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Opportunistic Infections: Shingles

Basic Information

Shingles is a painful infection of the skin caused by the reactivation of the varicella-Zoster virus (VZV), the same virus responsible for chickenpox and a member of the herpes virus family. In fact shingles is an acute inflammation of herpetic vesicles along the region of an infected nerve. It is sometimes simply called zoster or herpes zoster.

Typically an individual will feel pain or itching for a few days before the eruption of the papules. When shingles appear:

  • It is usually as a red rash on the skin of the body area that is affected.
  • Within twenty-four hours the papules become vesicles filled with fluid and merge with adjacent vesicles to form larger blisters -- or clusters.
  • Crusting occurs during the second week.
  • Sometimes there may be residual scarring.

Shingles occurs at a higher incidence in persons who are infected with HIV than among persons in the general population -- it usually occurs when the immune system begins to weaken, as happens when cases of shingles occur in the elderly. Likewise it can occur in HIV-infected individuals at any CD4 count and can be one of the first opportunistic infections to be seen in immunocompromised persons. It can appear during any stage of HIV-infection however, usually affecting the systemic and central nervous systems and is much more serious when it occurs or recurs in patients in advanced stage of HIV disease. Unlike oral hairy leukoplakia, it is not thought to be an indicator of HIV progression.

Chickenpox is a common illness seen most frequently in childhood. After the illness has run its course, the causative agent VZV remains as a chronic infection in nerves of the face, trunk and pelvis. Sometimes in the general population it reactivates and lesions or rash, for a painful though limited time, resembling the lesions or rash of chickenpox, erupt on certain skin areas. The eruption of VZV goes back down the sensory nerve (it has lain dormant often in the dorsal root ganglia) causing shingles in the skin tended by this nerve.

Shingles occurs in three to four patients per 1,000 annually with HIV-infected individuals having the highest rate within this group along with the elderly. However, since nearly 90% of the adult population has already been infected with VZV, most HIV-infected individuals will not have primary VZV infection, but they can have quite different and mores serious manifestations of VZV infection than the normal host -- in some cases extremely serious. Usually the infection is not bound to clear up within an average amount of time nor is it limited to the areas of skin near the rash but can spread to areas beyond.

Symptoms

Patients with HIV disease can experience these symptoms:

  • pain surrounding the lesions
  • pain -- or postherpetic neuralgia even after healing of the blisters
  • large areas of skin becoming affected
  • infection of the cornea

Dissemination to internal organs like:

  • the liver
  • the brain, causing encephalitis with signs of confusion, headache, coordination difficulty and seizures
  • lungs, causing pneumonia
  • myelitis can be a late complication with bladder dysfunction and sensory deficits

Some of these symptoms indicate potentially life-threatening conditions and they are not usual in immunocompetent individuals.

Diagnosis/Treatment

Clinical diagnosis is made by examination of the vesicular rash. Direct examination of biopsy tissue is also a tool and diagnosis can also help be made by a positive Tzanck smear.

Acyclovir is most often used to treat shingles, however doses are tolerated differently depending on the individual. In severe cases intravenous acyclovir is recommended and patients treated intravenously usually experience:

  • reduced new papules
  • a shorter time of viral shredding
  • a smaller incidence of dissemination

Over time, some patients may become resistant to acyclovir. Sofcarnet may be indicated for cases of VZV that are acyclovir-resistant.

There is no direct way to prevent shingles from occurring but reducing the risk to exposure may help prevent the disease under certain conditions. For both HIV-infected adults and children, it is recommended

  • to avoid coming into contact with persons who have shingles or chickenpox if you have not had chickenpox and have tested negative for VZV and
  • that in case you do come into contact with an individual who has either shingles or chickenpox to get a zoster immune globulin within 96 hours.

We at Always Your Choice have had experience in diagnosing and treating HIV-related shingles. Should you have symptoms of shingles or have questions about this infection, we would be glad to see you.