What is the next best treatment step for a 62-year-old immunocompromised man with multiple myeloma, presenting with burning and tingling pain in his forehead, blurring of vision, erythema, and discharge near the right eye, suspected of having herpes zoster?

Treatment for Herpes Zoster Ophthalmicus in an Immunocompromised Patient with Multiple Myeloma

Intravenous acyclovir is the most appropriate treatment for this immunocompromised patient with herpes zoster ophthalmicus.

Clinical Assessment

• The patient presents with classic signs of herpes zoster ophthalmicus:
  • Burning and tingling pain in the forehead
  • Unilateral rash on the right side of forehead extending to the nose (following the ophthalmic division of the trigeminal nerve)
  • Blurred vision in the right eye
  • Erythematous right eyelid with yellow crusting and discharge 1
• The patient is significantly immunocompromised due to:
  • Multiple myeloma
  • Active treatment with immunosuppressive agents (daratumumab, bortezomib, melphalan, prednisone) 1

Treatment Recommendation

First-line Treatment

• High-dose intravenous acyclovir is the treatment of choice for VZV infections in immunocompromised hosts 1
• Oral antiviral therapy (acyclovir, valacyclovir, famciclovir) should be reserved for:
  • Mild cases of VZV disease in patients with transient immune suppression
  • Completion therapy after clinical response to IV acyclovir 1

Rationale for IV Therapy

• Immunocompromised patients are at 10-20% risk of developing disseminated disease without prompt and effective antiviral therapy 1
• Multiple myeloma patients on proteasome inhibitors (bortezomib) are at particularly high risk for severe herpes zoster infections 1
• Ophthalmic involvement represents a severe form requiring aggressive treatment 2, 3
• Without adequate treatment, immunocompromised patients may develop:
  • Chronic ulcerations with persistent viral replication
  • Secondary bacterial and fungal superinfections 1

Treatment Protocol

• Begin IV acyclovir immediately (do not wait for laboratory confirmation) 4, 5
• Standard dosing: 10-15 mg/kg IV every 8 hours (adjust for renal function) 4
• Duration: Minimum 7-10 days, potentially longer based on clinical response 5, 6
• Monitor for:
  • Clinical improvement of skin lesions
  • Resolution of ocular symptoms
  • Signs of dissemination 1, 2

Additional Management

• Ophthalmology consultation is strongly recommended for management of ocular VZV disease 2
• Consider topical antibiotics to prevent secondary bacterial infection of vesicles 2
• Appropriate analgesic therapy should be combined with antiviral treatment to reduce acute zoster pain and risk of postherpetic neuralgia 5
• Close monitoring for complications including:
  • Keratitis
  • Uveitis
  • Secondary glaucoma
  • Corneal scarring 2

Special Considerations

• Acyclovir-resistant VZV can occur in immunocompromised patients, especially those with prolonged exposure to antivirals 5
• If resistance is suspected (poor clinical response despite adequate therapy), foscarnet is the drug of choice 5
• Prophylactic antiviral therapy should be considered after resolution of the acute episode, especially for patients continuing on proteasome inhibitors 1

Follow-up Care

• Schedule follow-up visit within 1 week of treatment initiation 2
• Consider transition to oral antiviral therapy once significant clinical improvement is observed 1, 7
• Long-term suppressive therapy may be needed in patients with chronic immunosuppression 8, 3