M2 Genotype of Varicella zoster virus associated with Severe Herpes zoster in Pakistan.

This case report is of herpes zoster which is caused by Varicella zoster virus (VZV). The patient was presented with acute renal failure associated with intravenous acyclovir administration for its management. A 50 years old man visited the hospital with rashes on his back. The serum sample was positive for anti-VZV IgM via Enzyme Linked Immunosorbent Assay (ELISA), and vesicular swab for VZV via polymerase chain reaction (PCR). Phylogenetic analysis identified it as M2-genotype. Patient was treated with intravenous acyclovir administration, which led to acute renal failure. Later with shift to oral acyclovir, renal functions were restored. Elderly patients with reactivation of VZV in Pakistan are at risk to contract herpes zoster. Acyclovir is drug of choice via intravenous route was found to be nephrotoxic, however oral acyclovir was safe and effective. This is first report on pathogenic VZV genotype from Pakistan and is presented to highlight that the herpes zoster cases of elderly patients' treatment option need to be revisited.

Prior herpes zoster occurrence and high-dose corticosteroids increase herpes zoster risk in rheumatoid arthritis patients receiving janus kinase inhibitors in a retrospective and observational study.

Herpes zoster (HZ) risk is increased in rheumatoid arthritis (RA) patients receiving Janus kinase inhibitors (JAKi) therapy. Identifying and evaluating the risk factors of HZ development in patients receiving JAKi therapy would be clinically helpful. We investigated HZ's incidence rates (IR), identified the risk factors, and further assessed their influence on HZ development in RA patients undergoing JAKi therapy. We retrospectively evaluated 249 RA patients who received JAKi therapy between 2015 and 2023. Data regarding clinical characteristics, HZ reactivation, HZ vaccination status, and concomitant medication use were collected. Among 249 JAKi-treated patients, 44 developed new-onset HZ (tofacitinib, 28/142; baricitinib, 6/35; upadacitinib,10/72), with an IR of 5.11/100patient-years. Multivariate analysis revealed significant predictors of HZ development: a long JAKi exposure period, prior HZ or COVID-19 history, and concomitant high-dose corticosteroids use. The interval between JAKi initiation and HZ development was significantly shorter in patients with prior HZ history than in those without (median, 6.5 months versus 33.5 months, p < 0.001), suggesting "biphasic" emergence of HZ. Only one patient who had experienced an HZ episode while receiving JAKi developed recurrent HZ. None of the seventeen patients immunized with the non-live recombinant zoster vaccine developed HZ. Our JAKi-treated patients had elevated HZ risks, a class effect across different JAKi. A long exposure period, prior history of HZ or COVID-19, and concomitant high-dose corticosteroid treatment may further increase the risk. The emergence of HZ shows a biphasic pattern: early HZ development in patients with prior HZ and late development in those without. Key Points • An increased risk of HZ was observed in Taiwanese RA patients treated with JAKi, presenting as a class effect. • Patients with a long JAKi exposure period, prior history of HZ or COVID-19, and concomitant use of high-dose corticosteroids were at high risk of HZ while receiving JAKi therapy. • The interval between JAKi initiation and HZ occurrence was shorter in patients with prior HZ than in those without, showing "biphasic" emergence.

Cost-Effectiveness of the Recombinant Zoster Vaccine Among People Living With HIV in Japan.

