herpes zoster is a reactivation of the latent varicella zoster virus in the dorsal spinal ganglion that is initiated by triggering factors such as trauma , aging , an immunocompromised state , malignancy , and radiotherapy . when reactivated , the virus replicates , resulting in inflammation , host cell death , and transportation of the virus along the axonal length of the sensory nerves to the skin . patients clinically present with early symptoms of dysesthesia , tingling sensations , numbness , and itching , followed by the characteristic appearance of a rash in a few days . vesicle formation is seen along the course of the nerve in a week to 10 days . these vesicles transform into bullae and eventually burst open to form scabs . when the trigeminal ganglion is involved , the pain produced by the infection can mislead clinicians into diagnosing the disorder as trigeminal neuralgia or odontalgia . herpes zoster may produce complications such as blindness as seen in trigeminal opthalmicus1 , acute or chronic encephalitis , myelitis , retinitis , autonomic dysfunction , motor neuropathies , guillain - barr syndrome , hemiparesis , and cranial or peripheral nerve palsies2 . more common complications include bacterial superinfection of the scabs by staphylococcus aureus or streptococcus pyogenes , scarring , and hyperpigmentation . individuals infected with human immunodeficiency virus ( hiv ) show a higher prevalence for zoster infection than the general population1 . although a reduction in immunity is considered the rationale for this feature , it has not been well documented in the literature that individuals on anti - retroviral therapy ( art ) experience a condition known as immune reconstitution inflammatory syndrome . during the first two months post - art or due to the change to a highly active antiretroviral therapy ( haart ) , the patient 's immunity tends to improve and respond better to latent infections , resulting in the manifestation of the infection . also called immune recovery syndrome , haart is characterized by an increase in the cd4 count and a significant reduction in the viral load345 . the national aids control organisation ( naco ) , a government initiative launched in 1992 to prevent and control hiv infection in india , estimated the epidemiological status of hiv / aids in 2012 as 20.89 lakh . the immunocompromised state in hiv patients makes them susceptible to various infections , including shingles or herpes zoster . a study carried out from 2004 to 2005 in karnataka , india , confirmed that out of 90 reported herpes zoster infections , 37.77% were sero - positive cases of hiv6 . thoracic and lumbar dermatomes are commonly affected , and the trigeminal nerve is involved in 13% of patients7 . currently , no evidence - based pharmacological strategy or a definitive guideline table for the prevention of immune reconstitution inflammatory disease can be recommended , as none of the pharmacological clinical trials have been completed . clinical trials involving the use of maraviroc , a ccr5 chemokine receptor antagonist and a nonsteroidal anti - inflammatory drug ( nsaid ) , are currently ongoing . statins , vitamin d , and corticosteroids have also been suggested as other possible immune recovery inflammatory disease prevention strategies8 . since the early initiation of art is not always possible due to a lack of awareness and economical limitations , a late presentation along with advanced hiv leads to high rates of opportunistic infections in these patients . herpes zoster is a reactivation of the latent varicella zoster virus in the dorsal spinal ganglion initiated by triggering factors such as trauma , aging , an immunocompromised state , malignancy , and radiotherapy . the virus is transported along the axonal length of the sensory nerves to the skin and clinically presents with early symptoms of dysesthesia , tingling sensations , numbness , and itching ; a characteristic rash appears after a few days . vesicle formation is seen along the course of the nerve in a week to 10 days . these vesicles transform into bullae and eventually burst open to form scabs . when the trigeminal ganglion is involved , the pain produced by the infection can mislead clinicians to diagnose it as trigeminal neuralgia or odontalgia . the national aids control organisation ( naco ) , a government initiative launched in 1992 to prevent and control hiv infection in india , estimated the epidemiological status of hiv / aids in 2012 as 20.89 lakh . the immunocompromised state in hiv patients makes them susceptible to various infections , including shingles or herpes zoster . a study carried out from 2004 to 2005 in karnataka , india , confirmed that out of 90 reported herpes zoster infections , 37.77% were sero - positive cases of hiv6 . thoracic and lumbar dermatomes are commonly affected , and the trigeminal nerve is involved in 13% of patients7 . currently , no evidence - based pharmacological strategy or a definitive guideline table for the prevention of immune reconstitution inflammatory disease can be recommended , as none of the pharmacological clinical trials have been completed . clinical trials involving the use of maraviroc , a ccr5 chemokine receptor antagonist and a nonsteroidal anti - inflammatory drug ( nsaid ) , are currently ongoing . statins , vitamin d , and corticosteroids have also been suggested as other possible immune recovery inflammatory disease prevention strategies8 . since the early initiation of art is not always possible due to a lack of awareness and economical limitations , a late presentation along with advanced hiv leads to high rates of opportunistic infections in these patients . herpes zoster is a reactivation of the latent varicella zoster virus in the dorsal spinal ganglion initiated by triggering factors such as trauma , aging , an immunocompromised state , malignancy , and radiotherapy . the virus is transported along the axonal length of the sensory nerves to the skin and clinically presents with early symptoms of dysesthesia , tingling sensations , numbness , and itching ; a characteristic rash appears after a few days . vesicle formation is seen along the course of the nerve in a week to 10 days . these vesicles transform into bullae and eventually burst open to form scabs . when the trigeminal ganglion is involved , the pain produced by the infection can mislead clinicians to diagnose it as trigeminal neuralgia or odontalgia . a 75-year - old male patient visited the hospital with a chief complaint of pain in the entire right half of his face for the past eight days . the patient revealed a history of extraction of the right maxillary third molar tooth eight days before at a private clinic . his pain was severe in intensity and continuous in frequency , radiating to the forehead on the same side . the patient had been on art two months earlier for a period of three months , which was revealed only after the results of the investigations were obtained . there was history of a loss of appetite and weakness for the past six months . on examination , multiple cutaneous vesicles and scabs covered the same side of his cheek , ear , upper and lower lips , chin , and submandibular region.(fig . 1 ) mild diffuse swelling on the right half of the lips was noted , and generalized ulceration of the right buccal and labial mucosa was present.(fig . 2 , 3 ) ulcerations on the anterior two - thirds of the right half of the tongue , lingual mucosa , tonsillar pillars , and the soft palate were also present . the ulcers were irregular and more than a centimeter in size and were covered with slough . herpes simplex is the most common skin infection that presents a clinical picture similar to herpes zoster ; others include impetigo , contact dermatitis , folliculitis , scabies , insect bites , papular urticaria , candidal infection , and dermatitis herpetiformitis . therefore , laboratory testing with polymerase chain reaction , direct fluorescent antibody staining , and immunoglobulin m enzyme - linked immunosorbent assay ( elisa ) have proven useful for such cases . a history of or exposure to the zoster virus or the clinical presentation of a rash with a dermatomal pattern helps distinguish varicella infection from disseminated herpes zoster . in this case , the patient had a distinct pattern of lesions along the sensory distribution of the maxillary and mandibular nerves . his laboratory report showed a marked decrease in his lymphocyte count , and he tested positive for hiv . anti - inflammatory drugs such as corticosteroids are reserved for mild to moderate symptoms of pain . any interruption of art during the phase of opportunistic infection is not recommended unless it is a life - threatening opportunistic infection because the cessation of art can lead to art resistance . since the patient was immunocompromised , the recommended oral dosage of 1,000 mg of acyclovir three times a day for seven days was prescribed . the patient was treated for the next two days and then was discharged against medical advice since he wanted to be admitted to a government hospital . a 75-year - old male patient visited the hospital with a chief complaint of pain in the entire right half of his face for the past eight days . the patient revealed a history of extraction of the right maxillary third molar tooth eight days before at a private clinic . his pain was severe in intensity and continuous in frequency , radiating to the forehead on the same side . the patient had been on art two months earlier for a period of three months , which was revealed only after the results of the investigations were obtained . there was history of a loss of appetite and weakness for the past six months . on examination , multiple cutaneous vesicles and scabs covered the same side of his cheek , ear , upper and lower lips , chin , and submandibular region.