[CIS-PAGID] Adult with recurrent "Zoster"

[Colin Freccia]

Dr. Church, you asked about any similar cases to the "Adult with recurrent Zoster"...

I sent out the following case about 6-8 months ago to the listserv:

****
17YO Caucasian male with a painful, recurrent, vesicular cutaneous eruption (HSV-1 positive by PCR on multiple occasions, VZV not detected) involving the forehead only.  Since January 2009 he has had 7-8 localized recurrences despite suppressive doses of valacyclovir, taken as directed, and severe post-herpetic neuralgia requiring pain management and a recent trigeminal nerve block.  The only known risk factors are moderate-to-severe eczema as a young child, resolved, with residual xerosis; uncomplicated chickenpox in early childhood, and aseptic meningitis without sequela at age 10; otherwise healthy, without genital herpes.  No family history of similar illness or immune deficiency disease.

Pertinent laboratory tests:
- CBC:  WBC 5000/mcL, absolute neutrophils 2000, lymphocytes 1580, monocytes 440, eosinophils 870 and basophils 40
- quantitative IgGAM all normal; IgE 3200 U/L
- negative HIV antibody screen
- lymphocyte flow cytometry immunophenotyping:  ALC 1269 (1140-4430/mcL), CD19+ 203 (34-1019), CD3+ 964 (638-3721), CD4+ 546 (364-2659), CD8+ 381 (239-1728) and CD56+ 38 (23-797)
- in vitro PBMC mitogen stimulation:  slightly low responses to PHA and PWM, low to ConA
- anergy to candida DHS skin test
****
Just as a follow-up on that case:  I've been a bit out of touch with this former 17 yo patient, but when I last spoke with his family a few months ago he had been doing well after unilateral trigeminal nerve block.  At that time, he had only one side of the forehead blocked with good results, and he was scheduled for a contralateral block soon after.  His biggest issue was pain management, so the family and patient were quite pleased with the results of the unilateral block.  A recommendation from Dr. Sorensen through the listserv was to consider vitamin D treatment, specifically high-dose vitamin D - he referenced the review in JACI 2008; 122; 261-6.  We did check the patient's vitamin D levels, and he was, at least, insufficient (25OHD concentration 20-30 ng/mL) if memory serves me correctly.  While we didn't opt for high-dose therapy at the time, we did recommend standard therapy of 1000 units of vitamin D3 daily.
Hope that helps!
-Colin

--
Colin Freccia, MD - Fellow
Section of Allergy/Immunology
Department of Immunology/Microbiology
Rush University Medical Center
________________________________
From: pagid-bounces at list.clinimmsoc.org [pagid-bounces at list.clinimmsoc.org] on behalf of Church, Joseph [JChurch at chla.usc.edu]
Sent: Thursday, December 30, 2010 9:18 AM
To: pagid at list.clinimmsoc.org
Subject: Re: [CIS-PAGID] Adult with recurrent "Zoster"

Thanks, Mel.

Has anyone had a similar case?

Joe Church

________________________________
From: pagid-bounces at list.clinimmsoc.org [mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Berger, Melvin
Sent: Wednesday, December 29, 2010 10:27 PM
To: pagid at list.clinimmsoc.org
Subject: RE: [CIS-PAGID] Adult with recurrent "Zoster"

1. Good old-fashioned DTH skin tests.  2. T-cell response by Elispot to autologous cells infected with VZV - see what cytokines he makes compared to controls. 3. TLR responses. 4. Reminders to take his prophylaxis.

Melvin Berger, M.D., Ph.D.
Adjunct Professor of Pediatrics and Pathology
Case Western Reserve University
Cleveland, OH 44106

________________________________
From: pagid-bounces at list.clinimmsoc.org on behalf of Church, Joseph
Sent: Wed 12/29/2010 7:09 PM
To: pagid at list.clinimmsoc.org
Subject: [CIS-PAGID] Adult with recurrent "Zoster"
Colleagues:

A 57yo man was referred for recurrent Herpes zoster.   Lesions have recurred ~ 2 times a year for 20 years.  They affect the same facial location (right ear).  Outbreaks are associated with increased stress and missing Valtrex prophylaxis.  He has absolutely no other infectious history and is otherwise healthy.

NORMAL laboratory findings include the following:

  *   CBC, CMP, sed rate, CRP
  *   IgG, IgA, IgM
  *   Antibody responses to tetanus, hepatitis A and Pneumovaxtm
  *   T, B and NK numbers
  *   PHA and PWM LPAs
  *   Tetanus, Candida and VZV LPAs
  *   NK cytotoxicity (Cincinnati Children’s)
  *   CTL cytotoxicity (Cincinnati Children’s)

Other than the possibility that these episodes are not VZV-related, does anyone have any other ideas?

Joe Church
Children’s Hospital Los Angeles



---------------------------------------------------------------------
CONFIDENTIALITY NOTICE: This e-mail message, including any attachments,
is for the sole use of the intended recipient(s) and may contain confidential
or legally privileged information. Any unauthorized review, use, disclosure
or distribution is prohibited. If you are not the intended recipient, please
contact the sender by reply e-mail and destroy all copies of this original message.
---------------------------------------------------------------------

---------------------------------------------------------------------
CONFIDENTIALITY NOTICE: This e-mail message, including any attachments,
is for the sole use of the intended recipient(s) and may contain confidential
or legally privileged information. Any unauthorized review, use, disclosure
or distribution is prohibited. If you are not the intended recipient, please
contact the sender by reply e-mail and destroy all copies of this original message.
---------------------------------------------------------------------
-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://seven.pairlist.net/mailman/private/pagid/attachments/20101230/4e4c4eb1/attachment.html>