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    usmlemate is offline Junior Member
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    Varicella Zoster Virus HIV

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    A 27-year-old HIV-infected man with a CD4 count of 51 cells/mm3 presents to clinic for an urgent appointment after the onset of severe, unrelenting chest wall pain that began two days prior to presentation. He initiated highly active antiretroviral therapy 2 months ago. Today he noticed a rash on his back (Figure 1). His examination in clinic shows a vesicular rash in a dermatomal distribution. One of the lesions is unroofed and the fluid is applied to a glass slide; Giemsa (Tzanck) staining reveals multinucleated giant cells and a presumptive diagnosis of herpes zoster is made.

    Which of the following statements is TRUE regarding varicella zoster virus (VZV) infection in HIV-infected patients?

    A. The Tzanck stain is diagnostic for VZV infection and it rules out other causes of vesicular skin lesions, such as herpes simplex virus infection.

    B. The development of herpes zoster occurs with increased frequency within 6 months of starting highly active antiretroviral therapy and thus this patientís herpes zoster may be related to his recent initiation of antiretroviral therapy.

    C. The preferred therapy for dermatomal herpes zoster in HIV-infected patients consists of oral valganciclovir (Valcyte).

    D. The incidence of herpes zoster in HIV-infected individuals is the same as age-matched HIV-negative persons.

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    usmlemate is offline Junior Member
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    Re: Varicella Zoster Virus HIV

    Quote Originally Posted by usmlemate
    A 27-year-old HIV-infected man with a CD4 count of 51 cells/mm3 presents to clinic for an urgent appointment after the onset of severe, unrelenting chest wall pain that began two days prior to presentation. He initiated highly active antiretroviral therapy 2 months ago. Today he noticed a rash on his back (Figure 1). His examination in clinic shows a vesicular rash in a dermatomal distribution. One of the lesions is unroofed and the fluid is applied to a glass slide; Giemsa (Tzanck) staining reveals multinucleated giant cells and a presumptive diagnosis of herpes zoster is made.

    Which of the following statements is TRUE regarding varicella zoster virus (VZV) infection in HIV-infected patients?

    A. The Tzanck stain is diagnostic for VZV infection and it rules out other causes of vesicular skin lesions, such as herpes simplex virus infection.

    B. The development of herpes zoster occurs with increased frequency within 6 months of starting highly active antiretroviral therapy and thus this patientís herpes zoster may be related to his recent initiation of antiretroviral therapy.

    C. The preferred therapy for dermatomal herpes zoster in HIV-infected patients consists of oral valganciclovir (Valcyte).

    D. The incidence of herpes zoster in HIV-infected individuals is the same as age-matched HIV-negative persons.
    The correct answer is B. Several reports have shown that herpes zoster occurs with an increased frequency within 4-6 months of patients initiating antiretroviral therapy. In one study, 8% of patients initiating highly active antiretroviral therapy were noted to develop herpes zoster at a mean of 5 weeks after starting therapy. Patients with a brisk increase in CD8 cells were at the greatest risk of developing zoster, suggesting that immune reconstitution plays a role in this clinical syndrome.

    Answer A is incorrect. The finding of multinucleated giant cells on Tzanck (Giemsa) staining is neither sensitive nor specific for diagnosing viral vesicular lesions. Direct fluorescent antibody (DFA) testing would be more appropriate and can specifically differentiate VZV from other viruses. The DFA uses fluorescent labeled antibodies that detect antigens specific to VZV, and it yields more rapid and accurate results than culture.

    Answer C is incorrect. In HIV-infected patients, therapy for localized herpes zoster consists of oral therapy with acyclovir (Zovirax), famciclovir (Famvir), or valacyclovir (Valtrex). Neither intravenous ganciclovir (Valcyte) nor oral valganciclovir (Valcyte) are recommended to treat herpes zoster.

    Answer D is incorrect. The incidence of zoster among HIV-infected adults is more than 10-fold greater than age-matched immunocompetent persons.

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