating between BiPAP and heated high flow nasal cannula with FiO2 ranging from 70-85% persisted. Daily imaging also showed worsening airspace disease. Negative viral, bacterial, and fungal cultures led to subsequent discontinuation of Hydroxyurea therapy due to suspicion of medicationinduced pneumonitis. Three days after cessation of Hydroxyurea, the patient's oxygen requirements began to decrease and imaging revealed interval resolution of pneumonitic changes in the absence of antimicrobial therapy. The patient was later transitioned to Ruxolitinib for his underlying CGL prior to his discharge home without the need for home oxygen therapy. Discussion: Thought to be caused by hypersensitivity pneumonitis, pulmonary toxicity from Hydroxyurea can easily be misdiagnosed. Unfortunately, while much is known about the pancytopenic, gastrointestinal, and cutaneous side effects of Hydroxyurea, few cases in the literature highlight the potentially fatal interstitial pneumopathy caused by Hydroxyurea, first reported in 1999. Thus, this case serves as an additional contribution to the minutiae of literature detailing Hydroxyurea's adverse pulmonary side effect profile. (Figure Presented).

Unilateral total ophthalmoplegia with proptosis and loss of vision in a patient of herpes zoster ophthalmicus: A rare case report

Herpes zoster Ophthalmicus accounts for a minority of all patients with zoster infections. It leads to varied clinical presentations, but total unilateral ophthalmoplegia has rarely been reported in the literature. We hereby present a 50-year-old male patient presenting with the above combination for aiding the clinical diagnosis by dermatologists and ophthalmologists. Early initiation of treatment leads to a near total recovery of ophthalmoplegia in the majority of treated patients.