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Whereas valacyclovir is widely used and is recommended by some authors in moderately immunocompromised HIV-infected patients, its use has not been validated by clinical studies. We report a case of herpes zoster in an HIV-infected patient for whom neurologic complication was not avoided despite valacyclovir therapy. Clinical outcome was favorable after intravenous acyclovir. This case suggests careful monitoring of valacyclovir in HIV-infected patients is necessary.

In a retrospective study of 421 patients infected with human immunodeficiency virus, 15 (3.5%) had varicella. Twelve patients had a typical varicella. Complications were as follows: profuse eruption, 6; hemorrhagic eruption, 1; hepatitis, 5; and pulmonary involvement, 1; 1 patient developed an intravascular disseminated coagulation and died of varicella. Three patients with acquired immunodeficiency syndrome, having a history of varicella, presented with an atypical form of varicella with a small number of disseminated cutaneous poxlike lesions; 1 of these patients experienced three relapses of atypical varicella. Assay of serum antibodies to varicella zoster virus showed that, while typical varicella was the primary varicella zoster virus infection, atypical varicella was a reactivation of varicella zoster virus infection. Acyclovir was given to 11 patients and vidarabine to 1 patient. The one patient who died and the one who suffered a relapse had received acyclovir. Thus, varicella in patients infected with human immunodeficiency virus may be complicated and even lethal. Atypical forms of varicella could be, as is the case with herpes zoster, a reactivation of endogenous varicella zoster virus.

Between January 1981 and April 1989, 50 patients infected with HIV were examined for herpes zoster. Herpes zoster enabled HIV infection to be detected in 23 patients (46 percent). It had only one localisation (involving contiguous dermatomes) in 37 patients, two localisations in 6 patients, three or four localisations in 1 patient each, and was disseminated in 5 patients. Localisations were mostly thoracic and cervicofacial. Herpes zoster was treated with acyclovir in 29 patients. All patients, treated or untreated, recovered from herpes zoster, but 9 of them (18 percent) had sequelae: pain in 8 and hypoacousia in 1. Herpes zoster recurred once in 8 patients and twice in 2. Among the patients with AIDS related complex 20 percent developed AIDS after herpes zoster at one year and 30 percent at two years. Among all the patients, the proportion of deaths after herpes zoster was 13 percent at one year and 34 percent at two years.

Forty-three immunosuppressed patients presenting with varicella or generalized herpes zoster were treated with adenine arabinoside (as monophosphate in 10 patients). All those who received the recommended 5-day course were rapidly cured without relapse; the skin lesions were virus-free after the 5th days of treatment. Five patients with malignant varicella involving several organs and who had only been treated for a few hours died. It is concluded that adenine arabinoside is a useful drug in VZ virus infections, although it has no immediate action. The monophosphate presentation, more soluble and requiring lesser amounts of solvent, is easier to administer and as effective as the ordinary presentation.

A comparative assessment of vidarabine and acyclovir in the treatment of varicella and disseminated zoster in immunosuppressed patients was undertaken. Thirty-eight immunosuppressed patients with varicella (N = 18) or disseminated zoster (N = 20) were treated intravenously with 10 mg/kg/day of vidarabine or 30 mg/kg/day of acyclovir for 5 days according to a preestablished code within each diagnosis group--varicella and disseminated zoster. Two deaths, although not directly related to VZV infection, were observed in the vidarabine-treated varicella group. The times to cessation of formation of new lesions and to the disappearance of fever were similar for vidarabine and acyclovir in each group. In the varicella group, VZV was isolated on day 5 in four out of five vidarabine patients versus one out of five acyclovir patients. No severe adverse effects were observed with either drug. Neutropenia present in patients of both drug groups was transitory and most often related to previous cytolytic chemotherapy. These data suggest that either vidarabine or acyclovir could be used in the treatment of severe VZV infections in immunosuppressed patients, although a larger number of patients would be required for definitive conclusion. Because of the large amount of solute required for vidarabine administration, acyclovir may be preferred when the risk of cardiorespiratory failure is high.