The National AIDS Control Organisation (NACO), a government initiative launched in 1992 to prevent and control HIV infection in India, estimated the epidemiological status of HIV/AIDS in 2012 as 20.89 lakh. The immunocompromised state in HIV patients makes them susceptible to various infections, including shingles or herpes zoster. A study carried out from 2004 to 2005 in Karnataka, India, confirmed that out of 90 reported herpes zoster infections, 37.77% were sero-positive cases of HIV6. Thoracic and lumbar dermatomes are commonly affected, and the trigeminal nerve is involved in 13% of patients7. Currently, no evidence-based pharmacological strategy or a definitive guideline table for the prevention of immune reconstitution inflammatory disease can be recommended, as none of the pharmacological clinical trials have been completed. Clinical trials involving the use of Maraviroc, a CCR5 chemokine receptor antagonist and a nonsteroidal anti-inflammatory drug (NSAID), are currently ongoing. Statins, vitamin D, and corticosteroids have also been suggested as other possible immune recovery inflammatory disease prevention strategies8. Since the early initiation of ART is not always possible due to a lack of awareness and economical limitations, a late presentation along with advanced HIV leads to high rates of opportunistic infections in these patients.

Herpes zoster is a reactivation of the latent varicella zoster virus in the dorsal spinal ganglion initiated by triggering factors such as trauma, aging, an immunocompromised state, malignancy, and radiotherapy. When reactivated, the virus replicates, producing inflammation and host cell death. The virus is transported along the axonal length of the sensory nerves to the skin and clinically presents with early symptoms of dysesthesia, tingling sensations, numbness, and itching; a characteristic rash appears after a few days. Vesicle formation is seen along the course of the nerve in a week to 10 days. These vesicles transform into bullae and eventually burst open to form scabs. When the trigeminal ganglion is involved, the pain produced by the infection can mislead clinicians to diagnose it as trigeminal neuralgia or odontalgia.

A 75-year-old male patient visited the hospital with a chief complaint of pain in the entire right half of his face for the past eight days. The pain was accompanied by burning and a tingling sensation. The patient revealed a history of extraction of the right maxillary third molar tooth eight days before at a private clinic. His pain was severe in intensity and continuous in frequency, radiating to the forehead on the same side. There was no history of fever or lymphadenopathy. The patient had been on ART two months earlier for a period of three months, which was revealed only after the results of the investigations were obtained.

The patient was conscious, delirious, irritable, and appeared tired and distressed. He was moderately built and poorly nourished. There was history of a loss of appetite and weakness for the past six months. On examination, multiple cutaneous vesicles and scabs covered the same side of his cheek, ear, upper and lower lips, chin, and submandibular region.(Fig. 1) Mild diffuse swelling on the right half of the lips was noted, and generalized ulceration of the right buccal and labial mucosa was present.(Fig. 2, 3) Ulcerations on the anterior two-thirds of the right half of the tongue, lingual mucosa, tonsillar pillars, and the soft palate were also present. The ulcers were irregular and more than a centimeter in size and were covered with slough. The patient also complained of restriction in his jaw opening due to severe pain. There were no signs of systemic dissemination.

Herpes simplex is the most common skin infection that presents a clinical picture similar to herpes zoster; others include impetigo, contact dermatitis, folliculitis, scabies, insect bites, papular urticaria, candidal infection, and dermatitis herpetiformitis. Immune suppression also may have an atypical presentation. Therefore, laboratory testing with polymerase chain reaction, direct fluorescent antibody staining, and immunoglobulin M enzyme-linked immunosorbent assay (ELISA) have proven useful for such cases. A history of or exposure to the zoster virus or the clinical presentation of a rash with a dermatomal pattern helps distinguish varicella infection from disseminated herpes zoster. In this case, the patient had a distinct pattern of lesions along the sensory distribution of the maxillary and mandibular nerves. His laboratory report showed a marked decrease in his lymphocyte count, and he tested positive for HIV.

Anti-inflammatory drugs such as corticosteroids are reserved for mild to moderate symptoms of pain. Any interruption of ART during the phase of opportunistic infection is not recommended unless it is a life-threatening opportunistic infection because the cessation of ART can lead to ART resistance. Since the patient was immunocompromised, the recommended oral dosage of 1,000 mg of Acyclovir three times a day for seven days was prescribed. A topical application of acyclovir was also prescribed. Tramadol infusions in saline were administered to relieve the pain. The patient was treated for the next two days and then was discharged against medical advice since he wanted to be admitted to a government hospital. The patient was therefore referred to a government hospital for continuation of the ART.