Would you prescribe a steroid in addition to antiviral therapy for a patient with herpes zoster on the hard and soft palate who is also positive for influenza A (flu A) to prevent trigeminal nerve pathology?

Management of Herpes Zoster with Concurrent Influenza A Infection

Steroids should not be added to antiviral therapy for a patient with herpes zoster on the hard and soft palate who is also positive for influenza A, as the risks outweigh the benefits in this scenario.

Rationale for Recommendation

Antiviral Therapy Considerations

• For herpes zoster infections, high-dose antiviral therapy is the cornerstone of treatment:

  • Acyclovir 800mg orally five times daily for 7-10 days 1
  • Valacyclovir 1g three times daily for 7-10 days 2
  • Famciclovir 500mg three times daily for 7 days 3

• For influenza A infection, prompt antiviral therapy is essential:

  • Oseltamivir 75mg twice daily for 5 days (may extend to 10 days in immunocompromised patients) 1
  • Treatment should be initiated within 48 hours of symptom onset for maximum benefit 1

Steroid Therapy Considerations

1. Infection Risk:

   • Corticosteroids suppress the immune system and increase the risk of infection with any pathogen, including viral, bacterial, fungal, protozoan, or helminthic pathogens 4
   • They can exacerbate existing infections and increase the risk of disseminated infections 4

2. Influenza Concerns:

   • The patient already has influenza A infection, which could be worsened by steroid therapy
   • CDC and IDSA guidelines emphasize antiviral therapy for influenza without recommending adjunctive steroids 1

3. Limited Evidence for Benefit:

   • A randomized trial of acyclovir with and without prednisolone for herpes zoster showed only slight benefits with the addition of steroids during the acute phase, with no significant differences in time to cessation of pain 5
   • Steroid recipients reported more adverse events 5

4. Trigeminal Nerve Involvement:

   • While the question raises concern about trigeminal nerve pathology, there is insufficient evidence that steroids prevent this complication specifically in oral/palatal zoster

Treatment Algorithm

1. First Priority: Initiate dual antiviral therapy

   • For herpes zoster: Valacyclovir 1g three times daily for 7-10 days
   • For influenza A: Oseltamivir 75mg twice daily for 5 days

2. Monitoring:

   • Assess for signs of disseminated infection or worsening of either condition
   • Monitor for development of postherpetic neuralgia
   • If lesions do not begin to resolve within 7-10 days, consider antiviral resistance 2

3. Pain Management:

   • Use appropriate analgesics (acetaminophen, NSAIDs if not contraindicated)
   • Topical anesthetics may be considered for pain relief during the vesicular phase 2

4. Special Considerations:

   • If the patient is immunocompromised, extend antiviral therapy duration and consider IV acyclovir 1
   • For severe cases with extensive involvement, consider IV acyclovir 5-10 mg/kg three times daily until lesions begin to regress 2

Potential Pitfalls

1. Delayed Treatment: Antiviral therapy for both conditions should be initiated as soon as possible to maximize effectiveness

2. Misdiagnosis: Confirm both diagnoses with appropriate testing (PCR for influenza, clinical diagnosis or PCR for herpes zoster)

3. Overlooking Complications: Monitor for bacterial superinfection of zoster lesions, which may require antibiotics

4. Inadequate Pain Control: Herpes zoster can cause significant pain; ensure adequate analgesia is provided

5. Assuming Steroids Are Always Beneficial: While steroids may have a role in some herpes zoster cases, the presence of influenza A creates a situation where risks likely outweigh benefits

In conclusion, while steroids are sometimes used in herpes zoster management, the concurrent influenza A infection presents a contraindication to steroid therapy due to the risk of exacerbating the viral infection and potential for other complications.