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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"
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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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
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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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
$. 4 5"67 councellsml of blood4
of 1004000 cop
This case
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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Ac&clovir 9:00mg 4
8x1 for < da&s
Antiretrovtherap& 9$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& $erpesviridae
b& droplet inhalation into the respirator& s&stem
incubation period from 10 to 23 da&sviral "#A resides in a dormant 9latent state in the
root ganglia-
i
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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immuno-compromis
ed
viruses migrate alonsensory
Nerves to the skin andthey replicate and
Cause the characterist
reactivated orm o
chicken po !"aricella# is termed$erpes %oster&
the virus maybecome
activated
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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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'
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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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
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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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&
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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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
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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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&
$er ophthalmic and
Acyclovir medicationsthe chronic orm ocornea ulcer& 1here
was a total resolutiono the keratopathy&1he visual acuity !"A#on right eye improvedto 875) by ) month
9atient without
eperieherpetic
Case report
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(ISC)SSIO*
2i i
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2iscussion
Herpes
viri
ae
double
stranded "#Avirus
reactivatedinfection beingclinicall& EuitediFerent from
the diseasecaused b&
primar& infection
llifelongpersistent
infection
underg
reactiva
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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attack of chicken pox
some virus spread along the sensor& nerves fromthe skin lesions
the ganglia ad,acent to the spinal cord 9dorsroot ganglionsemilunar ganglion in the basethe skull
reduced immunit& b& such factors as
ps&chological4 ph&siological stress4 age o
causes the characteristic facial lesio
net
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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net
antige
n!antibo
d&reactio
ns
viralinfect
ion
dela&ed cellmediated
h&persensitivit& reactions
denervati
on andischaemia
inducedb&
vasculitis
5,; ll
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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$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 $>/- G
generalpopulation
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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$>/
• greaterskin
• ocularinvolvements
@rodromesign
• fever4malaise
andheadache
#euralgiasign
• burninsensa
to sevdeepboringlancinpain
• persisorintermnt
totall& resolve +ithinthe rst
6 +eeks
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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The skin lesions of $erpes %oster are histopathologicall& identical to those of .aricella44
ophthalmic distribution of the trigeminal nerve-
• =ashes distributed along the ophtha• branches of the right Trigeminal of
• patient
• the lesion is maculopapular and pus• crusting ulcers
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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•ocularcomplicati
ons
involveme
nt of thenasociliar&
nerve
9$utchinson(s sign
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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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 $%O - numm
keratitis• 9unctate epithelial =eratitis - 2is
=eratitis• >icrodendritic ulcers - >ucous
keratitis
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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+icroenrites on patient
right cornea that stain %it
ourescein'
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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T he neurological complications arecranial
nerve palsies particularl" of the .rcranial pair'
Recover" occurs spontaneousl" %i
si/ months
Optic neuritis occurs in a$out 0 in
cases'
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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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-
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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The presence of HZV in a young otherwise
patient should provide pause for the consid
of underlying HIV.
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of 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-
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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Treatment of $erpes >os
/phthalmicus
•/ral antiviral drugs•m&driatics and topicalcorticosteroids
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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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
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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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
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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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'
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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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 $ithout thexperience of diplopia-
After . months on her HAART the viral loa %as mar7ereuce to less than 08222 copies9ml an her C(1: co
increase to 0222 cell9ml
7/25/2019 Herpes-zoster Virus Ophthalmicus as Presenting Sign of HIV
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%&V in'ection should al$ays b
considered in patients youthan years $ith herpes ophthalmicus (%*+)