Detection of varicella zoster virus in genital specimens using a multiplex polymerase chain reaction

OBJECTIVE: To compare the relative proportions of varicella zoster virus (VZV) and herpes simplex viruses in specimens obtained from the genital lesions of adults presenting with presumed genital herpes infection. METHODS: Swabs of genital lesions from 6210 patients attending general practices, infectious diseases clinics within hospitals, or sexual health centres for treatment of their genital lesions were tested using polymerase chain reaction (PCR) technology. The multiplexed PCR was capable of detecting herpes simplex virus types 1 and 2 (HSV-1, HSV-2), VZV, and cytomegalovirus in a single sample. RESULTS: A total of 2225 patients had viruses detected by PCR. HSV-1 was detected in 36%, HSV-2 in 61%, and VZV in 2.9% of PCR positive samples. Of the 65 patients with VZV genital infection, many were thought to have HSV infection before laboratory testing. CONCLUSIONS: The finding of VZV in nearly 3% of virus positive genital specimens demonstrates that this virus needs to be considered as a differential diagnosis for genital herpetic lesions. Advice provided to patients with VZV genital infection regarding the source of infection, likelihood of recurrence, and potential for transmission of the virus will be different from that given to patients with HSV infection.     

Herpetic Folliculitis

BACKGROUND: Although herpetic skin infection is very common, herpetic folliculitis is infrequently reported in the literature. It has varied presentations, some of which are clinically atypical requiring histopathological confirmation of follicular involvement. OBJECTIVE: We describe an otherwise healthy young adult male with extensive herpetic sycosis of the beard area, which is a variant of herpetic folliculitis. The diagnosis was confirmed by typical herpetic cytopathic changes in Tzanck smear and positive viral culture for HSV-1. METHOD: This article includes a case report and a literature review of herpetic (simplex and varicella/zoster) folliculitis. Conclusions: More cases of herpetic folliculitis should be reported to improve our understanding of this disease entity. Physicians should consider herpetic or other viral etiology in patients with folliculitis even if they were healthy, especially if they show resistance to antibacterial and antifungal therapy.     

Rapid diagnosis in varicella and herpes zoster: re-evaluation of direct smear (Tzanck test) and electron microscopy including colloidal gold immuno-electron microscopy in comparison with virus isolation

The Tzanck test and electron microscopy with the technique of colloidal gold labelling in varicella-zoster virus (VZV) infections were compared with virus isolation in 54 patients with clinically suspected varicella or herpes zoster infection. The Tzanck test and direct electron microscopy can determine whether or not an eruption is herpetic but cannot distinguish between herpes simplex virus (HSV) and VZV infection. However, colloidal gold immuno-electron microscopy, using monoclonal antibodies against HSV and anti-VZV IgG, can distinguish between these two herpes viruses. This achieves the same specificity as virus isolation followed by virus neutralization or virus typing using immunofluorescence techniques. The Tzanck test was positive in 91%, virus isolation, under optimal conditions of sampling and transportation, in 80%, direct electron microscopy (negative staining) in 80%, and colloidal gold immuno-electron microscopy after a virus concentration procedure in 95% of the cases. The colloidal gold technique offers a rapid diagnosis in patients with suspected VZV infection.     

Varicella-zoster virus antigen expression of eccrine gland and duct epithelium in herpes zoster lesions

Background It is well known that varicella‐zoster virus (VZV) exhibits tropism for the epidermis and follicular epithelium, while little attention has been paid to eccrine gland and duct involvement by VZV. The presence of herpetic syringitis in immunocompromised hosts suggested the possibility of eccrine gland and duct involvement by VZV. Objectives To determine whether VZV antigens could be detected in eccrine gland or duct epithelium of herpes zoster (HZ) lesions obtained at various intervals after the onset of a rash, and whether this expression could also be detected in eccrine units from other inflammatory disease lesions suggestive of VZV infection. Methods We investigated immunohistochemically in vivo localization of VZV glycoprotein E (gE) antigen in HZ lesions and control inflammatory disease lesions, using the murine monoclonal antibody directed against the VZV gE. Results VZV gE was differentially detected in the epidermis, follicular and eccrine epithelium, and dermal infiltrating cells in HZ lesions obtained at various intervals after onset. The VZV gE was most persistently detected in eccrine units, regardless of the age of individual HZ lesions, compared with keratinocytes and follicular epithelium. The gE expression was also observed in other inflammatory disease lesions suggestive of VZV infection. Conclusions Immunohistochemical detection of VZV gE in eccrine epithelium can be a subtle clue to the diagnosis of HZ which displays most unusual manifestations, and VZV‐related disorders.     

