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Clinical Summary

Varicella-zoster virus (VZV) infection presents as shingles in HIV-infected patients at a greater frequency and severity than the general population. Despite the high incidence of shingles in this population, severe disseminated disease is rare.

The diagnosis of herpes zoster in the ED is often made clinically, by either recognizing the pain syndrome or visualizing the rash. Patients can present with a well-defined area of hyperesthesia for days prior to an outbreak of the characteristic lesions. Immunocompromised patients may demonstrate multidermatomal distribution or scattered vesicles at a distant site. Approximately 20% of patients will have systemic symptoms such as malaise, fever, headache, or fatigue. Culture, serologic testing, or PCR confirms the diagnosis, but treatment may be empiric based on the clinical appearance of the lesions or a well-defined area of hyperesthesia. A Tzanck test can be obtained by scraping the base of a lesion in an attempt to demonstrate multinucleated giant cells.

Management and Disposition

Three antiviral drugs are used to treat herpes zoster infections: acyclovir, famciclovir, and valacyclovir. Patients with severe disseminated disease or ophthalmic zoster should receive intravenous acyclovir (10-12.5 mg/kg intravenously every 8 hours for 10-14 days), often in conjunction with infectious diseases consultation. Treatment of zoster ophthalmicus should include topical antibiotics and immediate ophthalmology consultation. Providing treatment of the disease within 72 hours of rash onset will result in a more rapid resolution of cutaneous lesions and decrease viral shedding but will not change the incidence of postherpetic neuralgia. Immunocompromised patients should not be placed on glucocorticoids. Narcotics, capsaicin cream, and tricyclic antidepressants can be used for pain control.


  1. Worsening cases of herpes zoster, complicated herpes zoster, or ophthalmic zoster all require intravenous acyclovir and admission.

  2. Herpes zoster encephalitis is rare but can occur months after the cutaneous phase and can be difficult to diagnose. Common presenting symptoms include mental status changes, headache, fever, photophobia, vomiting, or even focal neurologic deficits.

  3. Patients presenting with localized hyperesthesia may have a zoster-related prodrome, and treatment should be initiated if clinical suspicion is high.

  4. The presence of vesicles on the tip of the nose (Hutchinson sign) indicates involvement of the nasociliary branch of cranial nerve V and is associated with a higher risk of ocular involvement.

FIGURE 20.26

HZV (Shingles). A painful eruption of many tiny vesicles on an erythematous base in this patient with HIV. (Photo contributor: Jeffery Gibson, MD.)

FIGURE 20.27

HZV—Multiple Dermatomes. Severe painful shingles (vesicles and bullae) spanning multiple cutaneous dermatomes in this HIV patient. (Photo contributor: John O’Mara, MD.)

FIGURE 20.28

Disseminated Herpes Zoster Infection. Vesicles are seen over the entire face, representing disseminated HZV infection (multiple dermatomal distributions). (Photo contributor: Department of Dermatology, National Naval Medical ...

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