---------------------------------------------------------------------------
Emerging Infectious Diseases * Volume 2 * Number 4 * October-December 1996
---------------------------------------------------------------------------
Letters

Epidemic Zoster and AIDS

---------------------------------------------------------------------------


To the Editor: Zoster (exogenously reactivated varicella-zoster virus
infection) may seem an unlikely candidate for emergence and epidemicity. A
recent report, however, describes a zoster outbreak associated with
epidemic HIV in injecting drug users in Manipur State, India (1). In
addition to underscoring the variety of ways in which "old" diseases may
reemerge under complex bio-ecologic conditions, this outbreak may also have
implications for anticipating and diagnosing HIV infections and AIDS in
developing countries. The Manipur outbreak was associated with a doubling
of zoster frequency above background levels, with increased occurrence most
notable in males 12-44 years old, who also had the highest HIV prevalence.
In a separately studied group of 120 injecting drug users, 20 developed
zoster and all were found to be HIV positive (1), a correlation
substantially greater than for such other clinical predicters of HIV
infection as persistent lymphadenopathy, weight loss, or recurrent
dermatoses. Increased zoster occurrence associated with HIV transmission
has also been seen in Ho Chi Minh City, Vietnam, and in other Southeast
Asian countries, particularly in injecting drug using populations
(unpublished). Zoster as a sentinel indicator of community HIV transmission
is also suggested by reports from Africa (2).

For over 150 years, it was believed that zoster occurred in local epidemics
(3,4). By the 1950s, however, it was generally agreed that zoster
represented reactivation of latent gangliar varicella virus either
sporadically, or in response to immunosuppression or trauma. Epidemics of
"endogenous" immunosuppression, such as those associated with epidemic HIV
infection, might thus be expected to produce outbreaks of zoster, as seems
to have occurred in Manipur and Vietnam. In the Indian outbreak traumatic
zoster seemed unlikely: truncal and facial dermatomes predominated, rather
than dermatomes corresponding to drug injection sites (usually the hands or
legs). Recognition of zoster outbreaks may be important in developing
countries where HIV diagnosis is limited, CD4 cell counts are unavailable,
and diagnosis of AIDS is delayed. Zoster is not currently accepted as an
AIDS-defining condition (5), and the extent to which it may reflect immune
collapse or predict HIV disease progression is uncertain. Nevertheless,
greater awareness of zoster as a sentinel indicator of community HIV
transmission may be of help not only in clinical diagnosis, but also in
public health efforts to recognize epidemic HIV occurrence.

D. M. Morens,* A.K. Agarwal,† S. Sarkar,† S. Panda,† and R. Detels‡

*University of Hawaii School of Medicine, Honolulu, Hawaii; ICMR Unit for
Research on AIDS in Northeastern States of India, Calcutta, India†; and
University of California at Los Angeles, Los Angeles, California‡

References

  1. Panda S, Sarkar S, Mandal BK, Singh TBK, Lokendra Singh K, Mitra DK,
     et al. Epidemic of herpes zoster following HIV epidemic in Manipur,
     India. J Infect 1994;28:167-73.
  2. Tyndall MW, Nasio J, Agoki E, Malisa W, Ronald AR, Ndinya-Achola JO,
     Plummer A. Herpes zoster as the initial presentation of human
     immunodeficiency virus type 1 infection in Kenya. Clin Infect Dis
     1995;21:1035-7.
  3. Simon L. Questions sur diverses branches des sciences médicales. Thèse
     202. Paris: Rignoux, 1840.
  4. Kaposi M. Bemerkungen über die jüngste Zoster-Epidemie und zur
     Aetiologie des Zoster. Wien Med Wochenschr 1889;25:961-4, 26:1001-4.
                                [end of page 361]

  5. World Health Organization. Interim proposal for a WHO staging system
     for HIV infection and diseases. Wkly Epidemiol Rec 1990;65:221-4.

---------------------------------------------------------------------------