17-Herpes simplex - Zoster - Chickenpox/Varicella - Herpes Stomatitis - Herpetic Keratitis

Herpes simplex

(Resistant herpes simplex is common if CD4<100)

Common!  axx030//ghx011// ghx063// ghx077// bxx001// bxx061//(See 7-Mouth & 15-Genital area) -------See also (axx001) (ghx003) (ghx008) (ghx068) (bxx040)...

Symptomatic treatment if mild (or acyclovir cream5x/d).  If severe and painful give acyclovir 400mg 1 tablet 5x/day

Sometimes herpes involves the whole lip and/or mouth (stomatitis).  Confusion with Steven Johnson is common... (bxx039...) You will have to treat with acyclovir 800mg 5x/d if possible (expensive, night time...).  See "32-Unable to Eat"

Varicella-chickenpox

One can observe new, old and broken vesicles present at the same time all over the body of the patient.  (pxx031) - (pxx301...) - ??(ptx036-pxx242-pxx243-pxx244)??

If disease has just started : acyclovir 800mg po 5x/day for 10 days or more. This is useless if the disease started many days before.  (!!!acyclovir is expensive!!!)

Local care to avoid secondary infection: calamine 2-3x/day is the easiest, the cheapest and the most effective; make sure fingernails are cut short to help prevent serious excoriation.

Herpes zoster

(Common if CD4<500)

Vesicles on one clearly limited part of the body (dermatome).  Lesions on more than one dermatome are very rare.  (pxx035...) (pxx036) (pxx037) (pxx073) (pxx218) (pxx300...) (pxx396...)

If disease has just started: acyclovir 800mg po 5x/day for 10 days or more. This is useless if disease started many days before.  (!!!acyclovir is expensive!!!)

Local care to avoid secondary infection: calamine 2-3 x a day is the easiest, the cheapest and the most effective (this serves to dry the vesicles quicker, and in this situation is not used for its anti-pruritic effect).

If pain: Tramadol 1-2tab/inj 3-4x/day

Herpes stomatitis versus Stevens Johnson/erythema multiforme

- See "6-Allergy" & "32-Unable to Eat"

"(...) Differential diagnosis between "herpes stomatitis" and "Stevens Johnson/erythema multiforme" is sometimes impossible.  Usually, Stevens Johnson/erythema multiforme will involve the entire lip, unlike herpetic stomatitis which is often a localized lesion (see photos + comments: bxx011- 014- 015- 016- 017- 031- 032- 056...- ) All become more complex when we know that the herpes virus can be the cause of the Stevens-Johson syndrome as well!!! //yxx010- 011- ghx094- 095- 096- pxx381- 382- 383- 384- 385- 398- 399- bxx 065- 066- 067// (...)" See "6-Allergy" for more details/photos.

Herpes virus + secondary infection?

If fluid in vesicles is sticky/yellow, you should consider secondary infection. (pxx033) (pxx034) (axx001) (ghx003) (ghx008)

Mild secondary infection: cloxacillin 500mg 1tab 4x/day

Severe secondary infection (inflammation, fever...): gentamycin IM 160mg every day

Herpetic keratitis

If herpes simplex is the cause: unilateral painful red eyes.  Photophobia.  Tearing, no sticky pus.  Visual acuity can decrease!  ...  If you observe the eyes carefully even without contrast tincture, you can see corneal lesion: "dendritic" white lesion (like large fissure in a wall) or even, in severe case, large "geographic" white macules (yxx006) (yxx007) (yxx008)

If herpes zoster or chickenpox is involved... cutaneal signs help the diagnosis.

Keratitis responds to acyclovir 800mg 1 tablet 5x/day

Note:

1. Acyclovir CREAM is useless for zoster and varicella-chickenpox but can help for early stage herpes simplex
2. Herpes and corticoids?  Answer is not clear.  In Europe, they do not like association; but in America some authors recommend dexa for zoster?!?  Our experience: The majority of our patients have herpes lesions... Many of them have received dexa for a few days and more, rarely for more than one week (cataclysmic dyspnea, cataclysmic depression, last step, some dangerous dysphagia...).  In fact I was never able to associate the use of corticoid with the degradation or emergence of herpes lesions.  No more simplex, no more zoster, no herpetic stomatitis...  Even patients who reach the last step never display increasing herpes even when receiving very high doses of dexa.  Now, we no longer consider herpes a contra indication for corticoids.  (Unfortunately we cannot say the same for CMV!!! We had at least one bad experience.)