Dermatology Online Journal

A study of HIV seropositivity with various clinical manifestation of herpes zoster among patients from Karnataka, India
Kikkeri Narayanashetty Naveen MD, RS Tophakane MD, Keloji Hanumanthayya MD, Bhagawat Pv MD, Varadraj V Pai MD
Dermatology Online Journal 17 (12): 3

SDMCMS&H Dharwad, Karnataka, India

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Abstract

AIMS:To study the various clinical presentations of herpes zoster and to find out the proportion of HIV positivity in these patients. METHODS: A time bound study was conducted from Nov 2004 to Oct 2005. All clinically diagnosed cases of herpes zoster were tested for HIV infection with ELISA and confirmed by Tridot and Coomb AID. RESULTS: Total numbers of 90 zoster cases were recorded. Mean duration of pre herpetic neuralgia was 2.134 (standard deviation=1.424, F=8.951, P<0.001). The thoracic dermatome (46.66%) was most commonly involved, followed by the cranial nerves (18.88%), lumbar (14.44%), cervical (13.33%) and sacral (6.66%) nerves. A substantial proportion, 34 (37.77%) out of 90 cases, were found to be HIV positive. Of these, 64.7 percent of the HIV seropositive herpes zoster patients belonged to the age group of 21-40 years. Out of 39 who had a risk of exposure to STDs and whose ages were less than 50 years, 31 (79.48%) tested positive for HIV infection. CONCLUSION: The occurrence of zoster in the young age group in patients who report a history of risk factors for HIV, may need testing. Herpes zoster serves as a clinical indicator of HIV seropositivity and one of the earliest manifestations.

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Introduction

Herpes zoster is one of the opportunistic infections occurring in HIV seropositive patients. The incidence of herpes zoster is greatly increased in persons infected with HIV. In India, where diagnostic facilities are often limited, herpes zoster may be used as a sentinel event for estimating the number of HIV infected patients in a given population who will be requiring further screening tests for HIV [1]. The present study is undertaken to delineate various clinical presentations of herpes zoster and association with HIV infection.

Materials and Methods

A time bound study was undertaken in the Skin and STD department of Karnatak Institute of Medical Science, Hubli, Karnataka, from November 2004 to October 2005. Karnatak Institute of Medical Science is a tertiary center. Patients attending Skin and STD OPD constituted the source of data. All new clinically diagnosed cases of herpes zoster were included in the study. Those cases of herpes zoster, in patients with previously known HIV positivity, were excluded from this study.

Considering a prevalence of 47.3 percent HIV seropositivity in herpes zoster and considering an 80 percent confidence interval and 20 percent permissible error, the size of the sample needed would be 111. Considering the inclusion and exclusion criterias, a time bound study was undertaken from the period of Nov 2004 to Oct 2005 (Approximately 100-120 cases by hospital statistics). The general rate of herpes zoster is 0.1 percent and the rate of HIV positivity in the population served by our institution is 0.96 percent.

A comprehensive history was recorded in every patient, with reference to their age, sex, religion, occupation, residence, prodromal symptoms, and distribution of lesions. A detailed sexual history pertaining to the risk of sexually transmitted diseases, premarital and extramarital contacts, and homosexual practices, was recorded. A history of blood transfusion, drug addiction, associated diseases like tuberculosis, and cancer, was recorded. Past and family history of herpes zoster and chickenpox were also recorded.

Routine investigations like hemoglobin percentage, total and differential count, ESR, RBS, urine for sugar, albumin and microscopy were carried out.

In all the patients, blood VDRL and HIV testing were carried out. HIV status was confirmed by ELISA, Tridot, and Coomb AIDS tests. Chest X-ray was done whenever indicated.

The study was approved by the hospital ethical committee of our institution.

Results were tabulated and calculated. Percentage and Student-t test methods were applied whenever necessary.

Results

A total of 90 cases of herpes zoster was diagnosed among 23100 patients attending the Skin and STD department, Karnatak Institute of Medical Science, Hubli, between November 2004 and October 2005 (frequency - 0.38%). The present study was conducted in Skin and STD OPD and was not a community based study, so overall incidence cannot be calculated.

The male to female ratio was 2.1(61):1(39). Patients from a rural background (55%) were slightly more numerous than those from an urban population (45%).

In the present study, the youngest patient was 4 years and the oldest patient was 72 years old. The maximum number of zoster cases (23 cases, 25.55%) was seen in the third decade. The mean age of our study population was 38.77 years with a standard deviation of 15.55; the median was 38 years.

Figure 1	Figure 2

July had the maximum number of cases (13 cases, 14.44%) and October had the least (3 cases, 3.33%).

A majority of patients (58.88%) presented within 5 days of the onset of their first symptom; 30 percent reported between 6 to 10 days. Only 7.77 percent presented after 10 days and 3.33 percent after 20 days of the onset of the first symptom.

Pain was the first symptom to occur in a majority of patients (58.88%), followed by skin lesions in 16.66 percent of patients.

Figure 3	Figure 4

Thirteen cases presented with a history of skin lesions and pain starting simultaneously. In 8 cases, skin lesions started one day after the onset of pain. Sixteen cases presented with a history of onset of skin lesions two days after the onset of pain. Out of 19 cases presenting with the history of skin lesions three days after the onset of pain, 16 (84.21%) had zoster affecting the thoracic dermatome. In the remaining 10 cases in which skin lesions erupted four days or more after the onset of pain, all of them had lesions in thoracic dermatome.

