Herpes zoster: a photo gallery

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Abstract

Herpes zoster is a viral disease. Its development is directly related to the reactivation of the human herpesvirus type 3. At certain points in life, 10%–20% of the population is at risk of developing this condition. The likelihood of disease increases significantly in immunocompromised individuals, including those with HIV infection, malignancies, or those who have undergone bone marrow transplantation, or are receiving long-term cytostatic or systemic glucocorticoid therapy. In people living with HIV, herpes zoster occurs 8–15 times more frequently than in the general population. In immunodeficient states, including HIV-associated immunodeficiency, the course of herpes may have distinct features.

This photo gallery presents cases of herpes zoster that developed in the setting of HIV infection. In such cases, clinical manifestation typically occurs when CD4+ T-cell counts fall below 400 cells/μL. In patients not receiving antiretroviral therapy, deeper immunosuppression may lead to recurrence. In some patients with low immune status, herpes zoster may appear as a manifestation of immune system reconstitution inflammatory syndrome. The severity and clinical presentation of the disease are largely determined by the degree of immunodeficiency. In HIV-infected individuals, multidermatomal involvement—affecting two or more dermatomes simultaneously—is common. Compared to HIV-negative individuals, the vesicular eruption phase may last more than 10 days, and atypical forms are more frequently observed (e.g., hemorrhagic, ulceronecrotic, verrucous, disseminated, generalized), which may occur in combination and present with more intense and deeper skin lesions. In HIV-infected individuals, localization of lesions in the external auditory canal is associated with a high risk of auditory involvement, whereas localization in the area innervated by the ophthalmic branch of the trigeminal nerve implies a risk of visual impairment. One possible complication is Ramsay Hunt syndrome (characterized by vesicles in the auricular region, ear pain, and facial nerve paresis or paralysis).

According to the Russian clinical classification, the first episode of herpes zoster in a person living with HIV may serve as the basis for diagnosing stage 2B (acute HIV infection with secondary diseases) or stage 4A (secondary diseases) depending on the duration of HIV infection. Recurrent or disseminated herpes zoster corresponds to stage 4B.

This photo gallery presents various clinical forms and anatomical locations of herpes zoster in patients with HIV infection. The descriptions of the lesions specify their location in accordance with the innervation zones of peripheral sensory nerves.

All photographs presented in this article are from the author’s personal archive.

About the authors

Sergey V. Prozherin

Sverdlovsk Regional Center for Prevention and Control of AIDS

Author for correspondence.
Email: progsherin@mail.ru
ORCID iD: 0000-0001-9956-4700
SPIN-code: 5354-4893

MD

Russian Federation, 46 Yasnaya st, Ekaterinburg, 620102

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2. Fig. 1. Patient K., 38 years old. Uncomplicated Herpes zoster, erythematous-papular form. It is the second day since the appearance of the first rash. The process is asymmetrical. On the skin of the left half of the chest and the upper third of the left shoulder, in the innervation zone of the cervical spinal nerves C4–C5, there are merging erythematous, edematous foci with multiple grouped nodular and a few vesicular elements on the surface. Skin manifestations of Herpes zoster begin with swelling and redness of the skin. The erythematous phase of the rash is usually short-lived or absent altogether. Papules soon appear, which transform into vesicles within 1–2 days.

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3. Fig. 2. Patient R., 32 years old. Uncomplicated herpes zoster, vesicular form. On the anterolateral surface of the body (a) and in the subscapular region of the back (b) on the right, along the thoracic spinal nerves T7–T8, there are tense vesicles with transparent contents, prone to grouping, against a background of erythema and edema. The period during which new vesicular lesions appear usually lasts 3–4 days and can be extended to 7 days or more in immunocompromised patients.

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4. Fig. 3. Patient N., 46 years old. The process involves almost the entire area of innervation of the cervical spinal nerves C2–C5 on the right. If merging pustules predominate on the posterolateral surface of the lesion (a), then polycyclic erosions prevail on its anterior surface (b). Pustulization of vesicles usually begins several days after their appearance. Then the pustules rupture and lead to the formation of erosions, which occurred in this case (b). According to some authors, unilateral lesions of two or more adjacent dermatomes most often develop in the area of the cervical spinal nerves.

