Clinical Case Reports and Trails

Abstract

Varicella zoster virus (VZV) is a member of the family herpesviruses and causes two distinct clinical syndromes: varicella(chickenpox) and herpes zoster(shingles). reactivation of latent VZV, herpes zoster presents as a dermatomal vesicular rash and severe pain. Common presentation of herpes zoster in immunocompetent patients is mono dermatome involvement whereas in patients with immunosuppression may presents multi dermatome. (

Renal transplant recipients require lifelong care and receiving Immunosuppressive drugs to prevent rejection which can increase the risk of opportunistic infections. infections. patients who undergo renal transplantation are prone to reactivation of herpes zoster. Here we presented a 56 years old female patient who received renal transplant 3 month ago.later she felt tingling and itching in right thoracic and back region. After 8 days’ rashes started to appear. She admitted to hospital and Herpes zoster infection was confirmed by positive DNA polymerase chain reaction of the vesicle fluid. her transplant drugs dosage was decreased and we started renal adjusted dose intravenous Acyclovir.

Duration of intravenous treatment was 7 Days and the patient fully recovered.

Introduction

The risk of developing post-transplant zoster increased with older age at the time of transplantation, with each decade conferring a 1.42-fold (P=0.009) increase in risk of zoster development. Seronegativity of zoster at the time of transplantation conferred over 3 times the risk of development of post-transplant zoster (hazard ratio 3.4; P=0.04) compared with seropositivity. Adult kidney transplant recipients are at high risk for the development of post-transplant zoster [1].

Herpes zoster was common among all immunocompromised populations studied, exceeding the expected HZ incidence among immunocompetent adults aged ≥60 years [2].

The incidence of herpes zoster is higher in kidney transplant recipients than in immunocompetent individuals, and kidney transplant recipients are at increased risk of severe herpes zoster-associated disease [3].

The results of controlled trials and the clinical experience of the authors support the use of acyclovir, brivudin (where available), famciclovir, and valacyclovir as first-line antiviral therapy for the treatment of patients with HZ [4].

case

56 years old immunocompromised female kidney transplant (due to unknown aetiology underwent post-deceased donor renal transplant 3 months prior to admission) presented with chief complain of chest pain and vesicular lesions along the right adjacent multidermatom involvement. (T2-T6 dermatomes). Following her renal transplant surgery, the patient was put under immunosuppressant drugs (mycophenolate mofetil 500mg /tds, prednisolone5 mg/day, and tacrolimus 4 mg/day and Cotrimoxazole 400/80 daily). The patient has good drug compliance.

The programed of lesions started with pain, tingling and burn sensational along with right thoracic and back region .... days after participating in a long time and crude ceremony and continued for 8 days before appearance of skin lesions. The patient hasn’t any history of fever and chills, cough, dyspnoea, nausea, vomiting and mental status changes. on arrival she was afebrile with normal vital signs. On physical examination there were clusters of vesicles in which confluents in some area and formed bullae containing yellowish fluid on right T2-T6 dermatomes. (figure 1 at presentation) (figure 2:at discharge)

diagnosis of herpes zoster was performed based on clinical presentation and consequent treatment started with Intravenous Acyclovir 500 mg two times a day. Nephrology consultation was done and they recommended: increasing of prednisolone to 20 mg daily and discontinuing of cellcept and decreasing of tacrolimus to 3 mg/day).

At history taking She didn’t remember any previous history of chickenpox or zoster disease involvement. Also, she hasn’t vaccinated against VZV and recent history of contact with chickenpox patient.

laboratory tests of patient revealed: negative blood culture,

WBC:4/97, x10^ 3 /μl) (3/8-5/5, x10^ 3 /μl), HB:15/5g/dl (11/6-16 g/dl), plt:155, x10^ 3 /μl(150-450 , x10^ 3 /μl), PCT:0/3,ESR 14(up to 20),CRP:4 (up to 6)   ,CR:1/24 mg/Dl (0/6-1/3 mg/dL) ,

Clinical diagnosis was confirmed with positive VZV DNA PCR examination on blister. The patient discharged after 6 days and treatment convert parenteral valacyclovir for seven days. 3 weeks after discharge the lesions were healed. (figure 3)

Fig 1:

Fig 2:

Fig 3:

Discussion

VZV may be reactivated in multiple dorsal root ganglia only when the virus accidentally escapes from cellular immunity in a healthy person, but is more common in an immunosuppressed host [5].

Incidence of HZ in renal transplant recipients is significantly higher than in the healthy population. Prophylactic VZV vaccination before transplantation might reduce HZ associated morbidity after transplantation [6].

The crude HZ incidence was 17.1% in the heart, 14.0% in the lung, 5.8% in the liver, and 9.2% in the kidney transplant recipients. The overall HZ incidence in HTx (30.7 cases/1,000 PY) and LuTx (38.8 cases/1,000 PY) recipients was significantly higher compared to LiTx (22.7 cases/1,000 PY) and KTx (14.5 cases/1,000 PY) recipients [7].

Renal dysfunction and female sex were consistently strong risk factors for herpes zoster events [8].

chronic HBV or HCV infection seemed to be a risk factor for the disease [9].

The only clinical manifestation in four patients was general malaise, fever, and a disseminated vesicular rash; the other four patients also showed visceral involvement: two pneumonitis, one hepatitis, and thrombotic microangiopathy, and one developed multiorgan failure and died due to a delayed diagnosis in a patient positive for HBVs [9].

Complications occurred in 33 of 108 (31%) patients (39% of HTx, 47% of LuTx, 20% of LiTx, 20% of KTx): post-herpetic neuralgia, disseminated disease, and cranial nerve involvement [7].

Complications of herpes zoster included: Postherpetic neuralgia Herpes zoster ophthalmicus,

Acute retinal necrosis, Ramsay Hunt syndrome (herpes zoster oticus) and Disseminated infection [10].

Preventive strategies center around the recombinant zoster vaccine (RZV), which is approved for immunocompromised adults age 19 and older [10].

For (secondary) prophylaxis, currently two HZV vaccines are available for healthy older adults, a live attenuated VZV vaccine and a recombinant adjuvant VZV glycoprotein E subunit vaccine. The latter allows vaccination also in severely immunosuppressed patients [11].

Use of CMV prophylaxis significantly decreases HZ incidence [7].

Pregnant women, children, and immunocompromised patients respond well to acyclovir. Pregabalin and gabapentin along with oxycodone, vitamin C infusion, and MeB12 infusion have shown significant effect in the treatment of post-herpetic neuralgia. Spinal cord stimulation is effective in reducing and preventing post-herpetic neuralgia but at an increased cost. Acute zoster pain can be reduced with epidural anesthetics and steroids [12].

oral prednisone therapy is more effective than antiviral therapy at decreasing the edema and inflammation associated with herpes zoster. Moreover, oral prednisone therapy also greatly reduces the chance of developing post herpetic neuralgia [13].

Conclusion

In conclusion we presented a 56 years old kidney transplant recipient who didn’t receive varicella zoster vaccine. Also, she used immunosuppressive drugs.4 days after participating in crowded place, prodromal symptoms were started but the vesicles started to appear after 8 days. She didn’t have fever.no change in creatinine level or no change in immunosuppressive drugs dosage. As she was immunocompromised her treatment period was longer than immunocompetent patients.

Consent

Informed consent was obtained from the patient for the publication of this case report and accompanying images.

Potential conflicts of interest

The authors declare no conflicts of interest.

References

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