Identification and characterization of 20 immunocompetent patients with simultaneous varicella zoster and herpes simplex virus infection

Background It has been shown that varicella zoster virus (VZV) and herpes simplex virus (HSV) can co‐localize to the same sensory ganglion. However, only a few case reports on VZV/HSV co‐infections exist. Objective To identify and characterize patients with concurrent VZV and HSV infection at the same body site. Subjects/Methods In 1718 patients, the presence of VZV and HSV in suspicious skin lesions was investigated by polymerase chain reaction analysis. Clinical characteristics of co‐infected patients were compared with matched control patients infected with either VZV or HSV. The data are discussed in the context of an extensive review of the literature. Results Twenty (1.2%) of 1718 patients were infected with both VZV and HSV at the same body site. The mean age was 54 years (range, 2–83). The clinical diagnosis was zoster in 65%, herpes simplex in 20%, varicella in 10% and erythema multiforme in 5% of cases. The trigeminus region was affected in 60% and the trunk in 25%. Involvement of the head was most commonly associated with a severe course of disease and with older age. Conclusion Simultaneous VZV/HSV infection is rare but can occur in immunocompetent patients, which is often overlooked. The majority of cases is localized to the trigeminus region and affects elderly people.     

Pseudolymphomatous reaction to varicella zoster virus vaccination: role of viral in situ hybridization

Herpes zoster (shingles) is the result of a reactivation of the varicella zoster virus (VZV). Many adults obtain a VZV vaccine in order to prevent zoster. Non‐specific injection site reactions and generalized herpes eruptions have been reported to occur, especially in immunocompromised patients. However, these are most often anatomically generalized reactions and histopathologically resemble typical herpes infections. We report a 61‐year‐old female on immunosuppressant medications for rheumatoid arthritis who presented with a subcutaneous nodule at the site of a recent herpes zoster vaccination. Histopathological examination revealed a dense nodular and interstitial mononuclear infiltrate throughout the mid and deep dermis with extension into the superficial subcutaneous fat. Immunohistochemical staining revealed an admixture of T‐cells and B‐cells, with a predominance of T‐cells. These findings are consistent with a pseudolymphoma (PL), a reactive inflammatory disorder that can resemble cutaneous lymphoma and has rarely been described in herpes infections and post‐herpetic scars. In situ hybridization studies for VZV were performed and highlighted occasional deep fibroblasts with nuclear positivity for VZV DNA. A review of post‐vaccination reactions and herpes‐related PL is discussed with emphasis on using in situ hybridization in establishing the diagnosis. Porto DA, Comfere NI, Myers LM, Abbott JJ. Pseudolymphomatous reaction to varicella zoster virus vaccination: role of viral in situ hybridization.     

Detection of multinucleated giant cells in differentiated keratinocytes with herpes simplex virus and varicella zoster virus infections by modified Tzanck smear method

Herpes simplex virus (HSV) and varicella zoster virus (VZV) infections induce the formation of intraepidermal vesicles containing acantholytic cells and multinucleated giant cells in the skin. The Tzanck smear is most commonly used to diagnose cutaneous herpetic infections, but it leads to many false‐positive and ‐negative results. This study aimed at establishing a method detecting much larger multinucleated giant cells using the Tzanck smear because these cells characterize the viral cytopathic effect in skin infections. Morphological changes were analyzed among several layers of keratinocytes with HSV‐ or VZV‐related cutaneous lesions, clinically and in vitro. We compared the sensitivity of the Tzanck smear to detect large acantholytic cells using both the removed roof tissue part (our approach) and the floor of the lesion (conventional approach) of a fresh vesicle. Large acantholytic cells were detected 2.0‐times more frequently in the removed roof tissue part of the vesicle than in the floor of the lesion. Round cells were much larger in the removed roof tissue part of the vesicle corresponding to the granular or prickle layer of the epidermis than in its floor of the lesion corresponding to the basal or prickle layer with the Tzanck smear. Differentiated cultured keratinocytes formed multinucleated giant cells by cell‐to‐cell fusion with resolution of cell membrane with VZV infection. Differentiated keratinocytes promote multinucleated giant cell formation by cell‐to‐cell fusion with HSV‐1 or VZV infection. To increase the sensitivity, the Tzanck smear should be prepared from the removed roof tissue part of a fresh vesicle to detect multinucleated giant cells in herpetic infections.     