The duration of pre-herpetic neuralgia in different dermatomes varied. The overall mean duration of pre-herpetic neuralgia was 2.134 days, with a standard deviation 1.424 (F=8.951, P<0.001). Pre-herpetic neuralgia in the thoracic dermatome is 2.94 days. In the case of the ophthalmic, maxillary, mandibular, cervical and lumbosacral divisions, the mean duration of pre-herpetic neuralgia was 1.77, 0.5, 2, 1.21, and 1.21 with standard deviations 1.093, 0.70, 0.00, 1.00, and 1.05, respectively.

Past history of chicken pox was elicited in 48 (53.33%) cases in the present study. There was, however, no family history of chicken pox or herpes zoster in the recent past in any of these patients.

The thoracic dermatome (46.66%) was the most commonly involved, followed by the cranial nerves (18.88%). Among cranial nerves, the ophthalmic branch of trigeminal nerve was most commonly involved (14.44%), followed by the maxillary (2.22%) and mandibular (1.11%) branch. Only one case presented with facial nerve involvement. Lumbar, cervical, and sacral nerves were involved in 14.44 percent, 13.33 percent, and 6.66 percent, respectively.

Two cases of disseminated zoster were noted. In both the cases cervical nerves were the primary dermatomes affected.

Herpes zoster affected nerve distributions on the right side (57.77%) predominantly compared to the left side in the present study.

In the present study, 34 (37.77%) were HIV seropositive out of 90 cases of herpes zoster. Of these, 22 (64.7%) patients who were HIV seropositive belonged to the age group of 21-40 years. Out of 34 HIV seropositive pateints, 24 (70.54%) are males. The youngest patient was four years old and oldest was 50 years old.

In both HIV seropositive and HIV seronegative patients, uni-dermatomal involvement was predominant. But in HIV seronegative patients unidermatomal (87.5%) involvement was more common as compared to HIV seropositives (61.76%).

Two dermatomes were involved in 29.41 percent of HIV seropositive patients compared to 12.5 percent among HIV seronegative patients. One case exhibiting involvement of three dermatomes and two patients with disseminated zoster were noted in HIV seropositive patients, but none was noted in HIV seronegative patients.

Bullae, pustules, crusting, and ulceration were more commonly found in HIV seropositive patients than in HIV seronegative patients. Scarring was noted in six HIV seropositive patients as compared to two in HIV seronegative patients.

Two HIV positive patients exhibiting herpes zoster ophthalmicus developed corneal ulcer.

Five patients were found to have a recurrence, either in the same dermatome or a different dermatome. All of them turned out to be HIV positive. The previous attack of herpes zoster was suggested by history and by the presence of hyperpigmentation, hypopigmentation, or scars in a dermatomal distribution.

Out of 90 patients, 45 (50%) had exposure to the risk of STD. Only 1 (2.4%) of them used condoms while having sex with commercial sex workers. Two cases out of 90 (2.22%) had received a blood transfusion. None of the cases had a history of drug addiction.

VDRL test for Syphilis was negative in all the cases.

Discussion

The frequency of herpes zoster amongst our skin OPD patients was found to be 0.38 percent and agrees with other studies [2]. Compared to previous studies [3-8], our study showed an increased incidence of herpes zoster in the younger population. This may relate to an increased prevalence of HIV infection, which mainly affects the younger generation. In the present study, three patients were below 10 years; both or their parents are HIV seropositive and likely acquired their HIV infection through vertical transmission. Our male to female ratio of 2.1:1 agreed with other studies [6, 7, 9, 10] (Table 1).

In the previous studies as shown in Table 2, HIV seropositvity varied from 9.5 percent to 92 percent, probably because HIV is endemic in some areas where positivity rate was as high as 80-90 percent.

The majority of patients presented to us late compared to other studies [6, 7]. We found that many in our population carried misbeliefs such as that herpes zoster is caused by snakes and that drawing an eagle at the advancing end with raw mud will stop its progression.

In the present study like other studies [1, 6, 7], many patients gave a previous history of childhood varicella. Reinfection seems to be unlikely, as in none of the cases there was a history of recent contact with either herpes zoster or chickenpox.

The dermatomal distribution of this current study agrees with most of the other studies [2, 5, 6, 7, 10, 11] and suggests that thoracic segments are the most common to be involved. The 37.77 percent HIV seropositivity of the present study indicates a higher incidence compared to other studies [1, 2, 8, 11-18].

In the present study, bullae, pustules, and ulceration were more common in HIV seropositive patients compared to HIV seronegative patients, like other studies [11, 19]. However, such a striking difference was not found in the case of crusting because the practice of local people is to apply mud on lesions, which leads to crusting irrespective of their HIV status.

This study noted recurrent herpes zoster in 5 cases and all of them are HIV positive.

The occurrence of zoster in a young age group, in patients who give a history of multiple sexual exposures or risky sexual exposures should suggest a need for HIV testing. Herpes zoster serves as a clinical indicator of HIV seropositivity and one of the earliest manifestations.

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