New skin lesions typically continue to emerge for 3 to 4 days.The diagnosis of herpes zoster should prompt the clinician to consider HIV testing, particularly in persons with known HIV risk factors, those younger than 50 years of age, or those who develop multi-dermatomal herpes zoster.Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Source: Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Source: Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents.The factors governing the maintenance of latency or the progression to viral replication remain poorly understood, but the increased incidence of zoster among immunocompromised persons suggests that cell-mediated immunity probably plays a critical role.He initiated highly active antiretroviral therapy 2 months ago. His examination in clinic shows a vesicular rash in a dermatomal distribution. The finding of multinucleated giant cells on Tzanck (Giemsa) staining is neither sensitive nor specific for diagnosing viral vesicular lesions.Replication of VZV in the ganglia leads to inflammation and cell death, followed by transport of the virus down the neuronal axons to the skin, with the migrating virus subsequently causing vesicles to emerge along the path of sensory nerves in a dermatomal distribution.Professor of Medicine, Epidemiology, and Global Health Member, Fred Hutchinson Cancer Research Center Director, Scientific Program on AIDS-Associated Malignancies and Infections University of Washington School of Medicine presents to clinic for an appointment after the onset of severe, unrelenting chest wall pain that began two days prior to presentation.Although herpes zoster can occur in patients at any stage of their HIV disease, the risk of disease is the highest in patients who have a CD4 count less than 200 cells/mm As with all human herpesviruses, primary infection with VZV is followed by a period of viral latency, or "hibernation." Latent VZV resides in dorsal spinal ganglia, until a cycle of "lytic" or active viral replication is initiated.The duration of therapy is typically 7 to 10 days, but longer courses should be considered if the lesions are slow to resolve.Use of PCR or direct fluorescent antibody (DFA) testing would be more appropriate and can specifically differentiate VZV from other viruses.Patients with herpes zoster often present with dysesthesias of the skin several days prior to the onset of cutaneous lesions.Primary varicella infection ("chickenpox") in HIV-infected patients manifests as a generalized outbreak of vesicular lesions that follow a 1 to 2 day prodrome of malaise and fever (Figure 1) and (Figure 2).In some instances, the lesions may coalesce to form larger hemorrhagic bullae (Figure 4).The incidence of zoster among HIV-infected adults is more than 15-fold higher than age-matched VZV-infected immunocompetent persons, with nearly 30 cases per year observed for every 1,000 HIV-infected adults.
Corticosteroids are not recommended in this setting.The DFA uses fluorescent labeled antibodies that detect antigens specific to VZV, and it yields more rapid and accurate results than culture.Source: Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Source: Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents.Some patients develop dysesthesias of the skin without developing skin lesions in a condition referred to as "zoster sine herpete." The cutaneous lesions of zoster initially appear as clusters of vesicles surrounded by an erythematous base (Figure 3), with the individual lesions ranging in size from several millimeters to a centimeter.The medications acyclovir, valacyclovir, and famciclovir are all considered acceptable options for the treatment of dermatomal herpes zoster in HIV-infected patients.