7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV

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 Abia State University, Uturu, Abia,

Submitted 10 June 2011; accepted 30 Sep

CASE REPORT 

Herpes-zoster virophthalmicus as pres

sign of HIV iseas

 Journal Optomet

  !" Septh"

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Abstract

After a childhood episodeof chicken pox

 The viruses ge

reactivatedf individual is imm

compromised iadulthood

"#A reside in a dormantstate in the dorsal root

ganglia

cause characterilesions of $erpes %

on the skin and the

Varicella- #oster

infection

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'emale

32(nd )ears old

corneal dendranterior uveiticircumlimbal in,e

the right e&e-.isual acuit& /"0S-

crusting skin ulcersinvolving the ophthalmicdivision of the trigeminal

nerve

$. 4 5"67 councellsml of blood4

of 1004000 cop

 This case

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Ac&clovir 9:00mg 4

8x1 for < da&s

Antiretrovtherap& 9$AAStavudine 930>idovudine

mg ?favire900mg

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Introduction

5hicken pox 9varicella is a highl& contagious skin children 2 to < &ears of age

the .aricella!>oster virus 9famil& $erpesviridae

b& droplet inhalation into the respirator& s&stem

incubation period from 10 to 23 da&sviral "#A resides in a dormant 9latent state in the

  root ganglia-

i

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immuno-compromis

ed

viruses migrate alonsensory

Nerves to the skin andthey replicate and

Cause the characterist

 reactivated orm o 

chicken po !"aricella# is termed$erpes %oster&

the virus maybecome

activated

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This report escri$es HIV positive patien presente %ith Herpes zoster infection a&ecte the ophthalmic $ranch of the trigeminal nerve'

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Case report 

• Central ophthalmic clin'ket

 emale

()*nd

 +ears old

•  chickenpo in childhoodyears agohistor" 

• urning sensation• deep lancing pain on the su

the right eye. upper lid. antscalp / orehead

•  ollowed soon ater ew daever. malaise and headach

complains

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Case report 

• skin lesions on the right half of thfrontal and the nasociliar&-

• crusting ulcersdermatolog&

• microdendritic ulcers on the right• anterior uveitis +ith a circumlimb/cular sign

• no retinal involvement'unduscopicexamination

• /" 0 and /S -

.isual acuit&

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Case report 

• @5= test for .aricella >oster +as positive• enie rapid $. screening test +as pos

$.!2

• 5"67 count +as 380 cellsml blood and +as1004000 copiesml

BAC

• $erpes >oster /phthalmicus"x

• oral Ac&clovir 9:00 mg 8 times dafor < da&s

• topical prednisolone acetate 91D drops instilled four times dail& for da&s

• Atropine 91D of +hich 1drop +as

instilled three times dail& for one +•

 Treatment

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After treatment

Ater ( months onher $AA01. her C234count was

increased to 5666cells7ml

  the viral loadmarkedly

reduced to less than5.666 copies7ml&

$er ophthalmic and

Acyclovir medicationsthe chronic orm ocornea ulcer& 1here

was a total resolutiono the keratopathy&1he visual acuity !"A#on right eye improvedto 875) by ) month

9atient without

eperieherpetic

Case report 

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(ISC)SSIO*

2i i

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2iscussion

Herpes

viri 

ae

double

stranded "#Avirus

reactivatedinfection beingclinicall& EuitediFerent from

the diseasecaused b&

primar& infection

llifelongpersistent

infection

underg

reactiva

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attack of chicken pox

some virus spread along the sensor& nerves fromthe skin lesions

the ganglia ad,acent to the spinal cord 9dorsroot ganglionsemilunar ganglion in the basethe skull

reduced immunit& b& such factors as

ps&chological4 ph&siological stress4 age o

causes the characteristic facial lesio

net

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net

antige

n!antibo

d&reactio

ns

viralinfect

ion

dela&ed cellmediated

h&persensitivit& reactions

denervati

on andischaemia

inducedb&

vasculitis

5,; ll

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$erpes :oster 

Ophthalmicus

 

