Clinical Case – Herpes Zoster

I am on the inpatient ward of the Fevers Unit of Korle-Bu Hospital in Accra, Ghana. The patient is a woman in her forties. She presented with a 3 day history of a vesicular rash on her lower back, right lateral thigh, and perineum. The rash was preceded by 2 days of pain in the same distribution. She has no prior medical history.  An HIV test is done and she is found to be positive. A CD4 count is pending, but it is likely to be very low. It is probable that she has AIDS.

Her rash is herpes zoster also known as shingles. Herpes zoster is caused by the same virus, varicella zoster, that causes chickenpox. Anybody who has had chickenpox can get shingles as the virus remains dormant (sleeping) in nerve cells after a bout of chickenpox. In reality, only about 25% of people who have had chickenpox get shingles. These are usually adults older than 60 years of age or immunocompromised people.

Bacterial superinfection of herpes zoster

Unfortunately, this patient also has a bacterial super-infection which explains the erythema (redness). She is in a lot of pain. When the shingles clears up, which will take a while given the super-infection, she most likely will develop post-herpetic neuralgia, a tingling pain in the same distribution that can last for years.

Studying for the Boards

A popular MKSAP question (preparation for the Internal Medicine Boards) is about who to screen for HIV. At this time universal screening is not yet standard thus you would want to screen an otherwise healthy relatively young person for HIV if they have herpes zoster, thrush, recurrent yeast infections (women), or seborrheic dermatitis (severe dandruff).

Another case of herpes zoster

This patient was seen as an outpatient in the clinic. Her shingles, which is on her thigh is not super-infected with bacteria. She did not have any pain before the appearance of the vesicles. She is already known to have HIV but is not yet on HAART.