Routine detection of herpes simplex virus and varicella zoster virus by polymerase chain reaction reveals that initial herpes zoster is frequently misdiagnosed as herpes simplex

The differential diagnosis of herpes simplex and zoster may require virological confirmation, yet virus typing is not regarded as necessary in routine dermatological assessment. In an attempt to evaluate the clinical benefits of the routine detection of herpes simplex virus (HSV) and varicella zoster virus (VZV), we analysed skin swabs from 110 patients who were diagnosed at the first clinical visit as having herpes simplex ( n  = 45) or zoster ( n  = 65). Viruses were typed using the polymerase chain reaction (PCR) with the general primer pair GPHV-RU. PCR analysis showed that at the initial clinical presentation, herpes simplex in these patients was not mistaken for zoster but that zoster was incorrectly diagnosed as herpes simplex in nine cases. Thus these results suggest that initial zoster often mimics herpes simplex, hence routine PCR diagnosis of HSV and VZV or alternative rapid diagnostic approaches may be beneficial in these cases.     

Comparison of the Tzanck test and polymerase chain reaction in the diagnosis of cutaneous herpes simplex and varicella zoster virus infections

Background: Although the diagnosis of herpes simplex virus (HSV) and varicella zoster virus (VZV) infections is usually made clinically, the Tzanck test, electron microscopy, viral culture, polymerase chain reaction (PCR), and serologic tests can be utilized to verify the diagnosis. METHODS: We conducted a study on a total of 98 patients (77 patients with recurrent herpes simplex and 21 patients with herpes zoster) to evaluate the reliability and reproducibility of the Tzanck test in comparison with PCR. RESULTS: In herpes virus infections, the general positivity rates of the Tzanck test and PCR were 61.2% and 79.6%, respectively. The difference between the positivity rates of the two tests was statistically significant. The positivity rates of the tests differed according to the type and duration of the lesions. CONCLUSIONS: Although PCR was superior to the Tzanck test, the Tzanck test has also been proven to be a reliable diagnostic method, with a sensitivity of 76.9% and a specificity of 100%. We recommend the use of this easy, quick, reproducible, and inexpensive diagnostic test more often in dermatologic practice, especially in cutaneous herpes virus infections.     

Necrotizing varicella zoster virus folliculitis

Although the usual clinical features of the varicella zoster virus (VZV)-induced lesions are readily recognized, the same virus is also responsible for a series of atypical lesions. A patient is presented with a single large infiltrated plaque on the abdomen. Although histology showed a necrotizing folliculitis surrounded by a dense perifollicular inflammatory infiltrate, the clinical presentation was not suggestive of folliculitis. Subtle cyto-histological clues for viral infection were suggested. Immunohistochemistry revealed the presence of VZV in the remnants of the follicular structures. This report underlines one of the protean clinical presentations of VZV skin infections and highlights the discreteness of typical VZV-related cyto-histological alterations. Complementary VZV identification methods such as immunohistochemistry, are helpful in order to increase the diagnostic accuracy of unusual VZV lesions.     

