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VZV Cranial Neuropathy — SCE Infectious Diseases MCQ

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HardHIV MedicineVZV Cranial NeuropathySCE Infectious Diseases

A 55-year-old man with treated HIV (CD4 580, VL <50) develops a painful vesicular rash in the V1 distribution. He has ipsilateral ptosis and dilated pupil. What is the specific complication and management?

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Correct answer: A — VZV-related oculomotor (CN III) palsy; IV Aciclovir and urgent ophthalmology/neurology referral — assess for VZV vasculopathy

VZV reactivation in V1 can cause cranial nerve palsies (III, IV, VI) through direct viral invasion of cranial nerves or VZV vasculopathy affecting the vasa nervorum. A CN III palsy (ptosis, dilated pupil, eye deviated down and out) in the context of V1 zoster requires urgent investigation for VZV vasculopathy (which can cause stroke). IV Aciclovir is indicated rather than oral antivirals given the CNS involvement risk. MRI brain with vessel wall imaging and CSF VZV PCR/IgG should be considered.

Reference: BHIVA 2022 – OI guidelines; NICE CKS 2024 – Shingles complications