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Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, ItalyIII Division of Infectious Diseases, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milan, Italy
Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, ItalyIII Division of Infectious Diseases, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milan, Italy
A 58-year old man with HIV infection diagnosed in 2018 presented in July 2021 with a 7-day history of vesicular skin lesions localized to the right side of abdomen and diffuse vesicular lesions on the face, trunk, abdomen and both arms (Fig. 1A e 1B).
Fig. 1Vesicular skin lesions involving the right lumbar dermatome (1A); numerous varicella-like lesions at various stages of evolution (1B).
He was on antiretroviral therapy with dolutegravir plus darunavir/cobicistat with undetectable HIV-RNA (< 20 cp/mL) and a CD4+ cell count of 221/μL. He had received a complete cycle of mRNA BNT162b2 vaccine for SARS-Cov-2 (Comirnaty) with the last dose administered 41 days before the appearance of skin lesions. He was febrile (37.8 °C), alert and complained of mild headache and pain and paresthesia localized at the right flank. Blood tests showed mild leukopenia (3580/μL) and thrombocytopenia (109,000/μL)
What is your diagnosis?
Discussion session
The patient was diagnosed with shingles with cutaneous disseminated lesions (or herpes zoster with generalized varicelliform eruption) a condition that has been observed to occur in 2–10% of patients with Herpes Zoster (HZ) of whom 65% had associated underlying diseases responsible of immunocompromission. Serology showed a pattern of previous Varicella-Zoster virus (VZV) infection (positive IgG anti-VZV, negative IgM anti-VZV). He was hospitalized and treated with intravenous acyclovir (750 mg every 8 h) for 8 days followed by outpatient oral therapy for 6 more days.
HIV infection is a well recognized risk factor for reactivation of VZV with an incidence rate that is fourfold with respect to the general population [
Herpes zoster in persons living with HIV-1 infection: viremia and immunological defects are strong risk factors in the era of combination antiretroviral therapy.
]. Occasionally it may present as “recurrent varicella” characterised by diffuse vesicular rash or as “atypical generalized zoster” without primary dermatomal involvement [
]. VZV reactivation has been reported following SARS-CoV-2 immunization with a median time of appearance of 9 days (range 7–20 days) after the administration of the most recent dose (either first or second dose) [
]. In our patient the long time elapsed between the last dose of vaccine and the appearance of shingles seems to exclude a possible role of SARS-CoV-2 as a trigger of reactivation. Finally, it should highlighted that intravenous acyclovir is the treatment of choice for complicated, disseminated and severe HZ among people living with HIV infection.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for profit sectors.
Ethical approval
For this type of study, our ethics committee required patient agreement to the informed consent.
Author contributions
AP contributed to patient care, MVC was responsible for the diagnosis and medical care of the patient, SA drafted the manuscript. All authors contributed to the final version of the manuscript.
Declaration of Competing Interests
The authors declared no conflicts of interests associated with this manuscript
Informed consent
The patient gave his informed consent and agreed to the anonymized retrospective publication
References
Erdmann N.B.
Prentice H.A.
Bansal A.
et al.
Herpes zoster in persons living with HIV-1 infection: viremia and immunological defects are strong risk factors in the era of combination antiretroviral therapy.
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