OBJECTIVES: People living with HIV (PLWHIV) are susceptible to opportunistic infections including herpes zoster (HZ) and postherpetic neuralgia (PHN). The recombinant zoster vaccine (RZV) (Shingrix) is available in some countries. However, the cost-effectiveness for PLWHIV remains unknown. This study aimed to analyze the cost-effectiveness of RZV for PLWHIV ≥50 years old. METHODS: A Markov model was developed to compare the cost-effectiveness of the 2-dose RZV immunization program with no RZV immunization for PLWHIV aged ≥50 years. We built the model with a yearly cycle over a 30-year period and 6 health conditions: HZ free, HZ, PHN, HZ/PHN recovery, HZ recurrence, and death. The parameters in the model were based on previous studies and a nationwide administrative claims database in Japan. The incremental cost-effectiveness ratio (ICER), expressed as Japanese yen (JPY) per the quality-adjusted life-years (QALYs), was estimated from a societal perspective. We conducted a one-way deterministic sensitivity analysis, probabilistic sensitivity analysis with Monte Carlo simulations of 10 000 samples, and scenario analyses. RESULTS: The ICER of the 2-dose RZV immunization program over no RZV immunization was 78 777 774 JPY (approximately 600 000 US dollars)/QALY. The one-way deterministic sensitivity analysis showed that HZ-related utility was the most significant for ICER. All estimates in the probabilistic sensitivity analysis were located above the willingness-to-pay threshold of 5 million JPY/QALY. CONCLUSIONS: Our study revealed that no RZV immunization was more cost-effective than the 2-dose RZV immunization program for PLWHIV aged ≥50 years. This may be useful in evidence-based policy making.

Disseminated herpes zoster with varicella encephalitis and pneumonia following ChAdOx1 nCoV-19 (AZD1222) vaccine in an immunocompetent male-a case report.

A middle-aged gentleman, presented to our outpatient department with painful skin lesions suggestive of disseminated herpes zoster. Further examination revealed bilateral cerebellar signs. He had a history of receiving a third dose of AZD1222 vaccine fourteen days prior to the onset of skin lesions but had no other significant medical history. The patient was also evaluated for retroviral infection and other immunodeficient states, workup for which were negative. The patient was initially treated with intravenous acyclovir 7.5 mg/kg/q8H; however, the patient developed varicella encephalitis on treatment, which was followed by pneumonia and haemorrhagic cystitis. Subsequently, treatment was started with acyclovir 10 mg/kg/q8H for 14 days, followed by valacyclovir for eight days, following which there was near-complete resolution of symptoms with the persistence of minimal rigidity. Although there have been several reports of herpes zoster following SARS-CoV-2 vaccination, we found few reports of varicella zoster with systemic manifestations following ChAdOx1 nCoV-19 (AZD1222) vaccination. This case highlights the importance of considering varicella zoster reactivation in a patient presenting with encephalitis or pneumonia post SARS-CoV-2 vaccination.

Varicella Zoster Virus Vasculopathy: An Under-Recognized Entity.

Varicella zoster virus (VZV) vasculopathy is a rare yet potentially severe neurological manifestation resulting from VZV reactivation, primarily affecting immunocompromised individuals. We present a case report of a 61-year-old male with VZV vasculopathy who initially presented with herpes zoster ophthalmicus, subsequently complicated by meningoencephalitis and an acute infarct in the territory of the left middle cerebral artery (MCA). Imaging revealed acute and chronic infarcts in the capsuloganglionic regions, accompanied by thickening and enhancement of the left MCA wall. Treatment involved a 14-day course of intravenous acyclovir, supplemented with oral prednisolone, resulting in modest clinical improvement. VZV vasculopathy represents an infrequently acknowledged neurological syndrome, particularly prevalent among immunocompromised individuals. Early recognition and appropriate intervention offer promise in ameliorating outcomes for affected patients. This case emphasizes the importance of including VZV vasculopathy in the differential diagnosis of neurological deficits, especially within high-risk populations.

No Causal Effect of COVID-19 on Varicella-Zoster Infection, Herpes Zoster Progression, and Postherpetic Neuralgia: A Two-Sample Mendelian Randomization Study.

