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Neurologic Complications of the Reactivation of Varicella–Zoster Virus

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Neurologic Complications of the Reactivation of Varicella–Zoster Virus MEDICAL PROGRESS Review Article Medical Progress the infected person; however, the biologic mechanisms that underlie the transition from latency to active viral replication are unknown. Many laboratories have made NEUROLOGIC COMPLICATIONS serious efforts to determine the physical state of the virus during latency, because understanding this state OF THE REACTIVATION is essential to predicting or preventing the neurologic OF VARICELLA–ZOSTER VIRUS complications produced by reactivation of the virus. DONALD H. GILDEN, M.D., DNA of Varicella–Zoster Virus in Human Ganglia B.K. KLEINSCHMIDT-DEMASTERS, M.D., After it has produced chickenpox, varicella–zoster JAMES J. LAGUARDIA, M.D., RAVI MAHALINGAM, PH.D., virus becomes latent in ganglia along the entire neu- AND RANDALL J. COHRS, PH.D. raxis. Unlike herpes simplex virus, however, varicella– zoster virus cannot be cultured from human gan- glia.3 Although clinicians had long suspected that the ARICELLA–ZOSTER virus is an exclusive- ganglia were the site of latency, verification came only ly human herpesvirus that causes chickenpox after latent varicella–zoster virus was detected in hu- V (varicella), becomes latent in cranial-nerve and man trigeminal and thoracic ganglia by means of dorsal-root ganglia, and frequently reactivates decades Southern blot analysis and in situ hybridization.4-6 A later to produce shingles (zoster) and postherpetic PCR analysis that revealed varicella–zoster viral DNA neuralgia. In immunocompetent elderly persons or in trigeminal ganglia from 13 of 15 subjects and in immunocompromised patients, varicella–zoster virus thoracic ganglia from 9 of 17 subjects7 validated earlier may produce disease of the central nervous system. observations that the thoracic and trigeminal der- Since the last major review of varicella–zoster vi- matomes were the most common sites of reactivation.8 rus in the Journal,1,2 advances in molecular biology Most, if not all, of the DNA molecule of varicella– have provided important new insights into the patho- zoster virus is present during latency,7 but the viral genesis of infection with varicella–zoster virus. The burden is low. A competitive PCR assay revealed 6 to detection of varicella–zoster virus in blood vessels 31 copies of varicella–zoster viral DNA in 105 gan- and other tissues by methods based on the polymer- glionic cells.9 A noncompetitive PCR assay indicated ase chain reaction (PCR) has widened the recognized more varicella–zoster viral DNA,10 similar to the 103 clinical spectrum of acute and chronic disorders as- to 105 copies of latent DNA of herpes simplex virus sociated with varicella–zoster virus, including latent type 1 in 105 cells.11 The difference in the number of infections. In this article we highlight current progress varicella–zoster viral copies reported9,10 may result in understanding the latency of varicella–zoster virus from the fact that different techniques were used. La- and review the neurologic complications of viral re- tent varicella–zoster viral DNA is extrachromosomal activation, with a focus on previously underempha- (nonintegrated), possibly in a circular or concatamer- sized patterns of zoster, preherpetic and postherpetic ic (end-to-end) configuration,10 as is the DNA of la- neuralgia, myelitis, large-vessel granulomatous arteri- tent herpes simplex virus type 1.12 During latency, tis, and small-vessel encephalitis, all of which may oc- RNA corresponding to varicella–zoster viral genes cur without the rash typical of zoster (Fig. 1). 21, 29, 62, and 63 13 and proteins corresponding to LATENCY varicella–zoster viral genes 4, 21, 29, 62, and 63 have been detected in the cytoplasm of neurons.14,15 In latency, the condition that follows acute infec- tion (usually manifested as chickenpox), the virus per- Cell Type That Harbors Latent Varicella–Zoster Virus sists in a noninfectious form with intermittent periods Most studies indicate that neurons are the primary, of reactivation and shedding. Varicella–zoster virus re- if not exclusive, site of latent virus. In situ hybridiza- activates with increasing age or immunosuppression of tion alone or together with PCR detected varicella– zoster virus only in neurons initially,5,6 later in perineu- ronal satellite cells,16,17 and then in both neurons and From the Departments of Neurology (D.H.G., B.K.K.-D., J.J.L., R.M., R.J.C.), Microbiology (D.H.G.), and Pathology (B.K.K.