CASE REPORT |
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| Year : 1995 | Volume
: 61
| Issue : 1 | Page : 40-41 |
Disseminated cutaneous herpes zoster: A clinical predictor of human immunodeficiency virus infection
HK Kar, RK Gautam, RK Jain, P Puri, V Doda
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Correspondence Address:
H K Kar
Abstract
A 45-year-old woman presented with thoracic (3,4,5) herpes zoster with cutaneous dissemination. She was found positive for human immunodeficiency virus infection. Mucocutaneous examination revealed presence of oral thrush and oral hairy leukoplakia. The patient possibly acquired the infection through blood transfusion.
How to cite this article:
Kar H K, Gautam R K, Jain R K, Puri P, Doda V. Disseminated cutaneous herpes zoster: A clinical predictor of human immunodeficiency virus infection.Indian J Dermatol Venereol Leprol 1995;61:40-41
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How to cite this URL:
Kar H K, Gautam R K, Jain R K, Puri P, Doda V. Disseminated cutaneous herpes zoster: A clinical predictor of human immunodeficiency virus infection. Indian J Dermatol Venereol Leprol [serial online] 1995 [cited 2013 May 25 ];61:40-41
Available from: http://www.ijdvl.com/text.asp?1995/61/1/40/4127 |
Full Text
Introduction
In 1981, herpes zoster (HZ) was first reported to be associated with AIDS. Subsequently, it was found to precede AIDS in persons of high risk group. In study from the USA, the incidence of HZ was found significantly higher among HIV seropositive men (29 cases/1000 person-year) than among HIV seronegative men (2.0 cases/1000 person-year). Since there is paucity of reports on occurrence of disseminated HZ and other mucocutaneous manifestations in HIV infection in Indian literature, we report an HIV infected patient with cutaneous disseminated HZ as the presenting manifestation.
Case Report
In July 1994, a 45-year-old married housewife presented with extremely painful grouped reddish eruptions on the left side of the chest and back for past 1 week. It was accompanied with numerous, similar isolated and disseminated lesions all over the body for the past 4 days. There was history of radiating pain 2 days prior to the appearance of skin lesions. Four years back she had undergone caeserian section in a Govt. Hospital in New Delhi and 2 years later, hysterectomy was performed for uterine fibroid in a private nursing home in Uttar Pradesh. On both occasions, she had received blood transfusion.
The family and personal history disclosed that neither she nor her husband had any other sexual partner. There was no personal or family history of any sexually transmitted diseases (STD) or any drug addictions.
Cutaneous examination at the time of admission revealed grouped vesiculobullous lesions on erythematous base involving 3rd, 4th and 5th thoracic dermatomes. Some of the lesions were haemorrhagic. Further, she had multiple, isolated vesicles and a few of these vesicles were haemorrhagic. Three to five days later she developed ulcerative and necrotic lesions at the above sites. There were white adherent plaques over the dorsal surface of tongue, buccal mucosa and palate. In addition, there were filiform, hairy, white lesions on the lateral sides of the tongue. She had bilateral moderately enlarged soft and tender axillary lymph nodes. She was afebrile and there were no other constitutional symptoms.
The diagnosis of HZ was apparent on clinical findings. Tzanck smear from a vesicular lesion revealed giant cells. The viral culture for the confirmation of HZ and oral hairy leukoplakia (OHL) could not be done because of the non availability of facility. Oral thrush was confirmed by the demonstration of gram stained hyphae and yeast from a smear from the white plaques. Candida albicans was isolated on culture. The diagnosis of OHL was purely on clinical resemblance to the morphology of OHL. The laboratory evaluation revealed ELISA positive (twice) for both HIV-1 and HIV-2. Western blot test done at National Institute of Communicable Diseases, New Delhi, confirmed HIV infection. Her husband's serum sample showed ELISA negative for HIV. Her CD 4+lymphocytes count was 224/μl at the time of admission. VDRL and TPHA tests were nonreactive. The skiagram of chest, ultrasound examination of abdomen and computerised axial tomography of skull were unremarkable. The haematogical examination revealed anaemia (Hb 8 gm%) and TLC of 4000/cmm. The liver and renal function tests were within normal limits. Our case thus falls under clinical category "B2" of the 1993 revised classification system of CDC, USA.
The patient was treated with oral acyclovir (800 mg 5 times daily for 7 days) and ketoconazole (200 mg daily) for 2 weeks. Oral erythromycin was given for 1 week along with other supportive therapy. There was gradual improvement in HZ and oral lesion after 1 week. The patient was discharged on request on 10th day and was lost on follow-up.
Discussion
Herpes zoster often occurs early in HIV infection. The course is usually uneventful in majority of patients. It is mostly multidermatomal and/or disseminated. Limited cutaneous dissemination secondary to viremia is common in some patients with zoster, however uneventful recovery is the rule.[3],[4] Our case also manifested multidermatomal involvement with cutaneous dissemination but had partial recovery at the time of discharge. In this patient, OHL, oral thrush and herpes zoster was seen concomittantly. However, in a study from Africa, reactivation of latent varicella zoster infection (VZV) correlated with moderate HIV-induced immunodeficiency, occurring earlier than OHL and oropharyngeal candidiasis.[5] Zoster or reactivation of latent VZV infection with multi-dermatomal involvement and cutaneous dissemination should always raise the suspicion of the need for HIV serotesting. The associated oral candidiasis or OHL further makes it mandatory for serotesting for HIV infection. In our department, earlier, one case with severe seborrhoeic dermatitis and another with recalcitrant psoriasis was found to be HIV positive (unpublished observation).
Therefore, in dermatological practice, patients with high risk behaviour and multidermatomal herpes zoster with or without cutaneous dissemination and other mucocutaneous manifestations related to HIV infection should be counselled about the risk factors for HIV infection and offered HIV antibody testing. This recommendation applies to all cases without any other cause of immunosuppression, regardless of age group.
References
| 1 | Susan PB, Mitchell HK, Nancy AH, et al. Herpes zoster and human immunodeficiency virus infection. J Infect Dis 1992;166:1153-6. |
| 2 | George R, Jacob M, Babu PG, Saraswati NK, John TN. AIDS, oral hairy leukoplakia and tuberculosis : A case report. Ind J Sex Transm Dis 1992;13:88-90. |
| 3 | Williamson BC. Disseminated herpes zoster in a human immunodeficiency virus-positive homosexual man without complications. Cutis 1987;40:485. |
| 4 | Cohon PR, Beltrani VP, Grossman ME. Disseminated herpes zoster in patients with human immunodeficiency virus infection. Am J Med 1988;84:1076. |
| 5 | Colebunders R, Mann JM, Francis H, et al. Herpes Zoster in African patients : A clinical predictor of human immunodeficiency virus infection. J Infect Dis 1988;157:314. |
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