Purpose: Coronavirus disease (COVID-19) may trigger the reactivation of the latent varicella-zoster virus and may be a risk factor for herpes zoster (HZ). However, the causal relationship between COVID-19 and varicella-zoster infections remains controversial. This study aimed to estimate the causal inferences between COVID-19 and HZ. Methods: This study used a two-sample Mendelian randomization (MR) design. The inverse variance-weighted method was used as the primary method and sensitivity analyses were conducted, including the MR-Egger regression, weighted median and weighted mode. We searched at https://gwas.mrcieu.ac.uk/ using the keywords "COVID-19" for exposure data and "zoster" for outcome datasets. Results: We got 26 COVID-19 datasets and five zoster datasets. We used 26 COVID-19 datasets as exposure data corresponding to each zoster dataset for the MR analysis. There were nine datasets of COVID-19 where the number of SNPs was fewer than three in the MR analysis of the risk of HZ, varicella zoster virus (VZV) glycoprotein E and I antibody levels, anti-VZV IgG seropositivity, and post-zoster neuralgia. In addition, there were 10 datasets of COVID-19 where the number of SNPs was less than three in the MR analysis of anti-VZV IgG levels. The results of the MR analysis showed that all p-values were greater than 0.05. Sensitivity analysis revealed no evidence of horizontal pleiotropy in most two sample MR analyses. Conclusion: Our results indicate that there is no causal relationship between COVID-19 and varicella-zoster infection, HZ progression, and postherpetic neuralgia.

Herpes Zoster Ophthalmicus: Presentation, Complications, Treatment, and Prevention.

Herpes zoster (HZ) is caused by reactivation of latent infection of varicella zoster virus (VZV) in sensory (cranial, dorsal root) ganglia. Major risk factors for HZ are increasing age and immunosuppression. HZ ophthalmicus (HZO) is a subset of HZ with involvement of the ophthalmic division of the fifth cranial trigeminal nerve. Approximately 4-20% of patients with HZ develop HZO. Approximately 50% of patients with HZO develop ocular disease, among whom up to 25% develop chronic or recurrent disease. Common manifestations of ocular disease include conjunctivitis, keratitis, and uveitis, whereas optic neuropathy and retinitis are uncommon. Due to the potential for vision impairment, ocular involvement requires urgent ophthalmic consultation. Early recognition and timely treatment with antivirals may prevent ocular complications. HZO is preventable by vaccination against HZ. Vaccine efficacy/effectiveness studies have been largely conducted for HZ with few studies assessing HZO. Both the recombinant adjuvanted vaccine (RZV) and live-attenuated vaccine (ZVL) significantly reduce the incidence of HZ and HZO in older adults. RZV is more effective than ZVL. Data on the effectiveness of vaccines for prevention of recurrent disease in patients with HZO are limited; however, vaccination is recommended. Despite recommendations to vaccinate individuals likely to benefit from an HZ vaccine, coverage for adults remains suboptimal. Barriers to vaccination include patient beliefs about HZ or HZ vaccines, and factors related to healthcare providers. In particular, the lack of a recommendation from their primary care physician is often cited by patients as a reason for remaining unvaccinated. By encouraging vaccination against HZ, physicians not only prevent HZ and HZO but also potential vision loss due to HZO.Graphical abstract available for this article.

Shingles, also known as herpes zoster, is a common and painful rash that develops when the virus that causes chickenpox in children reactivates, most often in adults. When shingles affects the eye or the area surrounding the eye, it is called herpes zoster ophthalmicus, or HZO for short. Up to one-fifth of people with shingles have HZO, and this risk increases with age and in people with other conditions that affect their immune system. Common signs and symptoms include a rash on the face, pain, fever, and headache, as well as symptoms in the eye, such as discomfort, redness, and discharge. HZO has the potential to cause permanent vision loss, and because of this, it is important that people with symptoms are referred to an eye doctor ("ophthalmologist") as soon as possible. Early diagnosis of HZO is essential for effective treatment and prevention of the more serious complications it can cause. Treatment within 3 days of the symptoms occurring, with medications known as antivirals, can shorten the duration of a shingles episode and help relieve the pain. To help prevent the risk of shingles and its subtypes like HZO, vaccination is recommended. Two vaccines are currently approved for the prevention of shingles in adults. Although these vaccinations are recommended, some people do not have them for various reasons, which include their own personal beliefs about vaccinations or that their doctor has not recommended it to them. It is important that vaccinations against shingles are recommended to all patients eligible to receive one.

