1. Mayo Clin Proc. 2010 Feb;85(2):172-5. Clinical pearls in infectious diseases. Orenstein R, Litin SC. Division of Infectious Diseases, Mayo Clinic, Rochester, MN 55905, USA. orenstein.robert@mayo.edu PMCID: PMC2813826 [Available on 2010/8/1] PMID: 20118393 [PubMed - indexed for MEDLINE] 2. Ann Emerg Med. 2010 Feb;55(2):A15-7. A $9,000 bill to diagnose shingles? Doctor's ED visit highlights cost of care issues. Berger E. PMID: 20116023 [PubMed - indexed for MEDLINE] 3. Lancet. 2010 Jan 16;375(9710):252. An innocent gallbladder? Mumoli N, Cei M, Orlandi F, Luschi R, Niccoli G. Department of Internal Medicine, Ospedale Civile Livorno, Livorno, Italy. nimumoli@tiscali.it PMID: 20109926 [PubMed - indexed for MEDLINE] 4. Clin Med. 2009 Dec;9(6):630. Aciclovir neurotoxicity is an important side effect of therapy in patients with renal impairment. Brady M, Main J. Comment on: Clin Med. 2009 Jun;9(3):231-5. PMID: 20095318 [PubMed - indexed for MEDLINE] 5. N Engl J Med. 2010 Feb 4;362(5):416-26. Epub 2010 Jan 20. A placebo-controlled trial of oral cladribine for relapsing multiple sclerosis. Giovannoni G, Comi G, Cook S, Rammohan K, Rieckmann P, Soelberg Sorensen P, Vermersch P, Chang P, Hamlett A, Musch B, Greenberg SJ; CLARITY Study Group. Collaborators: Giovannoni G, Comi G, Cook S, Rammohan K, Rieckmann P, Soelberg Sorensen P, Vermersch P, Sandberg-Wollheim M, Cuzick J, Juliusson G, Reingold S, King J, Pollard J, Sedal L, Aichner F, Eggers C, Dive D, Medaer R, Ferreira M, Manchev I, Milanov I, Haralanov L, Deleva N, Petrova N, Bozhinov P, Zahariev Z, Stamenov B, Shotekov P, Petrov I, Moskov R, Emond F, Freedman M, Grand'Maison F, Jacques F, Vorobeychik G, Demarin V, Kovacicek M, Lusic I, Perhat-Bucevic T, Havrdova E, Talab R, Kanovsky P, Soelberg Sorensen P, Petersen T, Gross-Paju K, Kalbe I, Toomsoo T, Elovaara I, Eralinna JP, Reunanen M, Clavelou P, Damier P, Debouverie M, Edan G, Gout O, Labauge P, Laplaud D, Wiertlewski S, Vermersch P, Heidenreich F, Maurer M, Kieseier B, Limmroth V, Oschmann P, Schimrigk S, Steinbrecher A, Zettl U, Ziemann U, Karageorgiou K, Kyritsis A, Papadimitriou A, Amato MP, Bernardi G, Morra VB, Comi G, Galgani S, Gallo P, Patti F, Marrosu M, Pozzilli C, Trojano M, Mancardi GL, Gebeily S, Koussa S, Wehbe M, Yamout B, Vaitkus A, Metra M, Messouak O, Mossaddaq R, Slassi I, Yahyaoui M, Hupperts RM, Czlonkowska A, Kozubski W, Nyka W, Selmaj K, Szczudlik A, Figueiredo J, Pedrosa R, Alifirova V, Balyazin V, Barbarash O, Belova A, Boyko A, Gusev E, Elchaninov A, Jacoupov E, Julev N, Kotov S, Kudryavtsev A, Laskov V, Lesnyak O, Odinak M, Pasechnik E, Poverennonva I, Skoromets A, Spirin N, Stolyarov I, Vorobieva O, Voskresenskaya O, Zaslavskiy L, Zonova E, Bohlega S, El-Jumah M, Drulovic J, Nadj C, Goebels N, Schluep M, Ayed-Frih M, Hentati F, Mhiri C, Mrabet A, Mrissa R, Idiman E, Karabudak R, Turan OF, Ahmed F, Constantinescu C, Giovannoni G, Hawkins C, Palace J, Sharrack B, Loganovsky K, Moskovko S, Nehrych T, Voloshyna NP, Carlini W, Cook S, English J, Garmany G, Glyman S, Huddlestone J, Hurwitz B, Kresa-Reahl K, Mikol D, Pardo G, Rammohan K, Rao H, Reif M, Thrower B, Royal W, Webb R, Wynn D, Naga C, Allen N, Lin K, Stefoski D, Balabanov R. Queen Mary University London, the Blizard Institute of Cell and Molecular Science, Barts and the London School of Medicine and Dentistry, London, United Kingdom. g.giovannoni@qmul.ac.uk Comment in: N Engl J Med. 2010 Feb 4;362(5):456-8. BACKGROUND: Cladribine provides immunomodulation through selective targeting of lymphocyte subtypes. We report the results of a 96-week phase 3 trial of a short-course oral tablet therapy in patients with relapsing-remitting multiple sclerosis. METHODS: We randomly assigned 1326 patients in an approximate 1:1:1 ratio to receive one of two cumulative doses of cladribine tablets (either 3.5 mg or 5.25 mg per kilogram of body weight) or matching placebo, given in two or four short courses for the first 48 weeks, then in two short courses starting at week 48 and week 52 (for a total of 8 to 20 days per year). The primary end point was the rate of relapse at 96 weeks. RESULTS: Among patients who received cladribine tablets (either 3.5 mg or 5.25 mg per kilogram), there was a significantly lower annualized rate of relapse than in the placebo group (0.14 and 0.15, respectively, vs. 