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September 2010
Patient Care and Science
EIN Update: Varicella-Zoster Virus and Acyclovir Resistance

The Emerging Infections Network (EIN) is a forum for infectious diseases consultants and public health officials to report information on clinical phenomena and epidemiological issues with public health significance. Any diagnostic or therapeutic recommendations and all opinions presented are those of the individual contributor. They do not necessarily represent the views of EIN, IDSA (EIN’s sponsor), or the Centers for Disease Control and Prevention (CDC), which funds EIN. The reader assumes all risks in using this information.  

EIN members recently discussed treatment options for a patient with acyclovir-resistant varicella-zoster virus (VZV).

A member in Ohio asked about a patient “with Hodgkin’s who is still getting new lesions all over her body and buccal mucosa after 10 days of 10 mg/kg acyclovir IV Q8h. Culture  was grown on day five of acyclovir (second specimen),” the member wrote. “This is her second episode of zoster; the first responded much better/faster to acyclovir.”

An EIN member from Washington, D.C., wrote, “Assuming VZV has been confirmed by DFA [direct fluorescent antibody] and/or culture and dosing of IV acyclovir is appropriate (1,500mg/m2 divided q8 hours), and there has been no response to therapy, there would be concern for resistant virus, particularly if there is any evidence of dissemination, such as elevated LFTs [liver function tests], etc.” The member suggested “consider[ing] empirically adding/changing therapy .”

A respondent in Michigan asked if the patient had secondary hypogammaglobinemia. “If so, IVIG [intravenous immune globulin therapy] may be an option.”

The original commenter noted that the patient “does have relative hypo IgM [immunoglobulin M] (32), and VZV-specific IgM is low (0.47). Foscarnet worked like magic for the old lesions: They crusted in two to three days and faded in five, but now she is still having one to two new scattered vesicular lesions daily. Now there is a shortage of foscarnet, and I cannot obtain it from anywhere, so I am stuck.”

A respondent from the Food and Drug Administration (FDA) commented that foscarnet is currently manufactured by Hospira Inc. “However, availability is limited due to manufacturing delays. For updates on foscarnet availability, you can visit FDA's drug shortage webpage."

An EIN member in California shared a response from the Centers for Disease Control and Prevention (CDC) that noted experts there had not heard of IVIG being given or recommended for treatment of herpes zoster. CDC suggested following up with experts who work with immunocompromised patients for additional guidance.

CDC also highlighted recently published guidelines on the management of opportunistic infections among HIV-infected persons. Available online (PDF), the guidelines provide information on treatment of herpes zoster, including treatment failure and acyclovir–resistant VZV. The CDC respondent also shared two journal articles—an October 2003 paper in The Journal of Infectious Diseases, and a Pediatric Infectious Diseases Journal article published in Oct. 2008—that discuss VZV resistance to acyclovir.

Updating the case, the original commenter noted that the patient had since been readmitted with new lesions. “No foscarnet is available,” the member wrote. “I am in the process of obtaining CMX001 from Chimerix.”

E-mail the Emerging Infections Network.
The Emerging Infections Network (EIN) is a provider-based sentinel network designed to help the public health community detect trends in emerging infectious diseases.

A joint project of IDSA and the Pediatric Infectious Diseases Society (PIDS) with funding from the Centers for Disease Control and Prevention (CDC), EIN tracks emerging infectious diseases and keeps the public health community up to date with new disease trends, difficult cases, and other issues affecting members’ clinical practices. The Network provides a great opportunity for members to share knowledge quickly across large geographical distances. Both IDSA and PIDS members are eligible to join. Click here for more information or to join EIN.

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