A comprehensive, updated systematic review and meta-analysis of epidemiologic evidence on the connection between herpes zoster infection and the risk of stroke.

Stroke is a common worldwide cause of death and disability, resulting from an obstruction or reduction in blood flow to the brain. Research has demonstrated that systemic infection such as herpes zoster (HZ) / ophthalmicus herpes zoster (HZO) can potentially trigger stroke. This study includes an updated systematic review and meta-analysis of the epidemiologic data on the connection between HZ/HZO infection and the risk of stroke. A meticulous search of different database yielded 905 studies. Furthermore, an additional 14 studies from a previous meta-analysis were incorporated. Eligible studies underwent rigorous screening, resulting in 18 papers. Statistical analyses, including random/fixed effects models and subgroup analyses, were conducted to assess pooled relative risk (RR) and heterogeneity. The meta-analysis consisted of 5,505,885 participants and found a statistically significant association between HZ infection and the risk of stroke (pooled RR = 1.22, 95% confidence interval [CI] 1.12-1.34). The HZO infection showed a significantly higher overall pooled RR of 1.71 (95% CI 1.06-2.75), indicating a strong connection with the risk of stroke. Subgroup analysis revealed that the odds ratio might play a significant role in causing heterogeneity. Time since infection emerged as a crucial factor, with heightened stroke risk in the initial year post-HZ/HZO exposure, followed by a decline after the first year. Asian/Non-Asian studies demonstrated varied results in HZ/HZO patients. Meta-analysis reveals a significant HZ/HZO-stroke link. Subgroups highlight varied risks and warrant extended Asian/non-Asian patient investigation.

Outcomes of Twice Repeated High-Voltage Long-Duration Pulsed Radiofrequency Treatment in Subacute Postherpetic Neuralgia: a Retrospective Single-Center Analysis.

Background: The treatment of herpes zoster-related pain is challenging, and requires a variety of methods including pulse radio frequency modulation. Among them, single-time high-voltage long-term pulsed radiofrequency (HL-PRF) has been proved to be an effective treatment for subacute postherpetic neuralgia. However, it has the possibility of poor long-term curative effect and recurrence of neuralgia. In this study, we aim to identify the clinical efficacy and safety of twice repeated HL-PRF treatment in patients with subacute postherpetic neuralgia. Design: We conducted a retrospective analysis of subacute postherpetic neuralgia patients who underwent HL-PRF treatment. Setting: Pain Management Department of First Affiliated Hospital of Wannan Medical College. Patients: We enrolled all patients with subacute postherpetic neuralgia, who underwent HL-PRF treatment from January 2023 to October 2023. Measurements: The primary outcome variable was the visual Analog Scale (VAS) scores at 1, 4, 8, and 12 weeks after treatment. Secondary outcomes included Pittsburgh sleep quality index (PSQI), 36-item short-form health survey (SF-36) score, and total effective rate after treatment. Results: A total of 63 patients were included in the analysis. Among them, 33 patients received single-time HL-PRF treatment (Group S) and 30 patients received twice repeated HL-PRF treatment (Group T). Pain scores, PSQI scores, and SF-36 score were reduced in both groups after treatment (P < 0.001). Compared to group S, the VAS scores, PSQI scores, anxiety scores, and depression scores were significantly lower at 1, 4, 8, and 12 weeks in group T. (P < 0.001). The total efficiency rate at 12 weeks after treatment of group T was statistically higher than that of group S (60.6% vs 86.7%, P < 0.05). Conclusion: Twice repeated high-voltage long-duration PRF therapy demonstrates satisfactory efficacy in patients with subacute postherpetic neuralgia and is associated with no significant adverse reactions.

Herpes Zoster Optic Neuritis: A Catastrophe of a Disease.