-D.), University of non-neuronal cells of latently infected human gan- Colorado Health Sciences Center, Denver. Address reprint requests to Dr. glia.18 Two further studies found varicella–zoster vi- Gilden at the Department of Neurology, Mailstop B182, University of Col- rus predominantly in neurons.19,20 A different strategy, orado Health Sciences Center, 4200 E. 9th Ave., Denver, CO 80262, or at [email protected]. in which quantitative PCR analysis was used to study ©2000, Massachusetts Medical Society. neurons and non-neuronal cells from postmortem Volume 342 Number 9 · 635 The New England Journal of Medicine Downloaded from nejm.org at NORTHWESTERN UNIVERSITY on May 20, 2014. For personal use only. No other uses without permission. Copyright © 2000 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine Primary infection with1 varicella–zoster virus1 (varicella) Latency Reactivation Zoster sine1 herpete Zoster1 (shingles) Immunocompetent8 Immunocompromised8 patients patients Myelitis Large-vessel8 Postherpetic1 Myelitis Small-vessel8 granulomatous8 neuralgia encephalitis arteritis Figure 1. Neurologic Complications of the Reactivation of Varicella–Zoster Virus. The primary encounter (infection) with varicella–zoster virus usually occurs in childhood and produces chickenpox (acute varicella). After producing chickenpox, varicella–zoster virus becomes latent in gan- glia in virtually all people who have had chickenpox and remains present for the lifetime of the person. The reactivation of varicella–zoster virus, usually after the patient is 50 years of age, produces the char- acteristic dermatomal rash of shingles (zoster). Rarely, the reactivation of varicella–zoster virus can also produce pain without rash (zoster sine herpete). In immunocompetent patients, the main compli- cation of zoster is postherpetic neuralgia (pain that persists more than six weeks after the development of rash). In rare instances, myelitis or large-vessel granulomatous arteritis, which produces disease of the central nervous system, may develop in immunocompetent patients. After immunocompromised patients have zoster, there may be more severe complications of the central nervous system in the form of progressive small-vessel encephalitis or myelitis. Each of these complications can develop without clinically recognized rash, although they do so infrequently. ganglia that had been sorted according to size, re- COMPLICATIONS IN THE PERIPHERAL vealed two to five copies of varicella–zoster viral DNA NERVOUS SYSTEM that were primarily, if not exclusively, in neurons.21 Zoster (Shingles, Radiculoneuropathy, and Ganglionitis) Even though a considerable amount of information has been acquired about the physical state of varicella– More than 300,000 cases of zoster occur annually zoster virus in latently infected ganglia, none of this in the United States, mostly in elderly and immuno- information has yet been found to be directly appli- compromised patients. Varicella occurs mostly in the cable to treating human disease. A better understand- spring, but zoster develops throughout the year. A pa- ing of viral latency will produce testable hypotheses tient in whom varicella develops before 1 year of age designed to prevent the reactivation of varicella–zoster is predisposed to zoster before 60 years of age.24 virus and its neurologic complications. Millions of Zoster develops 8 to 10 times as frequently at or after children worldwide have received a live attenuated 60 years of age as before. Thirteen percent of Amer- vaccine against varicella–zoster virus. The virus in the icans are older than 65; this proportion is increasing, vaccine becomes latent and can reactivate, however.22 so the rate of zoster-associated complications will also Thus, the widespread use of a vaccine against vari- increase. The incidence of recurrent zoster in immu- cella–zoster virus is not likely to result in a reduced nocompetent patients is less than 5 percent.8 incidence of zoster and its attendant complications. Zoster is characterized by severe sharp, lancinating, Therefore, trials of a vaccine to boost immunity in radicular pain and rash. The pain is associated with middle age are already under way.23 itching and dysesthesias. In affected dermatomes, sen- 636 · March 2, 2000 The New England Journal of Medicine Downloaded from nejm.org at NORTHWESTERN UNIVERSITY on May 20, 2014. For personal use only. No other uses without permission. Copyright © 2000 Massachusetts Medical Society. All rights reserved. MEDICAL PROGRESS sation is decreased, yet the skin is exquisitely sensitive ed. Analgesic treatment usually includes extra-strength to touch (allodynia). Any level of the neuraxis can be acetaminophen and 30 to 60 mg of codeine every affected. The thorax is the most common site, fol- six hours when necessary; stronger narcotics should lowed by the face. Facial lesions are usually present be avoided. The administration of famciclovir (500 in the ophthalmic division of the trigeminal nerve and mg three times daily) or oral acyclovir (800 mg five are frequently accompanied by keratitis, which is
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