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PATIENT STORY

A 44-year-old HIV-positive Hispanic man presented with painful herpes zoster of his right forehead (Figure 131-1). He was particularly worried because his right eye was red, painful, and very sensitive to light (Figure 131-2). On physical examination, there was significant conjunctival injection, corneal punctate epithelial erosions, and clouding, and a small layer of blood in the anterior chamber (hyphema). The pupil was somewhat irregular. Along with the hyphema and ciliary flush, this indicated an anterior uveitis. The patient had a unilateral ptosis on the right side with limitations in elevation, depression, and adduction of the eye secondary to cranial nerve III palsy from the zoster. The patient was immediately referred to ophthalmology and the anterior uveitis, corneal involvement, and cranial nerve III palsy were confirmed. The ophthalmologist started the patient on topical ophthalmic preparations of erythromycin, moxifloxacin, prednisolone, and atropine. Oral acyclovir was also prescribed. Unfortunately, the patient did not return for follow-up until 6 months later, when he returned to the ophthalmologist with significant corneal scarring (Figure 131-3). The patient is currently on a waiting list for a corneal transplantation.

FIGURE 131-1

A 44-year-old HIV-positive Hispanic man with painful herpes zoster of his right forehead.

FIGURE 131-2

Acute zoster ophthalmicus of the same patient with conjunctival injection, corneal punctation (keratitis), and a small layer of blood in the anterior chamber (hyphema). A diagnosis of anterior uveitis was suspected based on the irregularly shaped pupil, the hyphema, and ciliary flush. A slit-lamp examination confirmed the anterior uveitis (iritis).

FIGURE 131-3

Corneal scarring and conjunctival injection of the same patient 6 months later after being lost to follow-up.

INTRODUCTION

Herpes zoster is a common infection caused by varicella-zoster virus, the same virus that causes chickenpox. Reactivation of the latent virus in neurosensory ganglia produces the characteristic manifestations of herpes zoster (shingles). Herpes zoster outbreaks may be precipitated by aging, poor nutrition, immunocompromised status, physical or emotional stress, and excessive fatigue. Although zoster most commonly involves the thoracic and lumbar dermatomes, reactivation of the latent virus in the trigeminal ganglia may result in herpes zoster ophthalmicus (HZO) (Figures 131-1, 131-2, 131-3, 131-4, 131-5, 131-6, 131-7).

FIGURE 131-4

A. Herpes zoster ophthalmicus showing a V1 distribution in this 55-year-old woman who is immunosuppressed with prednisone and azathioprine for her dermatomyositis. She had tremendous eye and facial pain and developed significant blepharospasm secondary to this pain. B. It began with eye pain with no findings evident to the ophthalmologist. A few days later there were vesicles on the upper lid and conjunctival injection with discharge. In this ...

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