Isolated herpes zoster optic neuritis is a rare sequelae of herpes zoster ophthalmicus (HZO). It can occur in the acute phase of HZO, or as post-herpetic complications. We report a case of a young patient with poorly controlled diabetes who developed herpes zoster optic neuritis one month after the initial skin manifestation despite completing a two-week course of oral acyclovir 800 mg five times a day. He complained of a five-day history of sudden onset, painless left eye blurring of vision. His vision over the left eye was no light perception with the presence of a left relative afferent pupillary defect. Fundus examination of the left eye revealed a swollen optic disc. Magnetic resonance imaging showed minimal fat streakiness over the left orbit. He was treated with one week of intravenous methylprednisolone 1 g/day, followed by a tapering dose of oral prednisolone (1 mg/kg/day) together with oral acyclovir 800 mg five times a day for another week. His visual acuity remained poor with a slight improvement in vision to hand motion.

Herpes Zoster Ophthalmicus Secondary to Periorbital Cellulitis.

Varicella zoster virus (VZV) infection, also commonly known as chickenpox, is a communicable disease most often contracted in childhood via contact, airborne, or droplet transmission. After about a two-week incubation period, patients can experience a prodromal phase, which includes a pruritic vesicular blistering rash with associated constitutional symptoms such as fever, headache, malaise, muscle aches, fatigue, and sore throat. Symptoms are often self-limiting and only require supportive care and observation. We report a case of a 54-year-old female who presented with an unusual background history and was found to have a rare manifestation of herpes zoster virus, presenting as herpes zoster ophthalmicus (HZO).

Association of Psoas: Lumbar Vertebral Index (PLVI) with Postherpetic Neuralgia in Patients Aged 60 and Older with Herpes Zoster.

Background/Objectives: The psoas: lumbar vertebral index (PLVI) is a simple and convenient measure to assess central sarcopenia. Recent studies have utilized the psoas area to indirectly assess sarcopenia and frailty, exploring their associations with various health outcomes. This study aims to investigate the relationship between the PLVI and postherpetic neuralgia (PHN) in patients aged 60 years and above following a herpes zoster (HZ) infection. Methods: We conducted a retrospective analysis of data from 351 patients (≥60 years) who developed HZ between January 2019 and December 2023; the patients were divided into two groups based on the presence or absence of PHN after HZ onset. Results: The analyses using receiver operating characteristic curves revealed a value for the area under the curve of 0.813 for PLVI and 0.769 for the modified frailty index (mFI). In a multivariate logistic regression analysis, numerical rating scale scoring, a low PLVI, and a greater number of categorical mFI variables (adjusted odds ratio: 1.30, 3.27, and 2.46, respectively) were found to be significant independent predictors of PHN. Conclusions: Our findings highlight the association between a low PLVI and PHN in an older population. The PLVI may have potential as a predictive tool for PHN in older patients with HZ, but further research is needed to confirm these results.

Increased Risk of Herpes Zoster in Rheumatoid Arthritis Not Only Due to JAK Inhibitors-Study of 392 Patients from Single University Center.

Background/Objectives: Patients with rheumatoid arthritis (RA) have an increased risk of infection. Their risk of presenting herpes zoster (HZ) is 1.5-2 times higher than immunocompetent individuals and disseminated presentation is more frequent. Our aim was to analyze the prevalence and general features of HZ in RA patients. Methods: This was a prospective study of 392 RA patients included in the vaccination program of our hospital between 2011 and 2016, and follow-up continued until December 2020. A diagnosis of HZ was made according to clinical manifestations: skin rash, blisters, paresthesia, and local pain in one or more dermatomes. Results: We studied 392 participants (309 women/83 men), mean age 59 ± 13 years. Every patient was followed-up over a mean period of 137 ± 110 months (range: 42 months-42 years). HZ infection was observed in 30 of 392 (25 women/5 men) patients, age (mean ± SD) 64.7 ± 11.8 years. Prevalence was 7.65% in this period and the incidence rate was 13.22/1000 patients/year. Three patients had facial involvement, one had optic involvement, and one patient presented disseminated HZ. Seven patients presented post herpetic neuralgia treated with gabapentinoids. The main features of RA of these 30 patients were: positive RF (n = 17; 56.6%), positive anti-CCP (n = 13; 43.3%), and erosive disease (n = 10; 33.3%). At HZ infection, the treatments were glucocorticoids (n = 19; 63.3%), conventional DMARDs (n = 15; 50%), biological DMARDs (n = 15; 50%), tofacitinib (n = 2; 6.6%), and upadacitinib (n = 1; 3.3%). Conclusions: HZ is a relatively frequent viral complication in RA patients. In our series, one patient presented disseminated HZ and nearly 25% of patients had post-herpetic neuralgia. Including a HZ vaccine in our vaccination program for RA patients may be beneficial.