0.33; P<0.001 for both comparisons), a higher relapse-free rate (79.7% and 78.9%, respectively, vs. 60.9%; P<0.001 for both comparisons), a lower risk of 3-month sustained progression of disability (hazard ratio for the 3.5-mg group, 0.67; 95% confidence interval [CI], 0.48 to 0.93; P=0.02; and hazard ratio for the 5.25-mg group, 0.69; 95% CI, 0.49 to 0.96; P=0.03), and significant reductions in the brain lesion count on magnetic resonance imaging (MRI) (P<0.001 for all comparisons). Adverse events that were more frequent in the cladribine groups included lymphocytopenia (21.6% in the 3.5-mg group and 31.5% in the 5.25-mg group, vs. 1.8%) and herpes zoster (8 patients and 12 patients, respectively, vs. no patients). CONCLUSIONS: Treatment with cladribine tablets significantly reduced relapse rates, the risk of disability progression, and MRI measures of disease activity at 96 weeks. The benefits need to be weighed against the risks. (ClinicalTrials.gov number, NCT00213135.) 2010 Massachusetts Medical Society PMID: 20089960 [PubMed - indexed for MEDLINE] 6. Gan To Kagaku Ryoho. 2010 Jan;37(1):99-102. [Alteration in antibody-mediated immunity in patients with rituximab-combined chemotherapy and incidence of herpes zoster] [Article in Japanese] Ito K, Okamoto M, Maruyama F, Handa K, Yamamoto Y, Watanabe M, Tsuzuki M, Mizuta S, Kumazawa S, Ohta H, Nakano I, Emi N. Department of Pharmacy, Fujita Health University Hospital, Japan. Rituximab, a chimeric monoclonal antibody against the CD20 protein, has an antineoplastic effect resulting from antibody dependent cellular cytotoxicity (ADCC) and complement-dependent cytotoxicity (CDC). In patients with rituximab-combined chemotherapy, a decline in immunoglobulin can be observed. This is more likely to cause virus reactivation, such as Herpes (H) zoster. However, this fact has not reported in a large-scale study. In order to research immunodeficiency conditions in patients with rituximab-combined therapy, we examined the alteration in immunoglobulin level throughout the treatment among 205 cases with B-cell lymphoma. We also studied the prevalence of H. zoster in those cases. The IgG level throughout the treatment was measured in 89 patients in the research. The median post-chemotherapy IgG level was 41.1% lower than its pre-chemotherapy IgG level. In 58 cases, the IgG level following chemotherapy was below the normal level. In 22 cases, the IgG level dropped to less than half of the pre-chemotherapy level. H. zoster developed in 17 cases (8.3%). There was no significant difference in IgG level between H. zoster-onset cases and non-H. zoster-onset cases. Antibody-mediated immunity can decrease greatly and prolong in cases with rituximab in combination with chemotherapy. Therefore, infection control is considered to be important. PMID: 20087040 [PubMed - indexed for MEDLINE] 7. Zhongguo Ji Hua Mian Yi. 2009 Aug;15(4):327-9. [Epidemiological characteristic of Varicella and Varicella-Zoster virus genotype in Minhang District of Shanghai] [Article in Chinese] Du Y, Jiang LF, Zhang LP. Minhang District Center for Disease Control and Prevention of Shanghai, Shanghai 201101, China. OBJECTIVE: To describe the epidemiological characteristic of varicella, and to find out the genotype of the prevalent Varicella-Zoster Virus (VZV) in Minhang, Shanghai. Analysis was carried out during Nov. 2007 to Apr 2008. METHODS: The data collected from the National Diseases Reporting Management System (NDRS) and Provincial Disease Surveillance Point System (DSP). Samples from herpes of patients were also collected to isolate VZV in Vero and Vero-E6 cell lines, then to detected if cytopathic effect (CPE) by PCR, and finally to identify the genotype by sequence analysis. RESULTS: 29 outbreaks of 271 cases occurred in Minhang during Nov. 2007 to Apr. 2008, and attack rate was 0.42% in average. Among the cases, 37 (13.65%) had vaccinated before getting varicella. Most cases occurred in November and December, and clustered in some areas with population migrant frequently. 