Clinical Guide > Comorbidities and Complications > Herpes Zoster

Herpes Zoster/Shingles

January 2011

Chapter Contents


Shingles is a skin or mucosal infection caused by the varicella-zoster virus (VZV) that occurs along a dermatome and represents a reactivation of varicella (chickenpox). Zoster is common in patients with HIV infection, including apparently healthy individuals before the onset of other HIV-related symptoms. The incidence may be higher among patients with low CD4 cell counts and during the four months after initiating potent antiretroviral therapy.

Zoster may be particularly painful or necrotic in HIV-infected individuals. Disseminated infection, defined as outbreaks with >20 vesicles outside the primary and immediately adjacent dermatomes, usually involves the skin and the visceral organs. Neurologic complications of zoster include encephalitis, aseptic meningitis, cranial nerve palsies, optic neuritis, transverse myelitis, and vasculitic stroke.

S: Subjective

The patient complains of painful skin blisters or ulcerations along one side of the face or body. Loss of vision may accompany the appearance of facial lesions. Pain in a dermatomal distribution may precede the appearance of lesions by many days (prodrome).

Assess the following during the history:

O: Objective

Perform a skin and neurologic examination to include the following:

A: Assessment

P: Plan

Diagnostic Evaluation

The diagnosis usually is clinical and is based on the characteristic appearance and distribution of lesions. If the diagnosis is uncertain, perform viral cultures or antigen detection by direct fluorescent antibody from a freshly opened vesicle or biopsy from the border of a lesion.


(See chapter Pain Syndrome and Peripheral Neuropathy for more options and specific recommendations.)

Severe or unresponsive cases


The vaccine for prevention of herpes zoster (Zostavax) currently is not recommended for HIV-infected patients but is under study.

Postcontact Chickenpox Prevention

All susceptible persons, including pregnant women, who have close contact with a patient who has chickenpox or zoster must be treated to prevent chickenpox. Exposed individuals who have no history of chickenpox or shingles or no detectable antibody against VZV should be administered varicella zoster immune globulin (VariZIG) as soon as possible, but at least within 96 hours after contact. Some experts also would recommend varicella vaccination for exposed patients with CD4 counts of ≥200 cells/µL, or preemptive treatment with acyclovir; these approaches have not been studied in HIV-infected persons. Even immunocompetent adults with primary VZV (chickenpox) can develop viral dissemination to the visceral organs. HIV-Infected patients may develop encephalitis, pneumonia, or polyradiculopathy during primary varicella (chickenpox) or reactivated zoster (shingles).

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