Case Report: Isolated Vertigo as the Sole Manifestation of Left Lateral Medullary Infarction Following Contralateral Varicella-Zoster Virus Infection.

Background: Cerebral infarct associated with varicella-zoster virus (VZV) has been reported in the literature, while isolated central dizziness due to lateral medullary infarct (LMI) following VZV infection is rarely reported. Case report: We report the case of a 65-year-old man who presented to the neurology department because of herpes zoster on the right trigeminal nerve distribution. At 12 hours after admission, he developed transient vertigo along with nausea and unsteady walking and left-sided spontaneous horizontal nystagmus, gaze-evoked nystagmus, and upbeat nystagmus. The other usual signs of LMI including Horner syndrome, dysarthria, swallowing difficulty, and hemibody sensory change were absent. Video head impulse indicated decreased head impulse gain of the vestibulo-ocular reflex for the bilateral horizontal, anterior, and posterior semicircular canals with abnormal saccade waves. Suppression head impulse paradigm showed few downward saccades reflecting anti-compensatory saccades after the end of the head impulse back to the head-fixed target and decreased vestibulo-ocular reflex gain values of bilateral semicircular canals. Brain magnetic resonance imaging (MRI) showed a small infarct in the far dorsolateral portion of the left rostral medulla. The cerebrospinal fluid was positive for VZV DNA. Conclusions: In patients with VZV infection who develop dizziness, the possibility of cerebral infarct should be considered. Patients with facial herpes zoster and neurological symptoms always be screened for stroke using MRI and lumbar puncture should be performed and acyclovir administered empirically.

Knowledge, Attitudes, and Practices Regarding Herpes Zoster Vaccination Among Specialists.

Recombinant zoster vaccine has been recommended by the US Advisory Committee on Immunization Practices (ACIP) for the prevention of herpes zoster (HZ) in immunocompetent adults aged at least 50 years since 2018. In January 2022, this was extended to immunodeficient/immunosuppressed adults aged at least 19 years. Key study objectives were to assess specialists' knowledge of the ACIP HZ vaccination recommendations, their attitudes toward HZ vaccination, and HZ vaccination practices/barriers. This cross-sectional, web-based survey (conducted in March 2022) included US dermatologists, gastroenterologists, infectious disease specialists, oncologists, and rheumatologists who treat patients with psoriasis, inflammatory bowel disease, human immunodeficiency syndrome, solid tumors/hematological malignancies, and rheumatoid arthritis, respectively. Although most of the 613 specialists correctly identified the ACIP HZ vaccination recommendations for adults aged at least 50 years (84%) and immunodeficient/immunosuppressed adults aged at least 19 years (67%), only 29% knew that recombinant zoster vaccine is recommended for individuals who have previously received zoster vaccine live, and only 18% knew all current ACIP recommendations. For patients with the diseases listed, 84% of specialists thought that HZ is a serious risk, 75% that HZ vaccination is extremely/very important, and 69% were extremely/very likely to recommend HZ vaccination. Only 36% administer vaccines themselves, mainly because patients receive vaccinations from others. Barriers to vaccination included more urgent/acute issues, insufficient time, and lack of patient motivation/willingness. Full knowledge of the ACIP HZ vaccination recommendations among the surveyed specialists was low. There may be a need to educate specialists to improve adherence to these recommendations. [Figure: see text].

