CC BY
0«C©LL©@yOUM-J©yPM&L» #14(193), 2023 / MEDICAL SCIENCES_2_
Melenko S.R.,
PhD, Associate Profesor of the Department of Infectious Diseases and Epidemiology
Bukovinian State Medical University Fediaieva S.I.,
PhD, Assistant of the Department of Rehabilitation and Alternative Medicine,
Danylo Halytsky Lviv National Medical University
Avramuk A.S., _thyear student Bukovinian State Medical University
Ratsa A.M. _thyear student Bukovinian State Medical University DOI: 10.24412/2520-6990-2023-34193-25-26 PROGNOSIS, TREATMENT AND PREVENTIONOF VARICELLA-ZOSTER VIRUS INFECTION IN
THE SETTING OF KIDNEY
Abstract.
In this article, we discuss the prevalence and clinical course of varicella zoster virus infection in people who are kidney transplant recipients, and consider the effectiveness of methods of preventing this disease in this cohort.
Keywords: Recipient, kidney transplantation, varicella zoster virus, vaccination against varicella zoster virus, antiviral therapy, immunosuppression.
Introduction
Medicine is a science that does not stand still. With the development of technology, doctors have learned how to save the lives of people whose only hope is an organ transplantation. Every year, hundreds of thousands of organ transplants are performed worldwide. In particular, in Ukraine in 2022, doctors performed 384 organ transplants, which is 20% more than in 2021 [1]. The need for this operation is growing every year, for example, among patients with kidney disease almost 2000 people need transplants, 1500 people need liver transplants, and 1000 people need heart transplants [2]. Unfortunately, this operation is not easy for the human body as the immune system can attack the transplant. In this regard, patients need to be on immunosuppressive therapy for the rest of their lives to prevent their own body from rejecting a new organ. The name of this therapy makes it clear that the body's immune system will be suppressed, making the person more susceptible to various infections, including the varicella virus.
Infection with the varicella zoster virus can lead to various consequences, ranging from deterioration of a person's condition, addition of other infections, transplant rejection, and death.
The varicella zoster virus belongs to the herpes virus family, which are DNA viruses capable of forming a latent infection and reactivating in immunosup-pressed individuals [3]. The risk of herpes virus infection depends on the recipient's age, immune status, serostatus, level of leukopenia, and the drugs the patient is taking for immunosuppressive therapy after transplantation [4].
In patients with kidney transplants, the risk of mortality increases to 30%. The severity of the disease in such recipients is much greater than in ordinary people who have no history of organ transplantation. There is a known case in Somalia of a 23-year-old patient who received a kidney transplant three years ago. As an im-
munosuppressive therapy, he took mycophenolate mo-fetil 2 g/day, tacrolimus 12 mg/day and prednisone 20 mg/day, The patient complained of a generalized rash for 5 days, chills and fever.
Objectively: consciousness was clear, blood pressure 145/90 mmHg, pulse 90/min, respiratory rate 14 per minute, temperature 38.6°C. Blood test showed
hemoglobin (Hb) 16.6 g/dL (12-17 g/dL), hematocrit (Ht) 49.8% (42%-52%), leukocytes 7.60 x 1000/mm 3 (4-10 x 1000), platelets 200 x 1000/mm 3 (x1000/mm 3 ), MCV 87.9 fL (80-100 fL), MCH 29.4 pg (27-34 pg/cell), MCHC 33.4 (32-36 g/cell). dL), creatinine 0.82 mg/dL (0.6-1.35 mg/dL), urea 34 mg/dL (10-45 mg/dL), blood glucose level (RBS) 110 mg/dL (60-110 mg/dL),
sodium 142 mEq/L (135-145 mEq/L) potassium 3.84 mEq/L (3.5-5.5 mEq/L). Rashes in the form of differently healed widespread erythematous papules and vesicles on the trunk and face.
Urinalysis showed no abnormalities. The abdominal ultrasound revealed only bilateral renal atrophy and a transplanted kidney in the pelvic area.
In this case, it is important to make a quick diagnosis using a PCR test and prescribe antiviral drugs within the first 24 hours after the rash appeared. The drugs of choice in this situation are intravenous acyclovir 3 x 750 mg for 5 days, which should be later switched to oral acyclovir 5 x 800 mg, acyclovir lotion, and antipyretics % [5].
The following case describes the course of the disease in a 22-year-old patient who received a kidney transplant six months ago. Immunosuppressive therapy consisted of mycophenolate mofetil 2 g/day, tacrolimus 3 mg/day, and prednisolone 5 mg/day. He complained of itchy skin lesions for four days, which first appeared on the abdomen and then spread to other parts of the
MEDICAL SCIENCES / «<g®[L[L®@U[]UM~J0U®MaL» ®33W2)), 2023
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body. Before the onset of the rash, the patient also complained of epigastric moderate continuous pain that radiated to the hypogastrium and mesogastrium, accompanied by nausea and vomiting, and no fever.
Examination revealed numerous disseminated erythematous vesicles, especially on the trunk and face, including the mucous membranes of the oral cavity and genitals. After hospitalization, the number of vesicles and the condition of the skin lesions increased. Some of the vesicles had a necrohemorrhagic appearance as a result of liver and lung complications.