2 VZV strains were isolated and identified as genotype J. CONCLUSION: The prevalence of varicella in Minhang was serious. The varicella prevention and control among schools and kindergartens should be strengthened by propaganda and vaccination. PMID: 20077731 [PubMed - indexed for MEDLINE] 8. Zhongguo Ji Hua Mian Yi. 2009 Feb;15(1):78-82. [Varicella] [Article in Chinese] Xu ST. State Key Laboratory for Molecular Virology and Genetic Engineering, Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 100050, China. Varicella is an acute, highly contagious respiratory and caused by Varicella-zoster virus (VZV). After the primary infection, VZV induce Varicella, then the virus remains dormant in sensory nerve roots in life. Upon the reactivation, shingles can occur. Most of patients can recovery very soon, but kinds of potentially severe complication can induce death. Nowadays the VZV vaccination isn't included in the expanded immunization program in our country. Varicella outbreaks take place at times in the middle of children of our country. The paper offers concise description about pathogen characteristics, diagnosis methods, clinical character, epidemiology knowledge and strategy of prevention. PMID: 20077683 [PubMed - indexed for MEDLINE] 9. Zhongguo Ji Hua Mian Yi. 2009 Apr;15(2):127-30. [Isolation identification and serological analysis on varicella-zoster virus from an outbreak in Shanghai in 2007] [Article in Chinese] Lu J, Li CS, Hu JY. Shanghai Municipal Center for Disease Control and Prevention, Shanghai 200336, China. OBJECTIVE: To make serological analysis and identify the etiology of an outbreak of chickenpox in Zhabei District of Shanghai in 2007. METHODS: IgM and IgG of the paired serums were detected by ELISA. The collected herpes were inoculated into MRC-5 cells to get VZV isolations and identify them by VZV standard serums. A 268bp fragment was amplified by specific PCR primers. RESULTS: Among the five paired serums, two of the acute phase serums were VZV IgM positive, one was VZV IgG positive, and two were equivocal for anti-VZV IgG. All of the convalescent serums were VZV IgG positive, and four of them were 4 times higher in antibody titer than those of acute phase serums. Viruses were isolated from all of the 5 herpes, and then identified by VZV standard serum. The electrophoresis result of PCR products showed the single specific strap. CONCLUSIONS: This outbreak was caused by VZV virus. 47.4% of the patients were inoculated in postnatal or domestic VZV vaccines in China 3 years after delivery. The effectiveness of VZV vaccine has been certified. It is necessary to consider the immunization strategy of VZV vaccine. PMID: 20077657 [PubMed - indexed for MEDLINE] 10. Neurology. 2010 Jan 5;74(1):85-6. Polyneuritis cranialis caused by varicella zoster virus in the absence of rash. Murata KY, Miwa H, Kondo T. Department of Neurology, Wakayama Medical University, 840-1 Kimiidera, Wakayama, Japan 641-8510. kemurata@wakayama-med.ac.jp PMID: 20038777 [PubMed - indexed for MEDLINE] 11. Hawaii Med J. 2009 Dec;68(11):277-8. Varicella zoster virus infection in patients taking the TNF-alpha inhibitor, etanercept: coincidence or causal? Izumi A. Department of Dermatology, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI 96813, USA. Ninety percent of varicella infections are seen in children under the age of ten and usually follow a benign clinical course with complete resolution of symptoms in one to three weeks. Herpes zoster an acute vesicular eruption due to the varicella-zoster virus (VZV), occurs mostly in adults. Biologic agents include tumor necrosis factor alpha (TNF-alpha) inhibitors that have significantly impacted the treatment of autoimmune and inflammatory conditions. Therapy with TNF-alpha inhibitors poses a potential risk of serious infections secondary to their immunomodulating properties; however multiple studies have demonstrated acceptable safety and tolerability profiles. A case of documented VZV infection (varicella) in an adult receiving the TNF-alpha inhibitor etanercept is described here. PMID: 20034255 [PubMed - indexed for MEDLINE] 12. Appl Opt. 2009 Dec 10;48(35):6734-9. doi: 10.1364/AO.48.006734. Linear polarization difference imaging and its potential applications. Nan Z, Xiaoyu J, Qiang G, Yonghong H, Hui M. Laboratory of Optical Imaging and Sensing, Graduate School at Shenzhen,Tsinghua University, Shenzhen, 518055, China. We demonstrate a novel linear polarization imaging technique and its potential application in dermatology. This technique records a series of images corresponding to different combinations of illumination and detection polarization and calculates intensity differences between orthogonal detection polarizations pixel by pixel. Fitting the polarization difference data to an analytical expression of the incident and detection polarization angles results in two new parameters, G and (phi3)/2. It is shown that G is strongly correlated to the order of alignment of the fibrous structure in the sample, and (phi3)/2 represents the angle of orientation of the fibers. Preliminary clinical testing implies that this method may be applied for medical diagnosis of skin diseases. PMID: 20011013 [PubMed - indexed for MEDLINE] 13. Adv Nurse Pract. 