Clinical Manual for Management of the HIV-Infected ... - myCME.com

Herpes Zoster/Shingles
Background
Shingles is a skin or mucosal infection caused by
the varicella-zoster virus (VZV) that occurs along a
dermatome and represents a reactivation of varicella
(chickenpox). Zoster is common in patients with HIV
infection, including apparently healthy individuals
before the onset of other HIV-related symptoms. The
incidence may be higher at low CD4 cell counts and
also within 4 months of initiating effective antiretroviral
therapy.
Zoster may be particularly painful or necrotic in HIVinfected
individuals. Disseminated infection, defined
as outbreaks with >20 vesicles outside the primary and
immediately adjacent dermatomes, usually involves the
skin and the visceral organs. Neurologic complications
of zoster include encephalitis, transverse myelitis, and
vasculitic stroke.
S: Subjective
The patient complains of painful skin blisters or
ulcerations along 1 side of the face or body. Loss of
vision may accompany the appearance of facial lesions.
Pain in a dermatomal distribution may precede the
appearance of lesions by many days (prodrome).
Assess the following during the history:
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Duration of pain or blisters (average of 2-3 weeks if
untreated)
Location of pain or blisters; severity of pain
History of chickenpox (usually in childhood)
O: Objective
Perform a skin and neurologic examination to include
the following:
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Vesicular lesions with erythematous bases in
a dermatomal distribution; may be bullous or
hemorrhagic
Necrotic lesions; may persist for as long as 6 weeks
Dermatomal scarring (particularly in dark-skinned
individuals)
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Section 6—Disease-Specific Treatment | 6–49
Lesions in the eye area or tip of nose, along the
trigeminal nerve represent ophthalmic nerve
involvement, which requires immediate evaluation
and intravenous treatment (see below)
A: Assessment
Rule out other causes of vesicular skin eruptions (eg,
herpes simplex virus, severe drug reactions).
Assess contact exposures (see below).
P: Plan
Diagnostic Evaluation
The diagnosis is usually clinical and is based on the characteristic
appearance and distribution of lesions. If the
diagnosis is uncertain, perform viral cultures or antigen
detection by direct fluorescent antibody from a freshly
opened vesicle or biopsy from the border of a lesion.
Treatment
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Treatment ideally should begin within 72 hours
of an outbreak or while new lesions are appearing.
Famciclovir (Famvir) 500 mg orally 3 times per day
for 7-10 days or valacyclovir (Valtrex) 1 g orally
every 8 hours for 7 days is the preferred regimen and
may attenuate a herpes/VZV attack if started early.
An alternative treatment is acyclovir 800 mg orally 5
times per day.
Dosage reductions of these drugs are required for
patients with renal impairment.
If new blisters are still appearing at the end of
treatment, repeat course of oral therapy or consider
intravenous treatment. Adjunctive corticosteroids
aimed at preventing postherpetic neuralgia are not
recommended.
Consult an ophthalmologist immediately if lesions
appear in the eye area or on the tip of the nose, or
if patient complains of visual disturbances, because
VZV-related retinal necrosis can cause blindness.
Because of the rapid progression associated with this
diagnosis, hospitalization for intravenous acyclovir
and possibly foscarnet is recommended.