What should be done for an adult, possibly in their 50s or older with a history of chickenpox, experiencing night sweats and a shingles rash?

Management of Night Sweats in an Adult with Shingles

For an adult experiencing night sweats alongside a shingles rash, initiate oral antiviral therapy immediately (valacyclovir 1000 mg three times daily or acyclovir 800 mg five times daily for 7-10 days until all lesions have scabbed), while simultaneously investigating the night sweats as a potentially separate symptom that may indicate immunocompromise, concurrent infection, or systemic disease. 1

Immediate Shingles Management

Antiviral Treatment

• Start antiviral therapy within 72 hours of rash onset for optimal efficacy in reducing acute pain, accelerating lesion healing, and preventing postherpetic neuralgia 1
• Valacyclovir 1000 mg orally three times daily offers superior bioavailability and less frequent dosing compared to acyclovir, potentially improving adherence 1
• Alternative: Acyclovir 800 mg orally five times daily for 7-10 days 1
• Continue treatment until all lesions have completely scabbed, not just for an arbitrary 7-day period—this is the key clinical endpoint 1

Escalation Criteria Requiring IV Acyclovir

• Multi-dermatomal involvement (disseminated disease) 1
• Facial involvement with suspected CNS complications 1
• Evidence of immunocompromise 1
• Visceral organ involvement 1
• If any of these are present, switch to IV acyclovir 10 mg/kg every 8 hours 1

Evaluating Night Sweats in This Context

Critical Distinction: Night Sweats WITH Shingles

The presence of night sweats alongside shingles raises concern for underlying immunocompromise, particularly HIV infection, which would fundamentally change management 2, 3, 4

Immediate Assessment Required

• Check HIV status immediately—HIV is a dominant cause of night sweats and predisposes to severe, disseminated shingles 2, 3
• Obtain complete blood count to evaluate for lymphoma or other hematologic malignancies 2, 3
• Tuberculosis testing (purified protein derivative or interferon-gamma release assay) 2, 3
• Thyroid-stimulating hormone level 2, 3
• C-reactive protein or erythrocyte sedimentation rate 2, 3
• Chest radiograph 2, 3

High-Risk Indicators Requiring Aggressive Workup

If the patient has fever with night sweats, prioritize infectious and malignant causes 4:

• Consider PET-CT if initial workup is unrevealing and symptoms persist 4
• Bone marrow biopsy may be indicated if hematologic malignancy is suspected 2, 3
• Computed tomography of chest and abdomen if lymphoma or tuberculosis is suspected 2, 3

Modified Treatment if Immunocompromise Detected

If HIV-Positive

• Escalate to higher oral doses: acyclovir 800 mg 5-6 times daily or switch to IV acyclovir 10 mg/kg every 8 hours 1
• Consider long-term acyclovir prophylaxis (400 mg 2-3 times daily) after acute episode resolves 1
• Monitor for acyclovir resistance if lesions persist despite treatment 1
• For acyclovir-resistant cases, foscarnet 40 mg/kg IV every 8 hours is the treatment of choice 1

If on Immunosuppressive Therapy

• Consider temporary reduction or discontinuation of immunosuppressive medications in cases of disseminated or invasive herpes zoster if clinically feasible 1
• Intravenous acyclovir 10 mg/kg every 8 hours is mandatory for severely immunocompromised patients 1
• Treatment duration extends beyond 7-10 days until complete clinical resolution 1

Common Pitfalls to Avoid

• Do not dismiss night sweats as merely a symptom of shingles—while shingles can cause systemic symptoms, night sweats warrant independent investigation for serious underlying conditions 2, 3
• Do not use topical antivirals—they are substantially less effective than systemic therapy 1
• Do not stop antiviral therapy at exactly 7 days if lesions are still forming or have not completely scabbed 1
• Do not assume immunocompetence—the combination of shingles and night sweats should prompt HIV testing even in patients without obvious risk factors 2, 3

Infection Control During Active Shingles

• Patient should avoid contact with susceptible individuals (those without chickenpox history or vaccination) until all lesions have crusted 1
• Cover lesions with clothing or dressings to minimize transmission risk 1

Prevention of Future Episodes

• After recovery, administer recombinant zoster vaccine (Shingrix) for all adults aged 50 years and older, regardless of this prior herpes zoster episode 1
• The two-dose series provides >90% efficacy in preventing future recurrences 1

Monitoring During Treatment

• Monitor renal function closely during IV acyclovir therapy, with dose adjustments as needed for renal impairment 1
• If lesions fail to begin resolving within 7-10 days, suspect acyclovir resistance and obtain viral culture with susceptibility testing 1

Prognosis Regarding Night Sweats

• If initial workup (HIV, CBC, tuberculosis testing, TSH, inflammatory markers, chest X-ray) is normal and no additional disorders are suspected, the presence of night sweats alone does not indicate an increased risk of death 3
• Life expectancy of primary care patients reporting night sweats does not appear to be reduced in the absence of serious underlying disease 5
• However, persistent night sweats warrant continued monitoring and reassessment if new symptoms develop 3