Herpes Zoster in the HIV-population

Introduction
Diagnosis
Management
Complications
Investigations
Referral criteria
Discharge criteria
Advice for caregivers

Introduction

Herpes Zoster (shingles) is common in immune compromised states and may be the first sign of HIV infection (average CD4 count at first episode = 350).

Diagnosis

A unilateral vesicular eruption with a well-defined dermatome distribution is characteristic. However, atypical lesions (affecting multiple dermatomes ± recurrent) may be found in immune compromised patients. These patients are also at risk of developing cutaneous and visceral dissemination.

Differential Diagnosis

• Herpes Simplex
• Contact dermatitis

Management

Immediate action

Drug treatment

The mainstay of drug treatment is anti-viral therapy:

• Valaciclovir 1 g tds for one week OR
• Acyclovir 800 mg five times daily for one week OR
• Famciclovir 250 mg tds for one week 

It is important when considering a differential diagnosis that there may be other, co-existing infections that require a different treatment.

Pain management

• Acute pain: Analgesics (NSAIDs, paracetamol, tramadol, morphine).  Bear in mind that NSAIDs is not a good idea for patients on anti-retrovirals
• Prolonged pain: Amitriptyline 10 – 100 mg nocte (maybe useful; start early)
• Soothing antibacterial creams (e.g. povidone-iodine, silver sulfadiazine)

Complications

• Bacterial skin infection
• Postherpetic Neuralgia
• Herpes Zoster Ophtalmicus
• Acute retinal necrosis
• Ramsay Hunt syndrome (Herpes zoster oticus)
• Other neurological complications:
  • Aseptic meningitis
  • Peripheral motor neuropathy
  • Myelitis
  • Encephalitis
  • Guillain-Barré syndrome
  • Stroke syndromes

Investigations

Only if clinical presentation is uncertain:

• Viral culture
• Direct immunofluoresence testing
• Polymerase chain reaction assay 

A lumbar puncture is required if aseptic meningitis/ encephalitis is suspected.

Referral criteria

Emergent referral to an ophthalmologist when ophthalmic involvement is present. A decision regarding an appropriate admission should be made in consultation with the inpatient teams, bearing in mind that Zoster is highly infective in the immunocompromised.

Discharge criteria

Herpes Zoster without complications can be treated as an outpatient.

Advice for caregivers / patient information leaflet

Offer HIV testing.

References:

1. Albrecht M.A. Clinical manifestations of varicella-zoster virus infection: Herpes zoster. In: D.S. b, editor. Up To Date. Waltham, MA: UpToDate; 2012.

2. Regensberg L, Whitelaw C, editors. Clinical guidelines 2010/2011. 8th ed. Cape Town: Aid for Aids; 2010.

3. Albrecht M.A. Treatment of herpes zoster in the immunocompetent host. In: Basow D.S., editor. Up To Date. Waltham, MA: UpToDate; 2012.