(fig . 1 ) mild diffuse swelling on the right half of the lips was noted , and generalized ulceration of the right buccal and labial mucosa was present.(fig . 2 , 3 ) ulcerations on the anterior two - thirds of the right half of the tongue , lingual mucosa , tonsillar pillars , and the soft palate were also present . the ulcers were irregular and more than a centimeter in size and were covered with slough . herpes simplex is the most common skin infection that presents a clinical picture similar to herpes zoster ; others include impetigo , contact dermatitis , folliculitis , scabies , insect bites , papular urticaria , candidal infection , and dermatitis herpetiformitis . therefore , laboratory testing with polymerase chain reaction , direct fluorescent antibody staining , and immunoglobulin m enzyme - linked immunosorbent assay ( elisa ) have proven useful for such cases . a history of or exposure to the zoster virus or the clinical presentation of a rash with a dermatomal pattern helps distinguish varicella infection from disseminated herpes zoster . in this case , the patient had a distinct pattern of lesions along the sensory distribution of the maxillary and mandibular nerves . his laboratory report showed a marked decrease in his lymphocyte count , and he tested positive for hiv . anti - inflammatory drugs such as corticosteroids are reserved for mild to moderate symptoms of pain . any interruption of art during the phase of opportunistic infection is not recommended unless it is a life - threatening opportunistic infection because the cessation of art can lead to art resistance . since the patient was immunocompromised , the recommended oral dosage of 1,000 mg of acyclovir three times a day for seven days was prescribed . the patient was treated for the next two days and then was discharged against medical advice since he wanted to be admitted to a government hospital . a reactivation of the zoster virus in the nerve ganglia can be precipitated by many triggering factors , such as aging , trauma , immunosuppression , malignancy , and radiotherapy . the patient in our case report had a history of trauma following a tooth extraction , which triggered the reactivation of the latent virus . although these drugs should theoretically be started within 72 hours of onset of rash , they should be initiated even in cases with delays , as they reduce the duration of viral shedding and also the severity and progression of the infection . corticosteroids , analgesics , and topical agents such as lignocaine are adjuvants that can be administered to reduce the pain and severity of the infection . patients who experience insomnia due to the discomfort may also benefit from tricyclic anti - depressants . the diagnosis of herpes zoster should prompt the clinician to consider hiv testing if risk factors , such as an age of less than 50 years or multi - dermatomal lesions , are present . he belonged to an older age group ( 75 years ) , and only his facial skin was affected , suggesting that clinicians can not always narrow down the probability of hiv infection based upon its relation with risk factors . it is imperative that every patient with zoster infection be tested for hiv infection regardless of their absence of risk factors . it is a lesser - known fact that art causes a manifestation of latent infections345 such as herpes zoster as a result of immune recovery , as seen in this case report . a high vigilance for the patient by the treating physician during the first few months of art , during which there is a peak incidence of immune recovery inflammatory disease , is recommended . all patients who present with a zoster should be questioned regarding their history of art .
following anti - retroviral therapy ( art ) or highly active antiretroviral therapy , there is an increased response to latent infections such as herpes zoster , which may lead to their reactivation . 
 this is a result of improved immunity brought about by art , also termed immune recovery syndrome . 
 a 75-year - old male patient arrived at our institute with widespread vesicles and scabs on the right half of his face and oral cavity , suggesting the involvement of the trigeminal nerve . 
 the patient had a history of being on art two months earlier and a history of tooth extraction eight days prior to his arrival at our institute . 
 the incidence of human immunodeficiency virus ( hiv)-positive cases amongst herpes zoster cases is high , and these patients become susceptible to infections following art . 
 therefore , regardless of the presence of risk factors , every herpes zoster patient should be tested for hiv infection , and high anti - retroviral therapy should be commenced / reinstituted as soon as possible . 
 in addition , the treating physician should maintain a high level of vigilance for the patient during the first few months of art , the peak incidence of immune recovery inflammatory disease .