Currently, the standard of care for allogeneic bone marrow transplant includes prophylaxis for herpes simplex infection and VZV, whereas preventive and preemptive measures are taken for other viral infections that pose significant risks to transplant recipients, including cytomegalovirus, Epstein-Barr virus, human herpesvirus-6, influenza, hepatitis B, hepatitis C, human herpesvirus 7, parvovirus B19, enteroviruses, BK virus, JC virus, and human metapneumovirus. All VZV-seropositive allogeneic and autologous bone marrow transplant recipients are recommended to have oral prophylaxis regimens that include acyclovir (800 mg twice daily) or valacyclovir (500 mg twice daily) for 1 year after transplantation. Equally important is the evidence from large randomized controlled trials showing no change in T-helper cell response in patients given antiviral prophylaxis, allowing appropriate protective immune responses in patients on prophylactic therapy.[12,13]
For patients in whom hepatitis as a complication of disseminated herpes zoster is suspected, VZV DNA quantitative PCR and liver function tests are useful in determining disease course and treatment response. Autoimmune and other viral hepatitides should be ruled out using serologic studies. Imaging can be useful in ruling out other causes of hepatocellular injury. All patients with disseminated varicella or herpes zoster should receive therapeutic dosing of intravenous acyclovir (10-15 mg/kg every 8 hours or 500 mg/m2 every 8 hours for 7-10 days).
Administration of intravenous VZV immunoglobulin has been proven in clinical studies to inhibit primary varicella infection in immunocompromised patients within 72 hours of exposure and may be considered for treatment of disseminated varicella or disseminated zoster; this use has been documented in some case reports. However, no definitive guidelines address its efficacy for ongoing infection, so its use should be considered on a case-by-case basis.[1,11,14] Given that zoster is largely a function of impaired cell-mediated immunity and that immunosuppressants are a known risk factor, all immunosuppressive medications should be held during treatment as well, if possible.[7,10,14] In cases of severe, fulminant hepatitis, liver transplantation may be required.[14,15]
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