Treatment was initiated with intravenous acyclovir 10 mg/kg every 8 hours, followed by oral acyclovir 800 mg 5 times daily for 21 consecutive days [6].
In both cases, the patients were not vaccinated against varicella zoster virus and had no history of varicella before kidney transplantation.
The third clinical case is more severe than the previous two. A 31-year-old cancer patient with a transplanted kidney complained of fever, shortness of breath, generalized rash, chest pain, and diarrhea. Initially, the patient developed watery diarrhea (2-3 times a day) accompanied by girdling abdominal pain, and over the next 10 days, the patient complained of fever and malaise, chest pain and shortness of breath. After these complaints, the patient began to be disturbed by a painful rash that first appeared on his head and then spread to his entire body. It is known from the anamnesis that the patient had chickenpox in childhood.
Objectively: BP 80/50 mm Hg. Hg, heart rate 114 beats/min, respiratory rate 24/min, temperature 39°C, SpO2 96%. Small rales are heard in the chest.
An erythematous vesicular, maculopapular, and hemorrhagic rash with pustules and crusts was noted all over the body. The ECG shows sinus tachycardia. CT scan of the chest and abdomen showed diffuse nodules and dilation and opacity with thickening of the intestinal loops.
In addition to the standard treatment of intravenous acyclovir 10 mg/kg/day (600 mg/day), the patient was also prescribed fluid intake, electrolyte replacement, and treatment of acidosis with sodium bicarbonate according to his symptoms [7].
From the above cases, we can see that the clinical manifestations of varicella in patients with a history of kidney transplantation vary and have a wide range of severity and severity of the disease. Treatment of these patients with the antiviral drug acyclovir is quite effective, especially when administered as early as possible.
One of the most effective methods of preventing this infectious disease in kidney transplant recipients is vaccination against VZV. The cross-sectional study analyzed VZV-specific IgG and T cells in 39 recipients receiving immunosuppressive therapy. They were vaccinated with 2 doses of a recombinant protein-based vaccine (Shingrix) containing glycoprotein E as an im-munogenic domain on the envelope. The vaccination was well tolerated and did not affect the function of the kidney allograft. VZV-specific IgG titers were detected in all vaccinated patients. In patients who already had titers of this immunoglobulin before vaccination, an average increase in titer of 1.8 times was noted, indicating a humoral response [8]. These results confirm and are consistent with an earlier study that revealed vaccination-induced immunogenicity in kidney recipients that lasts 12 months or more and has no side effects [9].
Conclusions
The risk of such an infectious disease as varicella -zoster virus in people with a history of kidney transplantation is much higher than in ordinary people who do not have a history of organ transplantation. This, as is already known, is due to the forced lifelong immunosuppressive therapy. Clinical manifestations of this disease do not depend on the varicella virus and range from mild to severe, and in the absence of adequate treatment can be fatal. Treatment of varicella in patients with kidney transplantation should be started as soon as possible, treatment consists of prescribing intravenous acyclovir with subsequent transition to its oral administration. In kidney transplant recipients, prophylaxis against varicella-zoster virus should be carried out, i.e. vaccination should be performed to prevent the disease through persistent immunogenicity induced by vaccination.
References:
1. https://www. kmu .gov.ua/news/u -2022-rot s i-ukrainski-likari-provely-na-20-bilshe-orhannykh-transplantatsii-nizh-u-dovoiennomu-2021-rotsi
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6. Holanda IRM, Dias MO, Amorim RP, Garcia AL, Almeida RAMB, Marques SA. Disseminated varicella with systemic implications in a renal transplant recipient. An Bras Dermatol. 2023 Nov-Dec;98(6):875-878. doi: 10.1016/j.abd.2022.10.013. Epub 2023 Jul 5. PMID: 37419774; PMCID: PMC10589492.
7. Alsultan M, Kliea M, Hassan O, Basha K. Delayed acyclovir therapy for disseminated varicella zoster in an adult kidney transplant recipient: a case report and literature review. Ann Med Surg (Lond). 2023 Mar 2;85(3):481 -485. doi: 10.1097/MS9.0000000000000231. PMID: 36923769; PMCID: PMC10010797.
8. Roch, Toralf PhD 1,2 ; Wehler, Patrizia PhD 1,2 ; Blazquez-Navarro, Arturo PhD 2 ; Bachmann, Friederike MD 3 ; Нойман, 1забель Е. Бакалавр наук 2 ; Калщик, Светлана 2 ; Thieme, Constantin J. MD, PhD 2 ; Anft, Moritz PhD 1 ; Stervbo, Ulrik PhD 1,2 ; Westhoff, Timm H. MD 1 ; Бабель, Нша MD 1,2 ; Чой, Мiра MD 3 . Пащенти тсля трансплантат! трки створюють Т-клггинний i гумораль-ний iмуштет, реактивний проти Varicella Zoster, ni-сля бшковог вакцинаци проти Varicella Zoster. Тра-нсплантацiя 107(2):p e58-e59, лютий 2023 р. | DOI: 10.1097/TP.0000000000004406
