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

Abstract

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.

Varicella Zoster Virus (VZV) and Herpes Simplex Virus (HSV) in Solid Organ Transplant Patients

“…VariZIG is available through a single US distributor (FFF Enterprises; Temecula, California). Although not studied in clinical trials, nonspecific pooled IVIG has been suggested as an alternate postexposure prophylaxis when VariZIG is not available; combination use of IVIG with antiviral therapy in immunocompromised patients can also be considered .…”

Use of intravenous immunoglobulin in a disseminated varicella infection in an immunocompromised child

“…The efficacy of alternative viral drugs alone or in combination with standard antiviral substances needs individual decision-making for situations13). Varicella-zsoter immunoglobulin was also used some in solid-organ transplant recipients14).…”

Varicella Zoster Virus in Solid Organ Transplantation

“…Nonspecific intravenous immunoglobulin (IVIG) or VZV immunoglobulin are unlikely to provide additional benefits to those with established infection and are therefore not recommended . However, IVIG and varicella zoster immune globulin (VZIG) have been used anecdotally in those with severe infection (III) .…”