Efficacy, reactogenicity, and safety of the adjuvanted recombinant zoster vaccine for the prevention of herpes zoster in Chinese adults ≥ 50 years: A randomized, placebo-controlled trial.

Phase III multi-country studies (ZOE-50/70) demonstrated that the adjuvanted recombinant zoster vaccine (RZV) was well tolerated and prevented herpes zoster (HZ) in healthy ≥ 50-year-olds, with a vaccine efficacy (VE) > 90% across age groups. These pivotal trials did not enroll participants from mainland China where RZV is licensed, therefore similar clinical data are missing for this population. In this phase IV observer-blind study (NCT04869982) conducted between 2021 and 2023 in China, immunocompetent and medically stable ≥ 50-year-olds were randomized 1:1 to receive two RZV or placebo doses, 2 months apart. This study assessed the VE (overall, as confirmatory objective, and descriptively by age category [50-69-year-olds/≥ 70-year-olds]), reactogenicity, and safety of RZV in this Chinese population. Of the 6138 enrolled participants, 99.2% completed the study. During a mean follow-up period of 15.2 (±1.1) months, 31 HZ episodes were confirmed (RZV = 0; placebo = 31) for an incidence rate of 0.0 vs 8.2 per 1000 person-years and an overall VE of 100% (89.82-100). The descriptive VE was 100% (85.29-100) for 50-69-year-olds and 100% (60.90-100) for ≥ 70-year-olds. Solicited adverse events (AEs) were more frequent in the RZV vs the placebo group (median duration: 1-3 days for both groups). Pain and fatigue were the most frequent local and general AEs (RZV: 72.1% and 43.4%; placebo: 9.2% and 5.3%). The frequencies of unsolicited AEs, serious AEs, potential immune-mediated diseases, and deaths were similar between both groups. RZV is well tolerated and efficacious in preventing HZ in Chinese ≥ 50-year-olds, consistent with efficacy studies including worldwide populations with similar age and medical characteristics.

What is the context? Herpes zoster, commonly known as shingles, is a painful rash resulting from the reactivation of the dormant virus causing chickenpox.Vaccines preventing shingles, such as Shingrix, were shown to be well tolerated and efficacious in healthy adults over 50 years of age from Europe, North and Latin America, Australia, and Asia (Taiwan, Hong Kong, Korea, Japan).However, data on real-world protective effect of Shingrix are limited in some regions where the vaccine is licensed for use, such as mainland China.What is new? We analyzed data from Chinese adults aged 50 years or older to determine the efficacy and safety of Shingrix.Around 6000 participants were divided in two equal groups to receive two doses of Shingrix or two doses of a placebo, given 2 months apart.We found that, during the study period, the vaccine was 100% efficacious in preventing shingles.We showed that the vaccine had an acceptable safety profile in this Chinese population.What is the impact? Shingrix is efficacious and well tolerated in Chinese adults over 50 years of age, as it is in similarly aged populations from other evaluated regions.

Delayed Superior Orbital Fissure Syndrome Arising More than One Month after Herpes Zoster Ophthalmicus and Meningitis.

A 79-year-old woman developed herpes zoster ophthalmicus (HZO) with a vesicular rash on the nasal root, which developed soon after intravenous acyclovir therapy. Although varicella zoster virus DNA was undetectable in the cerebrospinal fluid, she presented with ophthalmoplegia without optic nerve dysfunction 32 days after the onset of HZO. We diagnosed the patient with superior orbital fissure syndrome and administered intravenous immunoglobulin and systemic corticosteroids. Ophthalmoplegia did not immediately respond to these therapies but resolved 4 months later. We should be aware that ophthalmoplegia can occur, even after HZO and meningitis are completely treated.

Varicella-zoster virus-related neurological complications: From infection to immunomodulatory therapies.

