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CASE REPORT
Herpes Zoster as a Sign of AIDS and nonadherence to antiretroviral therapy: a case report
Helena Lucia Barroso dos ReisI,
Corresponding author
hbarroso@unimedvitoria.com.br

Tel.: 55 27 3335-7180
, Fernanda Sampaio CavalcanteII, Katia Regina Netto dos SantosII, Mauro Romero Leal PassosIII, Dennis de Carvalho FerreiraII
I Federal University of Espírito Santo (UFES), Gynecology and Obstetrics Department, Espírito Santo, Vitória/ES, Brazil.
II Federal University of Rio de Janeiro, Paulo de Góes Microbiology Institute, UFRJ.
III Microbiology Institute, Rio de Janeiro/RJ, Brazil, Fluminense Federal University (UFF), STD Sector, Niterói/RJ, Brazil.
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">The reactivation of varicella-zoster virus &#40;VZV&#41; infection may occur during the course of human immunodeficiency virus &#40;HIV&#41; infection as an initial indicator of the disease&#46; Post-herpetic neuralgia and multiple vesiculobullous lesions have been described in HIV-infected patients with herpes zoster&#46;<a class="elsevierStyleCrossRefs" href="#bib1">1&#44;2</a> Nonadherence to highly active antiretroviral therapy &#40;HAART&#41; has a significant impact on the patient&#39;s quality of life and increases the risk of mortality&#46;<a class="elsevierStyleCrossRef" href="#bib3">3</a> We report a case of an HIV-infected patient who developed herpes zoster due to nonadherence to HAART&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">CASE DESCRIPTION</span><p id="para20" class="elsevierStylePara elsevierViewall">A 55-year-old female patient of afro-descendant was diagnosed with AIDS in 1999&#44; when she developed chronic diarrhea and weight loss&#46; This patient was a homemaker born in Bahia and residing in Serra-ES &#40;Brazil&#41; with an HIV-positive and nonexclusive sexual partner and three children&#46; She had been in menopause for six years at the time of VZV diagnosis&#46; Antiretroviral treatment was initiated with zidovudine &#40;AZT&#41; &#43; didanosine in 2001 because her CD4&#43; count fell below 350 cells&#47;mm3&#46; Because of noncompliance&#44; she remained without anti-retroviral medication for 31 months&#44; which&#44; in 2008&#44; allowed her to be susceptible to a very aggressive clinical episode of herpes zoster with severe neuralgia&#44; which led to a seven-day hospitalization&#46; Initially&#44; she presented with maculopapular lesions that progressed into vesicles and then pustules and crusts on the right thoracic region following the nerve path &#40;<a class="elsevierStyleCrossRefs" href="#fig1">Figure 1 and Figure 2</a>&#41; that lasted for 12 days&#46; Laboratory tests showed a normal complete blood count &#40;CBC&#41;&#44; a viral load &#40;VL&#41; of 27&#44;500 copies&#47;mL and a CD4&#43; T lymphocyte count of 328 cells&#47;mm3&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia><elsevierMultimedia ident="fig2"></elsevierMultimedia><p id="para30" class="elsevierStylePara elsevierViewall">The patient was treated with intravenous acyclovir for seven days&#44; with marked improvement of the lesions&#46; She started therapy with AZT &#43; lamivudine &#43; abacavir&#46; At the same time&#44; the cervical oncotic cytology was suggestive of cervical intraepithelial neoplasia I &#40;CIN I&#41; and infection with human papillomavirus &#40;HPV&#41;&#46; Colposcopy suggested CIN I&#44; and the cytological samples from the cervix after 3&#44; 6&#44; 12&#44; and 18 months were normal&#46; A hypochromic scar remained in the affected area after the herpes zoster was treated &#40;<a class="elsevierStyleCrossRef" href="#fig3">Figures 3A and B</a>&#41;&#44; which caused constraints on the patient&#39;s social life and affected her quality of life&#46; Moreover&#44; she suffered from persistent post-herpetic neuritis that lasted for 12 months&#46; The patient remains in a clinical follow-up program in the infectious and parasitic diseases sector at a public hospital in Esp&#237;rito Santo state&#46; Currently&#44; the patient adheres correctly to the antiretroviral therapy and has had no relapses of herpes zoster&#44; and her quality of life has improved significantly&#46;</p><elsevierMultimedia ident="fig3"></elsevierMultimedia><p id="para40" class="elsevierStylePara elsevierViewall">Above&#44; we described an aggressive form of infection caused by VZV that served as a warning flag for AIDS in a patient who did not adhere to HAART&#46;</p><p id="para50" class="elsevierStylePara elsevierViewall">The next section describes the factors involved in noncompliance and provides support for a more effective approach to the clinical follow-up of individuals with HIV&#46;</p></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">DISCUSSION</span><p