2008 Dec;16(12):47-9. Herpes zoster alert. Prevent shingles with vaccination and awareness. Carcio H. Health and Continence Institute, Deerfield, Massachusetts, USA. PMID: 19999464 [PubMed - indexed for MEDLINE] 14. Mult Scler. 2009 Dec;15(12):1466-80. Epub 2009 Dec 7. Paediatric and adult multiple sclerosis: age-related differences and time course of the neuroimmunological response in cerebrospinal fluid. Reiber H, Teut M, Pohl D, Rostasy KM, Hanefeld F. Neurochemistry Laboratory, Department of Neurology, University Gottingen, Germany. ho@horeiber.de We investigate common pathophysiology in paediatric and adult multiple sclerosis (MS) by comparison of cerebrospinal fluid (CSF) data. We compared cerebrospinal fluid (CSF) data from eight patient groups with onset of MS at 7 to 29 years (n = 184). A new statistics program allows sensitive detection, quantifies the mean amount of intrathecal Ig synthesis in groups based on the 96% reference range of 4100 non-inflammatory controls, corrects for age-related increase of blood-derived albumin and immunoglobulins in CSF, and presents graphical data interpretation in Reibergrams. Already at onset of MS before puberty (< or =10 years) the frequency of intrathecal IgG synthesis (oligoclonal IgG) was 100% like in adults with 98%, but the amount of intrathecal IgG increases twofold during puberty. Intrathecal IgM synthesis is most frequent before and during puberty (in 57-67% of patients) compared with 41% in adults. The amount of intrathecal IgM synthesis before puberty is only 30% of that in adults. IgG and IgM Index are biased evaluations not suitable for characterizing age-related dynamics. A twofold age-related increase of the albumin quotient, Q(Alb), as a measure of the blood-CSF barrier function, represents normal physiological growth. Cell counts in CSF are low. The pre-puberty gender ratio is about 1:1. Intrathecal antibodies against measles, rubella and/or varicella zoster virus are detected in 73% of patients before puberty compared with 89% of adults. Individual paediatric patients (n = 17), with sequential punctures over 2-5 years, show constant quantities of intrathecal IgM and specific antibodies. In conclusion, paediatric MS already at first clinical manifestation shows the complete, neuroimmunological data pattern in CSF, i.e. inflammatory signs are not gradually evolving. Paediatric and adult MS differ quantitatively but not qualitatively in neuroimmunological patterns which does not allow for discrimination between 'early' and 'late' onset MS. CSF analysis may help to discriminate between acute and mono-symptomatic chronic inflammatory disease already at earliest clinical manifestation. PMID: 19995844 [PubMed - indexed for MEDLINE] 15. Zhongguo Zhen Jiu. 2009 Nov;29(11):887-90. [Observation on therapeutic effect of electroacupuncture at Jiaji (EX-B 2) combined with blood-letting and cupping on herpes zoster] [Article in Chinese] Liu YN, Zhang HX, Huang GF, Zou R, Wei W. Department of Acupuncture and Moxibustion, Wuhan Hospital of Integrated Chinese and Western Medicine, Wuhan 430022, China. shuiyueliang813@163.com OBJECTIVE: To compare the therapeutic effect differences between electroacupuncture at Jiaji (EX-B 2) combined with blood-letting plus cupping and western medicine therapy. METHODS: Fifty-three cases were randomly divided into an observation group (n=31) and a control group (n=22). The observation group was treated by electroacupuncture at Jiaji (EX-B 2) combined with blood-letting with a plum-blossom needle at the affected parts plus cupping, once each day. The control group was treated by oral administration of Valaciclovir Hydrochlordide, Indomethacin, Vitamin