Fulminating varicella despite prophylactic immune globulin and intravenous acyclovir in a renal transplant recipient: should renal patients be vaccinated against VZV before transplantation?

Robertson, Susan; Newbigging, Karen; Carman, William F.; Jones, Gwyneth; Isles, Chris

doi:10.1111/j.1399-0012.2005.00435.x

Cited by 9 publications

(6 citation statements)

References 13 publications

(14 reference statements)

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“…To our knowledge and review of literature, there were no reports on mortality rates among patients with ESRD on dialysis and ESRD not on renal replacement therapy for direct comparison. Most varicella patients died of multiorgan failure (from hepatitis, encephalitis, pneumonitis, and disseminated intravascular coagulation) [ 24 – 27 ], and respiratory failure [ 28 ].…”

Section: Discussionmentioning

confidence: 99%

Incidence and mortality rates of varicella among end stage renal disease (ESRD) patients in Singapore General Hospital, a 12-year review

et al. 2018

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BackgroundEnd stage renal disease (ESRD)/ end stage renal failure (ESRF) is on the rise globally and especially in Singapore. Varicella or chickenpox is not uncommon among adults especially ESRD/ESRF patients. It has been reported to cause complications and even death among immunocompetent adults.MethodsA retrospective data collection on patients with varicella infection and ESRD in Singapore General Hospital (SGH) from the year 2005 to 2016 was performed. Continuous data and categorical data were summarized as median (range) and count (%) respectively. The association of health care utilization (total length of hospital stay, readmission related to varicella, intensive care unit admission) and mortality with complication due to varicella were tested using chi-square and Mann-Whitney test for categorical and continuous outcomes respectively.ResultsSixty-six patients with ESRD developed varicella during the study period (2005–2016). The case incidence rates for varicella among ESRD ranges from 97 to 267 per 100,000 populations with ESRD yearly. There were 9 deaths (13.6%). Mortality was higher among the ESRD patients with one or more varicella complications compared to patients without complications ((25% vs 7.1%, 95% CI for difference: − 1.1%, 36.9%, p = .063). Likewise, utilisation of intensive or high dependency units were higher among patients with complications compared to those without (20.8% vs 2.4%, 95% CI for difference: 1.6%, 35.3%, p = .012). Length of stay was twice as long in the group with complications compared to patients without (median (IQR) days: 14 (8, 21) vs 7 (5, 14), p = .065), although it did not reach statistical significance.ConclusionsVaricella is associated with high morbidity and significant mortality rate in ESRD patients. Varicella vaccination is recommended for seronegative ESRD patients.

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Section: Discussionmentioning

confidence: 99%

Incidence and mortality rates of varicella among end stage renal disease (ESRD) patients in Singapore General Hospital, a 12-year review

et al. 2018

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“… + Sinha S, et al (2003) [ 46 ] India Case reports 2 patients described. + Robertson S, et al (2006) [ 22 ] Scotland, UK Case report 1 patient described. + Shahabazian H, et al (2007) [ 47 ] Iran Case report Report of chickenpox outbreak in renal transplant recipients.…”

Section: Methodsmentioning

confidence: 99%

“…Man, 10 days post-transplant, developed pancreatitis 2 weeks after pancreatitis. + NA – -Mild acute pancreatitis Robertson S, et al (2005) [ 22 ] -30 y.o. Man with a generalised maculopapular rash + NA + -Fulminant varicella with multiorgan involvement (acute renal failure, acute liver failure) - Died within 60 h of admission -Although regarded mild infection in children, chickenpox can cause fatality in adults and in the immunocompromised.…”

Section: Methodsmentioning

confidence: 99%

Varicella infections in patients with end stage renal disease: a systematic review

et al. 2018

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BackgroundEnd stage renal disease (ESRD) is on the rise globally. Varicella infection among adult patients with ESRD has been reported to lead to multiple complications and even death. While varicella vaccination has been recommended in paediatric renal patients; recommendation on varicella vaccination among adult patients with ESRD remained sparse. This review is aimed at evaluating the impact of varicella infection among adult patients with ESRD and make a recommendation for vaccination.MethodsThree databases (PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL)) were searched in April 2018 with keywords ‘varicella, chronic kidney failure, chronic kidney disease, renal replacement therapy, kidney transplantation, end stage renal disease, end stage renal failure, chicken pox, vaccine, vaccination and complications’.Results29 articles were selected for review. The studies were mainly case reports, and they included measured outcomes: prevalence of seronegativity, impact (morbidity, length of stay, and mortality) of varicella among patients with ESRD, seroconversion rates and safety of varicella vaccination. The prevalence of seronegativity among varicella-infected ESRD adults was found to be at 42 to 100%. Nineteen deaths were reported. At least 54 patients have had complications from varicella infection. Seroconversion rate post vaccination was found to be around 64–94%.ConclusionVaricella is associated with significant morbidity and mortality rates in adult patients with ESRD. Varicella vaccination should be considered for the vulnerable, seronegative patients.

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“…All patients were treated with intravenous aciclovir under reduction of immunosuppressive therapy (cyclosporine was discontinued, prednisolone continued at its prior dosage, prescribed mycophenolate mofetil at half of its prior dosage) and survived without complications. A fulminating VZV infection despite prophylactic VZIG and intravenous aciclovir was described in a 30-year-old renal transplant recipient, who died from complications [62]. In another case report, two adult patients with renal transplantation presented with disseminated VZV infection, but were successfully treated with aciclovir alone in one case, and with both aciclovir and VZIG in the second case [63].…”

Section: Renal Transplant Recipientsmentioning

confidence: 97%

Aciclovir and Varicella-zoster-immunoglobulin in solid-organ transplant recipients

2010

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Clear recommendations for the management of acute varicella-zoster virus (VZV) infections for cases of significant exposure and the use of prophylactic drugs after solid-organ transplantation are missing due to the lack of evidence by prospective studies. Heterogeneity in patient groups, patient numbers, age groups, immunosuppressive regimens, timing, and dosage of aciclovir and/or varicella-zoster immunoglobulin (VZIG), pre-transplant vaccination or VZV wild-type infection and inconsistency of data make comparability of different studies impossible. Although the benefit of aciclovir and/or VZIG is uncertain in immunosuppressed children, prospective controlled double-blind studies are not feasible for ethical considerations as fatal cases with disseminating varicella disease are well known in these patient groups despite the use of aciclovir and/or VZIG, whereas severe side-effects of these drugs are rare. However, a reporting bias is likely as mainly severe or fatal cases might have been predominantly published or cases of successfully used aciclovir and/or VZIG in mild cases or in cases of breakthrough infections after vaccination. As neither VZIG prophylaxis nor treatment with intravenous aciclovir offers complete protection against severe VZV infection to immunosuppressed pediatric solid-organ transplant recipients, high priority should be given to vaccination against VZV prior to transplantation, and, most importantly, in their close contact persons. Clinical observations suggest that only assessment of humoral immunity together with cellular immunity may allow predication about protection in exposed patients.

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Fulminating varicella despite prophylactic immune globulin and intravenous acyclovir in a renal transplant recipient: should renal patients be vaccinated against VZV before transplantation?

Cited by 9 publications

References 13 publications

Incidence and mortality rates of varicella among end stage renal disease (ESRD) patients in Singapore General Hospital, a 12-year review

Incidence and mortality rates of varicella among end stage renal disease (ESRD) patients in Singapore General Hospital, a 12-year review

Varicella infections in patients with end stage renal disease: a systematic review

Aciclovir and Varicella-zoster-immunoglobulin in solid-organ transplant recipients

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