Extensive herpes zoster involvement following mycophenolate mofetil therapy for sarcoidosis
© The Author(s) 2011
Received: 2 July 2011
Accepted: 13 September 2011
Published: 25 September 2011
Sarcoid uveitis is usually a presumptive diagnosis based on the simultaneous presence of uveitis and clinicoradiographic or histological findings of sarcoidosis. Mycophenolate mofetil (MMF) is an anti-metabolite, selectively aimed at affecting lymphocytic action [1, 2]. It has been proven to be safe and effective in post organ transplant  and seems to have similar efficacy in non-infectious uveitis . In patients who are corticosteroid resistant or require an unacceptable dose of corticosteroids to maintain remission, additional immunosuppression is used, including methotrexate, azathioprine, and MMF. We report an uncommon case of a 34-year-old male of sarcoid uveitis who developed extensive herpes zoster while on treatment with MMF.
MMF is useful in various ocular inflammatory conditions. Its advantage is its potent corticosteroid sparing effect and relatively benign side effects such as gastrointestinal disturbances, alopecia, and transient leucopenia [6, 7].Our patient showed a good response to combined treatment with MMF (2 g/day) and prednisolone (1 g/day). But he developed extensive herpes zoster after 10 months of treatment requiring discontinuation of the drug. Opportunistic infections have been rarely reported in sarcoid uveitis in spite of the immune dysregulation noted in these patients . Herpes zoster is known to occur in post organ transplant cases who are on multiple immunosuppressive drugs usually around the 9th to the 12th month as was seen in our patient . But a multicentre randomized controlled trial of MMF in doses of 2–3 g/day for renal transplant patients did not report even a single case of herpes zoster . Higher doses of MMF can have an atypical and disseminated varicella infection . But herpes zoster as an opportunistic infection with oral steroids is rare and generally mild and self-limiting . There are no reports of such extensive herpes lesions in otherwise immunocompetent individuals. Thus, in our patient, a cumulative immunosuppressive effect may have been the reason for such an extensive involvement with herpes zoster. A serology done prior to treatment is of no help as patients with varicella antibodies have also been found to develop full-borne varicella infection . With discontinuation of MMF and appropriate anti-viral therapy, the lesions resolved completely. Studies like SITE study  have shown that the overall risk of opportunistic infections with the use of long-term immunosuppressives is very low. Our case highlights the fact that reactivation of herpes zoster can occur with therapeutic doses of MMF for uveitis in otherwise healthy immunocompetent adults. It does not necessarily prove that other such opportunistic infections may be a possible side effect with MMF treatment. It would be wise to enlighten the patients regarding this possibility and allow for early recognition and treatment.
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