B1 and Vitamin B12. RESULTS: The cured and markedly effective rate of 96.8% in the observation group was better than that of 81.8% in the control group (P < 0.05), and improvements of pain, pruritus, burning sensation and sleep in the observation group were superior to those of the control group (all P < 0.01). CONCLUSION: Electroacupuncture at Jiaji (EX-B 2) combined with blood-letting and cupping is a better therapy for herpes zoster and its therapeutic effect is better than that of routine western medicine therapy. PMID: 19994687 [PubMed - indexed for MEDLINE] 16. Rev Prat. 2009 Nov 20;59(9):1287-93. [Herpesvirus infections of the immunocompetant child and adult] [Article in French] Vitrat-Hincky V, Brion JP. Clinique de maladies infectieuses, CHU de Grenoble, BP 217, 38043 Grenoble Cedex 9, France. vhinckyvitrat@chu-grenoble.fr PMID: 19961091 [PubMed - indexed for MEDLINE] 17. Can J Neurol Sci. 2009 Nov;36(6):787-8. MRI changes with acute shingles. Khu KJ, Bernstein M. Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada. PMID: 19960763 [PubMed - indexed for MEDLINE] 18. J Neuroophthalmol. 2009 Dec;29(4):325-37. Complete unilateral ophthalmoplegia in herpes zoster ophthalmicus. Sanjay S, Chan EW, Gopal L, Hegde SR, Chang BC. Department of Ophthalmology and Visual Sciences, Alexandra Hospital, Singapore. sanjay_s@alexhosp.com.sg Based on a review of 20 well-documented cases reported in the English literature between 1968 and 2008, herpes zoster ophthalmicus (HZO) may rarely be associated with complete unilateral ophthalmoplegia, defined here as impaired ocular ductions in all 4 directions within 3 months of onset of manifestations of HZO. Ophthalmoplegia occurred equally in immune-competent and immune-incompetent individuals. HZO preceded ophthalmoplegia in 75% by a mean interval of 9.5 days and a range of 2 to 60 days, occurred simultaneously with ophthalmoplegia in 20%, and followed by 2 days the onset of ophthalmoplegia in only 5%. Concurrent conjunctival inflammation, keratitis, or anterior uveitis was present in 90%. Lumbar puncture showed features of aseptic meningitis in 88%, slightly more than the 40%-50% found in patients with HZO without ophthalmoplegia. On orbit/brain imaging, abnormal enlargement of the extraocular muscles was present in 33%, and orbital soft tissue swelling was present in 17%. Enhancement of ocular motor cranial nerves was not reported. Complete or near-complete resolution of ophthalmoplegia occurred in 65% within a range of 2 weeks to 1.5 years (mean 4.4 months). A single autopsy report described granulomatous angiitis of the meninges and large vessels in the anterior cerebral circulation, as well as periaxial infarction in the optic nerve, pons, and medulla but without viral inclusion bodies or antigen. Unsettled issues are whether the pathogenesis is direct viral invasion or an immune reaction to the virus, whether the impaired ocular ductions are based on myopathic or neuropathic injury, whether there are predisposing factors to the combination of HZO and complete ophthalmoplegia, and whether treatment is effective. PMID: 19952908 [PubMed - indexed for MEDLINE] 19. J Neurosurg Pediatr. 2009 Dec;4(6):528-31. Going viral: fusiform vertebrobasilar and internal carotid aneurysms with varicella angiitis and common variable immunodeficiency. Daugherty WP, Clarke MJ, Cloft HJ, Lanzino GL. Department of Neurosurgery, Mayo Clinic, 200 1st Street Southwest, Rochester, Minnesota 55905, USA. daugherty.wilson@mayo.edu Intracranial aneurysms in the pediatric population are relatively rare entities. Immunocompromised patients (often from HIV/AIDS or pharmacological immunosuppression) represent a significant fraction of children with cerebral aneurysms. One proposed mechanism of aneurysm formation in these patients is from direct infection of the affected arteries. In this study, the authors report on a case of a 14-year-old girl with common variable immunodeficiency with T-cell dysfunction and a CSF polymerase chain reaction test positive for varicella-zoster virus who underwent evaluation for carotid and basilar artery fusiform aneurysms. PMID: 19951038 [PubMed - indexed for MEDLINE] 20. Joint Bone Spine. 2009 Dec;76(6):724-5. Zoster cruralgia in a pregnant woman. Daien CI, Cohen JD, Jorgensen C. PMID: 19945328 [PubMed - indexed for MEDLINE]