Herpes zoster ophthalmicus or Herpes zoster maxillaris?

Abstract

Dear Editor, We read with interest the article by Biswas et al.[1] The authors deserve to be congratulated for highlighting the anterior segment manifestations of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). We have certain observations to make. The authors have given a good external photograph of AIDS patient with facial skin lesions,[1] which clearly looks like a case of herpes zoster maxillaris rather than herpes zoster ophthalmicus. Involvement of forehead skin is a classical feature of herpes zoster ophthalmicus. In the picture shown [Fig. 1] the forehead skin was totally spared and maxillary division of trigeminal nerve supplying the facial dermatomes was involved. Dacryocystitis, basal cell carcinoma, chalazion, bacterial folliculitis, madarosis, stye, scleritis, episcleritis, complicated cataract, were also well documented rare anterior segment and adnexal manifestations of HIV and AIDS.[2–4] The authors fail to highlight orbital manifestations like orbital lymphoma, orbital eosinophilic granuloma, orbital cellulitis [Fig. 1], orbital abscess, subperiosteal abscess formation in HIV and AIDS patients. Opportunistic infections caused by bacteria, virus, fungi and protozoan organism have been associated with AIDS that may involve the orbit and sinuses. Orbital involvement usually occurs due to spread of infections from paranasal sinuses. Invasive or fulminant aspergillosis of the orbit carries a poor prognosis, particularly when the immunosuppressed state cannot be reversed. Pneumocystic carinii can affect the orbit in patients of HIV. Patients can present with proptosis, blurred vision, pain on eye movement, and papillodema. Orbital pneumocystis carnii responds very well with trimethoprim-sulfamethoxazole. Orbital abscess responds to surgical drainage and intravenous antibiotics.[24] The development of multiple warts (verruca vulgaris) in the periocular region can be seen in patients with HIV infection. A DNA containing papilloma virus causes the lesions of verruca vulgaris. They appear as circumscribed, elevated growths with a hyperkeratotic, filiform surface. Treatment options include surgical excision, electrocautry, cryotherapy, and application of trichloroacetic acid.[3] Non-Hodkins lymphoma (NHL) is the most frequent orbital manifestation of AIDS, yet it occurs relatively infrequently based on isolated case reports in the ophthalmic literature. These tumors behave more aggressively with multiple atypical features in AIDS patients compared with immunocompetent persons. In the general population, orbital lymphomas classically present as insidious, painless, slowly progressive lesions in the superior orbit with mild axial or non-axial displacement of the globe. In contrast AIDS related orbital lymphomas tend to develop more rapidly with painful eyelid swellings, proptosis, diplopia, or diminution of vision. NHL associated with HIV infections is generally monoclonal B cell proliferation that exhibits an aggressive histological pattern.[24] Figure 1: External photograph showing multiple styes with preseptal cellulitis in non-diabetic HIV patient