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Nosocomial VZV transmission leads to death in renal transplant patient
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Two renal transplant patients were infected — and one died — in what researchers in England called an “unusual case” of nosocomial transmission of varicella zoster virus, or VZV.
Although the two patients had no direct contact with the index case — also a renal transplant recipient being isolated in an adjacent ward — Daniel P. Depledge, PhD, investigator in the division of infection and immunology at University College London, and colleagues connected all three cases after developing a novel method to sequence whole pathogen genomes directly from clinical material.
“Traditional genotyping confirmed all three patients to be infected with Clade 1 viruses, the most common genotype in European populations,” Depledge and colleagues wrote in The Journal of Infectious Diseases. “However, [single nucleotide polymorphism (SNP)] genotyping failed to differentiate the putatively linked viruses from two epidemiologically unrelated viruses sampled from other patients at around the same time.”
Three patients undergo kidney transplants
The patient who died was a woman aged 55 years with end-stage kidney failure who was VZV immunoglobulin G negative and had not received a varicella vaccination before undergoing a cadaveric renal transplant. She was readmitted to the hospital 14 days after discharge and was clinically diagnosed with varicella. Six days later, she died. A diagnosis of varicella pneumonitis was made after the patient’s death. According to Depledge and colleagues, she had no known contact with cases of varicella or zoster.
The second patient, a man aged 61 years, was noted to be IgG VZV negative before his live-donor renal transplant surgery despite a history of chickenpox. He was readmitted 18 days after his discharge and was misdiagnosed with disseminated shingles. He made a full recovery and retained good graft function after weeks of treatment and a reactivation of VZV, and a retrospective review of his case found that he should have been diagnosed with recurrent varicella.
Initially, no link was made between these two cases and the index patient, a man aged 67 years who was readmitted to the hospital with shingles 4 weeks after undergoing dual cadaveric renal transplant surgery. The man developed respiratory failure and was transferred to the ICU, but recovered with a fully functioning kidney.
Linking the cases
According to Depledge and colleagues, nosocomial spread was not initially suspected because of a delay in diagnosis of shingles in the index patient and because he had been isolated. Instead, the patients were linked only after Depledge and colleagues genotyped and sequenced their samples, as well as samples from two unrelated cases that occurred simultaneously in the same hospital.
While SNP genotyping failed to differentiate the five cases, whole-genome sequencing (WGS) showed that the three epidemiologically linked patients were 100% identical, but did not match the control cases, proving that they were related.
In addition to documenting their novel use of WGS to show nosocomial spread of VZV, Depledge and colleagues said the case underlines two important clinical issues:
- primary varicella can be fatal in immunosuppressed patients even with early treatment and support, which may be preventable by testing and immunizing renal transplant patients; and
- to ensure infection control measures, doctors should not assume a widespread rash in an immunocompromised patient with a previous history of varicella is disseminated shingles.
“The data provide support for the risk of airborne transmission of VZV especially where the viral load is high and underline the vulnerability of immunocompromised patients to serious infection irrespective of past varicella history,” they wrote. “This report highlights the ongoing need for vaccines that can prevent viral reactivation in the immunocompromised as an important measure for control of nosocomial spread.” – by Gerard Gallagher
Disclosure: The researchers report no relevant financial disclosures.
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