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5. Fig. 4. Patient L., 61 years old. Herpes zoster, vesicular-bullous form. On the skin of the right mammary gland (a) and in the area of the right scapula (b), there are numerous grouped vesicles on an edematous erythematous base, in places merging into blisters. The pathological process involves thoracic dermatomes T2–T3.

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6. Fig. 5. Patient P., 38 years old. Herpes zoster, vesicular-bullous form. On the anterolateral surface of the right forearm, as well as on the palmar (a) and dorsal (b) surfaces of the right hand, in the areas of innervation of the spinal nerves C6, there are vesicles located both in groups and isolated, along with a few blisters. Some of the cystic lesions are filled with clear contents, others with cloudy fluid, and a small portion contains hemorrhagic fluid. On the palm, the blisters are characterized by the presence of a dense covering. Hyperemia and edema are noted in the lesions.

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7. Fig. 6. Patient A., 34 years old. Herpes zoster complicated: Ramsay Hunt syndrome. In the left auricular area, including the external auditory canal (a), the skin is pinkish-red, with grouped vesicular elements containing opalescent fluid. Similar changes are observed in adjacent areas innervated by the mandibular branch of the trigeminal nerve and cervical spinal nerves C2–C4 (a, b). The disease was accompanied by burning pain in the left ear and left-sided hemiparesis of the facial nerve.

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8. Fig. 7. Patient O., 52 years old. Herpes zoster, ulcerative-necrotic form. Ophthalmic herpes. In the area of innervation of the ophthalmic and maxillary branches of the left trigeminal nerve, the skin is bluish-red, with irregularly shaped ulcerations of various sizes, most of which are covered with crusts. On the forehead and bridge of the nose, the rash is sharply demarcated along the midline. In half of the patients with Herpes zoster localized in the orbital region, various structures of the visual organ are involved in the pathological process. The presence of vesicles on the tip or wings of the nose indicates a possible intraocular lesion (Hutchinson’s sign). Although this symptom is negative in this case, the patient was diagnosed with keratitis, conjunctivitis, and iridocyclitis.

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9. Fig. 8. Patient V., 41 years old. On the left lower limb and the adjacent lumbar region, along the lumbar spinal nerves L2–L4, there are multiple isolated and grouped vesicles filled with hemorrhagic contents.

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10. Fig. 9. Patient L., 45 years old. Herpes zoster, disseminated form. On the left half of the body along the spinal nerves T7–T8, the skin is pinkish-red, with a large number of vesicles merging in places into blisters, some of which are filled with hemorrhagic contents. Outside the lesion, there are scattered vesicular elements on an erythematous base with slight central depression. The presence of more than 20 such vesicles in a patient, located outside the affected area and adjacent dermatomes, allows the diagnosis of disseminated Herpes zoster.

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11. Fig. 10. Patient L., 46 years old. Herpes zoster. In this case, there are rashes characteristic of different clinical forms of Herpes zoster. Thus, numerous pustular elements located on an erythematous base (pustular form) are combined with vesicles and blisters filled with bloody contents (hemorrhagic form). The unilateral distribution of the rash in the lumbar region (a) and the lower third of the anterolateral surface of the body on the left (b) indicates involvement of two dermatomes innervated by spinal nerves T12–L1. Blisters and lesions with scalloped outlines covered with crusts represent the natural evolution of the rash.

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12. Fig. 11. Patient V., 28 years old. Herpes zoster, disseminated form. In the spinal nerves C2–C3 segment on the right side of the neck and the adjacent submandibular region (a), there are vesicles with turbid contents, irregularly shaped lesions covered with serous-hemorrhagic crusts, and isolated erosions. On the trunk (b), there are numerous vesicular eruptions with central depressions and a rim of erythema.

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13. Fig. 12. Patient S., 37 years old. Scars at the site of resolved herpes zoster rashes. In HIV-positive patients with Herpes zoster, rash elements are often accompanied by damage to the basement membrane. In such cases, the pathological process ends with the formation of scars.

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