Clinical utility of loop‐mediated isothermal amplification assay for the diagnosis of common alpha herpesvirus skin infections

Loop‐mediated isothermal amplification (LAMP) is a nucleic acid amplification method with a high specificity, efficiency and speed. No reports exist regarding the usefulness of LAMP for clinically suspected skin infections caused by herpes simplex virus (HSV) or varicella zoster virus (VZV). The aim of this study was to evaluate the clinical usefulness of LAMP in the diagnosis of common cutaneous alpha herpesvirus (HSV type 1 and 2, and VZV) infections. LAMP and real‐time polymerase chain reaction (PCR) were performed using swab samples collected from 106 patients with clinically suspected alpha herpesvirus skin infections. The results of LAMP performed with DNA extraction did not differ from those performed without DNA extraction. The sensitivity of LAMP tested against real‐time PCR was 96% in herpes simplex, 78% in eczema herpeticum, 93% in herpes zoster and 100% in varicella. No viral DNA was detected by LAMP in all negative real‐time PCR samples. Viral DNA load was significantly lower in samples with false‐negative LAMP results than in the LAMP‐positive samples. LAMP enables confirmation of clinically suspected cutaneous HSV and VZV infections. However, the sensitivity of LAMP is lower than real‐time PCR. The accuracy of LAMP may increase if sufficient viral DNA is obtained from lesions. LAMP performed without DNA extraction remains sensitive; thus, LAMP represents a quick and economical method for the diagnosis of common alpha herpesvirus skin infections.     

Herpes incognito most commonly is herpes zoster and its histopathologic pattern is distinctive!

Infections of the skin by herpesviruses do not always present themselves in typical fashion. Conventional microscopy is used routinely to confirm infection by herpesviruses, but sometimes typical signs such as multinucleated epithelial cells or "ghosts" of them are not encountered in a specimen (so-called herpes incognito). We studied 35 patients in whom infection with herpesviruses was differentially diagnosed clinically but in whom a biopsy specimen had been taken for confirmation. Only those patients in whom histopathologic findings had been interpreted as being "not diagnostic" of herpesvirus infection by 2 independent dermatopathologists were included. Clinical and histopathologic findings were correlated with results from polymerase chain reaction studies on formalin-fixed paraffin-embedded tissue. Polymerase chain reaction revealed herpesvirus-specific DNA in 12 of 35 specimens, 10 being varicella zoster virus (VZV) positive, 1 herpes simplex virus (HSV)-2 positive, and 1 HSV-1 positive. Ten of these 12 cases presented themselves in very similar fashion (8 VZV, 1 HSV-1, 1 HSV-2). All lesions were macular or papular and typified mostly by dense perivascular and sparse interstitial superficial and deep infiltrates of lymphocytes, sometimes assuming a patchy lichenoid pattern. Infiltrates were prominent in and around adnexal structures, often peppering follicles, sebaceous glands, and eccrine glands. Lymphocytes were also found in the lower part of the epidermis accompanied by a combination of spongiosis and vacuolar alteration. The papillary dermis was often edematous; extravasated erythrocytes in variable numbers were a common finding. Lymphocytes sometimes had large and polygonal nuclei. Neutrophils and nuclear dust were present occasionally; eosinophils were rare. We conclude that herpes incognito most commonly is herpes zoster and its histopathologic pattern is distinctive.     

Advances in Antiviral Therapy: Acydovir

Acyclovir [9-(2-hydroxyethoxymethyl)guanine] is a newly licensed acyclic nucleoside analog that is active in vitro and in vivo against herpes simplex virus (HSV) and varicella zoster virus (VZV). This agent is available in the United States in topical and intravenous forms, and the oral preparation is currently being evaluated in clinical trials. The precise therapeutic role for acyclovir in patients with herpesvirus infections is still evolving. This article reviews the current status of this exciting new antiviral agent.     

Varicella-zoster-virus folliculitis promoted clonal cutaneous lymphoid hyperplasia

Post herpes zoster (HZ) reactions have been associated with panoply of neoplastic, inflammatory, and fibro-inflammatory cutaneous disorders. Varicella zoster virus (VZV) DNA has not been identified in most of these reports. After an episode of HZ, a healthy, active 90-year-old female developed ulcerative nodules in the affected trigeminal V1 dermatome and the contra-lateral trigeminal region over a 1-year period. Excision and/or biopsy of all these lesions showed similar pathologic changes that consisted of herpetic folliculitis, adjacent dense mixed nodular lymphocytic infiltrates with germinal centers (cutaneous lymphoid hyperplasia (CLH)), and in the deeper excision specimens, an obliterative vasculitis of a vessel with smooth muscle in its wall. Immunophenotype analysis revealed a mixed, predominate T- and B-cell population without loss of pan-T cell antigens or aberrant expression by B cells of T-cell antigens. Polymerase chain reaction for herpetic DNA was positive for VZV DNA. Lymphocyte gene rearrangement analysis revealed 2 distinct, anatomically and chronologically, monoclonal B-cell populations and a monoclonal T-cell population in one nodule. Treatment with valacyclovir has lead to almost complete resolution of her cutaneous nodules after 6 months of therapy. In this case, it can be surmised that persistence of VZV infection and lack of effective cell-mediated immunity lead to development of both immunopathology (vasculitis) and excessive lymphoid cell proliferation (CLH).     

