What is the next step in managing a 62-year-old male with Human Immunodeficiency Virus (HIV) disease, admitted with leg cellulitis, who has developed vesicular lesions on the tip of his nose, in addition to starting on acyclovir (acyclovir)?

From the Guidelines

The next step after starting acyclovir for this 62-year-old HIV-positive male with vesicular lesions on his nose would be to obtain viral cultures and PCR testing of the lesions to confirm the diagnosis of herpes zoster (shingles) or herpes simplex virus infection, as these tests are crucial for guiding optimal management and potential adjustments to antiviral therapy 1. The patient's presentation with vesicular lesions in an immunocompromised state strongly suggests a herpetic infection, with herpes zoster being a likely consideration given the localized distribution of the lesions.

While empiric acyclovir treatment is appropriate, the specific dosing regimen may need to be adjusted based on the severity of the disease and the patient's immune status; for example, acyclovir 800 mg five times daily for 7-10 days could be considered for severe cases or in patients with significant immunosuppression. It's also important to note that if lesions persist despite acyclovir treatment, resistance to acyclovir should be suspected, and management in consultation with an expert, potentially including the use of alternative antivirals like foscarnet, may be necessary 1.

Key considerations in the management of this patient include:

• Assessment of the patient's CD4 count to evaluate the severity of immunosuppression, as patients with HIV and low CD4 counts are at higher risk for disseminated disease and complications.
• Close monitoring for ophthalmic involvement, given the nasal tip location of the lesions, which suggests possible involvement of the nasociliary branch of the trigeminal nerve and could lead to ocular complications requiring ophthalmology consultation.
• The potential need for hospitalization if the disease is severe or if there is suspicion of acyclovir-resistant strains, to ensure close monitoring and timely adjustment of treatment as necessary.

From the FDA Drug Label

A dosage adjustment is recommended for patients with reduced renal function (see DOSAGE AND ADMINISTRATION). Geriatrics:Acyclovir plasma concentrations are higher in geriatric patients compared with younger adults, in part due to age-related changes in renal function. Dosage reduction may be required in geriatric patients with underlying renal impairment (see PRECAUTIONS: Geriatric Use)

The next step to do is to evaluate the patient's renal function and consider a dosage adjustment of acyclovir if necessary, especially since the patient is 62 years old and has HIV disease, which may affect renal function 2.

From the Research

Diagnosis and Treatment

• The patient has been diagnosed with herpes simplex virus (HSV) infection, as indicated by the development of vesicular lesions on the tip of his nose 3.
• The patient has already been started on acyclovir, which is the standard treatment for HSV infections 4, 3.

Next Steps

• The next step would be to monitor the patient's response to acyclovir treatment and adjust the dosage or add other medications as needed 5.
• It is also important to consider the potential for drug interactions, particularly in immunocompromised patients like the one described, who may be taking multiple medications 6.
• Topical acyclovir cream may be considered as an additional treatment option, particularly if the lesions are localized and accessible 7.

Considerations for Immunocompromised Patients

• Immunocompromised patients, such as those with HIV, may be at higher risk for developing resistance to acyclovir and other anti-herpetic medications 5.
• Combination therapy with multiple anti-herpetic medications may be considered in these patients, but careful monitoring for drug interactions and toxicity is necessary 5, 6.