5,; o all cases o$erpes :oster afect therontal.  lacrimal / nasociliary

branches ophthalmicdivision o thetrigeminal nerve

  $. posipopulatio

18!28 G

general popu

risk

of developing $>/- G

generalpopulation

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$>/

• greaterskin

• ocularinvolvements

@rodromesign

• fever4malaise

andheadache

#euralgiasign

• burninsensa

to sevdeepboringlancinpain

• persisorintermnt

totall& resolve +ithinthe rst

 6 +eeks

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 The skin lesions of $erpes %oster are histopathologicall& identical to those of .aricella44

ophthalmic distribution of the trigeminal nerve-

 •   =ashes distributed along the ophtha•   branches of the right Trigeminal of

•   patient

•   the lesion is maculopapular and pus•   crusting ulcers

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•ocularcomplicati

ons

involveme

nt of thenasociliar&

nerve

9$utchinson(s sign

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Con<unctivitis 

• common and al+a&s associate+ith vesicles on the lid margin

'piscleritis 

•occurs in about 13 of cases atonset of 

• the rash

Cornealcomplicati

ons

• 8,; o cases with $%O - numm

keratitis• 9unctate epithelial =eratitis - 2is

=eratitis• >icrodendritic ulcers - >ucous

keratitis

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  +icroenrites on patient

  right cornea that stain %it

ourescein'

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T he neurological complications arecranial 

 nerve palsies particularl" of the .rcranial pair'

Recover" occurs spontaneousl" %i

si/ months

Optic neuritis occurs in a$out 0 in

cases'

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diagnoses in the laborator&

 staining smears of scrapings or s+abs of the bavesicles

multinucleated giant cellsnon!herpetic vesicle

 immuno Huorescein staining of smear

  rapid diagnosis electron microscopeexamination

 The virus can also be isolated from vesicle Huid u

cultures of human cell in 3!< da&s-

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The presence of HZV in a young otherwise

patient should provide pause for the consid

of underlying HIV.

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$erpers %osterstage of $.

infection4

 Irst clinicalpresentation-

!highest risk#C234 counts

between ,6 and)66 cells7ml

9rimarytreatment

is directed atreducing theviral load and

increasing theC234 

treating

opportunistic

inections-

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 Treatment of $erpes >os

/phthalmicus

•/ral antiviral drugs•m&driatics and topicalcorticosteroids

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• Ac&clovir :00 mg 8 times a da&;• 'amicidovir 800 mg• .alac&lovir 1 gram t-i-d for < da&s reduc

complications

/ral antiviraldrugs

• topical corticosteroids e-g- prednisolone

keratitis oruvetisreEuire

• Atropin 1D atau skopolamin 0428D 1 te

 The pupilshould be

dilated

Thi

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This case

1reated or $erpes %oster

Ophthalmicus !$%O# @•oral Ac&clovir 9:00 mg 8 times da< da&s

•topical prednisolone acetate 91Dfour times dail& for < da&s-

• The pupil of the right e&e +as kep

dilated

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#ucleoside reverse Transcriptaseinhibitors 9#=TS-

• >idovudine 9A>T• Stavudine 9d6t4•

Bamivudine 93T54"idanosine 9ddi• Abacavir 9AC54• >alcitabine 9ddc• ?mtricitabine-

. The #onnucleoside

nhibitors of =evene Trans criptase

9##=TS-

• #eviropine 9#.@4• ?faviren% 9?'.• "elaviridine

9"B.-

 The prinhibito

• SaEuinav• indinavir • =itonavir•

#el navir• Amprena• Bopinavir

 The antivirals for use in $. disease to increase5"67 count * reduce the viral load are of three

1$I CA'

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1$I CA'

 H"per Active Antiretroviral 3HAART45

•

Stavuine 3.2 mg4• #iovuine3.22 mg4

• Efavirenz 3622 mg4

2 month The visual acuity (VA) on the righimproved to !"2, presently the VA stands at !# on either The patient also restored a smooth ocular motility $ithout thexperience of diplopia-

 After . months on her HAART the viral loa %as mar7ereuce to less than 08222 copies9ml an her C(1: co

increase to 0222 cell9ml 

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%&V in'ection should al$ays b

considered in patients youthan years $ith herpes ophthalmicus (%*+)

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