The Varicella-zoster virus (VZV), classified as a neurotropic member of the Herpesviridae family, exhibits a characteristic pathogenicity, predominantly inducing varicella, commonly known as chickenpox, during the initial infectious phase, and triggering the reactivation of herpes zoster, more commonly recognized as shingles, following its emergence from a latent state. The pathogenesis of VZV-associated neuroinflammation involves a complex interplay between viral replication within sensory ganglia and immune-mediated responses that contribute to tissue damage and dysfunction. Upon primary infection, VZV gains access to sensory ganglia, establishing latent infection within neurons. During reactivation, the virus can spread along sensory nerves, triggering a cascade of inflammatory mediators, chemokines, and immune cell infiltration in the affected neural tissues. The role of both adaptive and innate immune reactions, including the contributions of T and B cells, macrophages, and dendritic cells, in orchestrating the immune-mediated damage in the central nervous system is elucidated. Furthermore, the aberrant activation of the natural defence mechanism, characterised by the dysregulated production of immunomodulatory proteins and chemokines, has been implicated in the pathogenesis of VZV-induced neurological disorders, such as encephalitis, myelitis, and vasculopathy. The intricate balance between protective and detrimental immune responses in the context of VZV infection emphasises the necessity for an exhaustive comprehension of the immunopathogenic mechanisms propelling neuroinflammatory processes. Despite the availability of vaccines and antiviral therapies, VZV-related neurological complications remain a significant concern, particularly in immunocompromised individuals and the elderly. Elucidating these mechanisms might facilitate the emergence of innovative immunomodulatory strategies and targeted therapies aimed at mitigating VZV-induced neuroinflammatory damage and improving clinical outcomes. This comprehensive understanding enhances our grasp of viral pathogenesis and holds promise for pioneering therapeutic strategies designed to mitigate the neurological ramifications of VZV infections.

Genetic insights into the gut microbiota, herpes zoster, and postherpetic neuralgia: a bidirectional two-sample Mendelian randomization study.

Background: An increasing amount of evidence suggests that gastrointestinal diseases are risk factors for herpes zoster (HZ) and postherpetic neuralgia (PHN). Among them, the gut microbiota may play a crucial role in this process. Therefore, this study aims to explore the potential causal association between the gut microbiota and HZ and PHN. Methods: Bidirectional two-sample Mendelian randomization (MR) analysis was used to detect the causal effect between HZ and PHN and the gut microbiota. Gut microbiota data were derived from the MiBioGen consortium, while HZ and PHN data were obtained from the FinnGen database. We selected single-nucleotide polymorphisms (SNPs) as instrumental variables with a threshold of p < 1 × 10⁻5 for the association with the gut microbiota in forward MR analysis and p < 5 × 10⁻8 for the association with HZ or PHN in reverse MR analysis and then removed SNPs in linkage disequilibrium (r 2 < 0.001) within a distance of 10,000 kb for both the gut microbiota and HZ and PHN. These SNPs were utilized to assess the causal effect between exposures and outcomes using inverse-variance weighting (IVW), MR-Egger, weighted mean, and weighted median tests. Results: The class Deltaproteobacteria, order Desulfovibrionales, family Desulfovibrionaceae, and genus Coprococcus 2 were found to reduce the risk of HZ, while the phylum Cyanobacteria, genus Eubacterium rectale group appeared to increase it. The class Coriobacteriia, order Coriobacteriales, family Coriobacteriaceae, genus Lachnospiraceae NK4A136 and genus Ruminococcaceae UCG011 were found to reduce the risk of PHN, while the genus Candidatus Soleaferrea, genus Eubacterium rectale group, and genus Methanobrevibacter appeared to increase it. Moreover, the onset of HZ was found to increase the level of the genus Eubacterium rectale group. These findings remained robust and unaffected by heterogeneity or horizontal pleiotropy among SNPs in both forward and reverse MR analysis. Conclusion: This MR study provided evidence supporting a potential causal relationship between the gut microbiota and HZ and PHN. Moreover, we found that the causal effect between the gut microbiota and HZ is bidirectional. Further studies are required to clarify the biological mechanisms linking the gut microbiota and these conditions.