A patient with HIV (CD4 count 90/µL) develops painful vesicles in the V1 dermatomal distribution of the trigeminal nerve, with ipsilateral conjunctival injection and decreased corneal sensation. VZV PCR of vesicle swab is positive. Which antiviral regimen and dose is recommended for this sight-threatening herpes zoster ophthalmicus?
- A Oral valacyclovir 1000 mg three times daily for 7 days
- B IV acyclovir 10 mg/kg every 8 hours for 10–14 days ✓
- C Oral acyclovir 800 mg five times daily for 7 days
- D IV foscarnet 60 mg/kg every 8 hours
Correct answer: B. IV acyclovir 10 mg/kg every 8 hours for 10–14 days
Explanation
Herpes zoster ophthalmicus in an immunocompromised patient (especially with CD4 <100 or ophthalmic branch involvement with corneal complications) requires intravenous acyclovir at 10 mg/kg q8h for 10–14 days to reduce risk of encephalitis, retinal necrosis and irreversible visual loss. Oral valacyclovir/acyclovir are appropriate only for uncomplicated HZO in immunocompetent patients. Foscarnet is reserved for acyclovir-resistant VZV. Ophthalmic consultation and topical steroids for keratitis should be added under antiviral cover.
Reference: Ananthanarayan & Paniker's Textbook of Microbiology, 11th ed.
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