Herpes Simplex Virus

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FIGURE 10-53 (see Color Plate)

Linear esophageal ulcers caused by herpes simplex virus (HSV) and Candida. Infection with HSV-1 and -2 leads to stomatitis and esophagitis post-transplantation without acyclovir prophylaxis. Additionally, paronychia, corneal ulcers, encephalitis, genital lesions, disseminated involvement of the gastrointestinal tract, pancreas, and liver, and interstitial nephritis has been seen. HSV-6 causes exanthem subitum in children, mononucleosis, and hepatitis. There has been some evidence that reactivation infections may be associated with rejection in transplant recipients. Both reactivation and reinfection may occur. HSV-8 is associated with Kaposi's sarcoma. Prevention of these infections has been achieved using prophylactic acyclovir following transplantation. If clinical symptoms occur from HSV, they usually are treated with acyclovir adjusted for renal function.

FIGURE 10-54 (see Color Plate)

Varicella-zoster virus (VZV) infection. Primary VZV infections usually result in typical vesicular eruptions of generalized onset without dermatomal localization. Reactivation infection of the virus from the dorsal root ganglion usually causes a dermatomally localized vesicular eruption. By the time of renal transplantation, over

94% of adults have evidence of a prior VZV infection. In those patients previously infected, antibody titers increase following transplantation. Pretransplant screening is recommended to advise the patient on treatment of post-transplant exposures. Post-transplant exposures to zoster or chickenpox in the nonimmune individual should be treated with acyclovir, famcyclovir, or varicella-zoster immune globulin. Immune globulin is rarely required at this time. Patients with the new onset of varicella infection following transplantation or with diffuse zoster should be treated with intravenous acyclovir, 10 mg/kg, three times per day, or famcyclorir depending on renal function. Infection in the transplant recipient, particularly in those who are primarily infected, can result in encephalitis, disseminated intravascular coagulation, pneumonia, bowel involvement, pancreatitis, dermatitis, and hepatitis.

The attack rate in nonimmune individuals of household contacts with varicella infections is 80% to 90%. Therefore, if individuals have not previously had varicella infections at the time of transplant evaluation, vaccination with a live attenuated strain could be considered. Recently this strategy has been used in children prior to renal transplantation. Attack rates in vaccinated individuals may be up to 31%, but the disease that develops is much milder compared with those susceptible individuals not previously vaccinated. Should resistant strains of varicella develop, foscarnet has been effective. Foscarnet is associated with a renal decline in renal function. (Adapted from Friedman-Kien [31]; with permission.)

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