HIV/AIDS Treatment and Care : Clinical protocols for the European ...

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HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION
7.1.3. Treatment
Table 17. treatment of cmV infection
Antimicrobial agenta Dose Frequency Route Duration
First line treatment
Induction phase
Ganciclovir
Maintenance phase
Ganciclovir
5 mg/kg
5 mg/kg
7.2. Varicella-zoster virus
every 12 hours
OD
IV
IV
7 days
2–3 weeks
7.2.1. Prophylaxis
Immunosuppressed HIV-infected children who are susceptible to varicella-zoster virus 9 (VZV)
should avoid exposure to people with chicken pox or shingles. For the prophylaxis of chicken pox,
HIV-infected patients susceptible to VZV should be administered varicella-zoster immunoglobulin
(VZIg) as soon as possible, ideally within 96 hours after any close contact with chicken pox or
shingles.
There are no data on the effectiveness of aciclovir for preventing chicken pox in HIV-infected children
or adults.
7.2.2. Diagnosis
The diagnosis of VZV infection is often suspected from the clinical presentation A generalized severe
pruritic vesicular rash and fever is diagnostic. Lesions appear first and are most numerous on
the trunk, neck, and face. The vesicles contain fluid, rest on an erythematous base and ulcerate and
dry to form crusts and scabs. Lesions during chronic VZV infection are varicelliform at onset but
may evolve into non-healing, necrotic and crusted ulcers that become hyperkeratotic (79).
The classical clinical presentation of zoster (a painful localized cutaneous vesicular eruption along
one or more contiguous dermatomes) is diagnostic. Lesions evolve over 1 to 2 days to form vesicles,
pustules, and crusts. In HIV-infected patients, zoster may be bullous, haemorrhagic, necrotic,
and particularly painful. Blisters and crusts usually last 2–3 weeks, although necrotic lesions may
last up to 6 weeks and heal with severe scarring. Zoster in HIV-infected children may also present
as an atypical rash that extends beyond dermatomal boundaries or is bilaterally distributed or generalized
or as multiple episodes of a disseminated rash more similar in appearance to chickenpox
than zoster (80).
Varicella pneumonitis in HIV-infected children is associated with severe pulmonary manifestations
resulting in hypoxaemia and diffuse reticulo-nodular densities on radiography. Encephalitis occurs
more frequently with zoster in the ophthalmic distribution, and cerebellar findings are typical;
prominent symptoms include ataxia, tremors, and dizziness. Cerebral involvement results in fever,
headache, vomiting and lethargy (81).
Direct immunofluorescence expressed on the surface of infected cells from scrapings obtained from
the base of skin, conjunctiva, or mucosal lesions allow VZV antigen detection, and is the diagnostic
procedure of choice. Direct and indirect immunofluorescence or immunoperoxidase methods can
also detect antigen in VZV-infected cells in tissue sections of lung, liver, brain, or other organs.
9 Susceptible patients are those who have no history of chicken pox or shingles or who have no detectable VZV antibody.