HIV-Associated Herpes Zoster

Prodromal symptoms of pain and itching may be severe enough to lead to a suspicion of serious illness. For example, the prodromal pain of thoracic zoster has led to critical care unit admission to rule out myocardial infarction.
Regional adenopathy may occur.
Varicella pneumonia may develop.
Cutaneous lesions may become chronic in patients with AIDS.
Grouped vesicles or bullae on an erythematous base affect all or part of a dermatome.
Lesions evolve into pustules and crusts and may erode. Chronic ulcerations and crusted or verrucous lesions may occur.
Severe scarring may result (Fig. 33.4).

Distribution of Lesions

Any dermatome can be affected.
Disseminated herpes zoster virus may occur. Occasional dissemination may lead to 25 or more lesions outside of the primary and two contiguous dermatomes (Fig. 33.5A,B). The disease usually begins with typical dermatomal herpes zoster virus that becomes widespread and chronic. The eruption may be indistinguishable from varicella.

Management

Recalcitrant Herpes Zoster

Intravenous acyclovir (10 mg/kg every 8 hours) is given for 10 to 14 days.
Dosage intervals are increased in patients with renal failure.
If lesions improve but persist beyond 10 to 14 days, treatment is continued until all lesions resolve.

Acyclovir Resistance

If lesions fail to resolve, the virus may be resistant to acyclovir.
Acyclovir-resistant varicella-zoster virus infection responds to foscarnet (40 mg/kg every 8 hours until lesions resolve).

Points to Remember

Undertreatment may lead to viral resistance.
Patients with herpes zoster can transmit the virus as chickenpox to nonimmune persons.