id="para60" class="elsevierStylePara elsevierViewall">Patients who meet the definition of AIDS&#44; such as the patient described in this report&#44; exhibit significant inhibition of the immune system and are susceptible to new bacterial&#44; fungal&#44; and viral infections and to the reactivation of prior infections&#46; Some of these infections are considered AIDS defining and can be categorized as opportunistic infections &#40;OI&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib4">4</a></p><p id="para70" class="elsevierStylePara elsevierViewall">Some viral agents&#44; especially herpesviruses&#44; can cause acute and persistent lytic infections&#44; signaling immunosuppression in an early symptomatic phase of AIDS&#46; Among these&#44; VZV stands out as one viral agent that can be reactivated by the HIV-positive patient&#39;s immunological changes&#44;<a class="elsevierStyleCrossRef" href="#bib5">5</a> manifesting clinically as vesicles that break down into ulcers following the nerve path and as pre- and post-injury neuralgia associated with intense pain&#46; All of these events&#44; associated with the immunosuppression&#44; occurred were experienced by the patient described in this report&#46;</p><p id="para80" class="elsevierStylePara elsevierViewall">The current literature indicates that noncompliance is the largest cause of failure of highly active antiretroviral therapy &#40;HAART&#41;&#46; HAART must be understood as an action in which the patient not only follows medical advice but also understands and agrees to follow the guidelines and requirements&#46; Adherence to HAART includes following schedules&#44; maintaining proper dosage with no interruptions &#40;regardless of social life or travels&#41; and even making use of a balanced diet to support the therapy&#46; Adverse effects or fear of exposure may influence the patient&#39;s motivation for not adhering to the therapy&#44; thereby jeopardizing the efficacy of the recommended treatment and potentially impairing the quality of life &#40;Ferreira et al&#46;&#44; 2011&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib6">6</a></p><p id="para90" class="elsevierStylePara elsevierViewall">Studies have identified different factors as causes of patient noncompliance with antiretroviral treatment&#44; including fear of side effects&#44; lack of adequate food&#44; difficulty integrating the treatment routine into their lives&#44; forgetting when to take the medicine&#44; the influence of other people in their social life&#44; the amount of medicine to take and the emotional state &#40;Kaishusha Mupendwa et al&#46;&#44; 2009&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib7">7</a></p><p id="para100" class="elsevierStylePara elsevierViewall">Other factors associated with noncompliance include age&#44; education&#44; injecting drug use&#44; alcohol use&#44; drug regimens with protease inhibitors&#44; the presence of clinical signs and symptoms&#44; loss of companions&#44; time of diagnosis of HIV infection&#44; a break in the continuity of care by one doctor or hospital and depression &#40;Glass et al&#46;&#44; 2010&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib8">8</a> Two of these issues are particularly notable&#58; the &#8220;emotional state&#8221; and depression&#46; The patient in this report was depressed and exhibited an altered emotional state&#44; which were considered possible causes for her refusal to use the proposed antiretroviral therapy&#46; The patient&#44; at present&#44; is on HAART therapy and antidepressants in outpatient care&#46;</p><p id="para110" class="elsevierStylePara elsevierViewall">Adherence measures are currently being reassessed because of flaws in their evaluation standards &#40;Zijenah&#44; 2006&#59; Bangsberg 2002&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib9">9&#44;10</a> The search for a better quality of life for HIV-infected individuals should be the central aim when following this clinical group&#46; This goal includes good doctor-patient communication&#44; respect for the specifics of the infection and the life dynamics of each individual&#44; support from a multidisciplinary team&#44; and a continual&#44; active search for these patients&#44; if necessary&#44; to increase adherence&#46;</p><p id="para120" class="elsevierStylePara elsevierViewall">In conclusion&#44; increasing adherence to HAART plays an important role in reducing opportunistic infections&#44; such as VZV&#44; and in improving the patient&#39;s life by reducing mortality&#46;</p></span></span>"
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ISSN: 18075932
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es en pt

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