激光捕获微切割技术在感染性皮肤病分子病理诊断机制研究中的应用

激光微切割技术可在背景复杂的固体组织切片中获得完整的特异性细胞群甚至单个细胞,联合分子生物学技术,可对目的细胞的DNA、RNA和蛋白质进行分析,提升了分子病理学诊断机制研究的水平。结合下游的PCR等分子技术,激光微切割技术应用于感染性皮肤病标本,可分析浸润的淋巴细胞克隆群,探讨感染的发病机制,同时能检测病灶中的单纯疱疹病毒、水痘带状疱疹病毒,结核杆菌等皮肤组织感染常见的病原微生物。     

Infektionen mit Herpes-simplex- und Varicella-zoster-Viren in der Schwangerschaft

Primary infections with herpes simplex virus (HSV) and varicella-zoster virus (VZV) may lead to severe illness in pregnancy. Both diseases may be associated with transplacental virus transmission and fetal infection. Such infections can lead to intrauterine death, severe malformations and premature birth; the fetal/congenital varicella syndrome is well-defined. Herpes genitalis and varicella at the time of labor may lead to life threatening neonatal-herpes or varicella of the newborn. Currently neither active immunization nor neutralizing immunoglobulin is available for HSV infections. VZV-seronegative women in child-bearing age can be vaccinated and pregnant women exposed to VZV can be given specific immunoglobulins. While an infection is rarely blocked, the severity is generally reduced. For severe disease antiviral treatment is necessary, with valacyclovir and acyclovir represents the drugs of choice. Primary or recurrent overt disease of the genital tract at the time of delivery an indication for caesarean section. Suppression of recurrent genital herpes during the last weeks of pregnancy with valacyclovir and acyclovir reduces the need for surgical intervention. Neonates exposed to VZV should receive specific immunoglobulin. If neonates show signs of either infection, immediate treatment with acyclovir must be initiated.     

Infections with herpes simplex and varicella-zoster viruses during pregnancy

Primary infections with herpes simplex virus (HSV) and varicella-zoster virus (VZV) may lead to severe illness in pregnancy. Both diseases may be associated with transplacental virus transmission and fetal infection. Such infections can lead to intrauterine death, severe malformations and premature birth; the fetal/congenital varicella syndrome is well-defined. Herpes genitalis and varicella at the time of labor may lead to life threatening neonatal-herpes or varicella of the newborn. Currently neither active immunization nor neutralizing immunoglobulin is available for HSV infections. VZV-seronegative women in child-bearing age can be vaccinated and pregnant women exposed to VZV can be given specific immunoglobulins. While an infection is rarely blocked, the severity is generally reduced. For severe disease antiviral treatment is necessary, with valacyclovir and acyclovir represents the drugs of choice. Primary or recurrent overt disease of the genital tract at the time of delivery an indication for caesarean section. Suppression of recurrent genital herpes during the last weeks of pregnancy with valacyclovir and acyclovir reduces the need for surgical intervention. Neonates exposed to VZV should receive specific immunoglobulin. If neonates show signs of either infection, immediate treatment with acyclovir must be initiated.     

Shingles update: common questions in caring for a patient with shingles

Varicella zoster virus (VZV) is a herpes virus that can cause two distinct clinical diseases, chickenpox and shingles. Primary infection of varicella, often called chickenpox, results in a generalized eruption of a vesicular exanthematous rash which is usually seen in children and is highly contagious. This virus (VZV) can then become latent and later reactivate causing herpes zoster, commonly known as shingles. Shingles is usually a localized phenomenon often seen in adults and is usually less contagious. The following is a discussion of infection control questions most commonly asked regarding the care of a patient with shingles.