in countries with high prevalence of hiv / aids infection , particularly in black africa , shingles is one of the main opportunistic infections during immunosuppression due to aids in young patients . if immunological weakness is important , usually when the cd4 cell count is less than 100 cells / mm , the risk of inflammatory reactions in the first three months after initiating of antiretroviral treatment ( art ) is very high . this observation reports the first documented case of iris with v1 shingles in a young hiv patient at university hospital of brazzaville . a 40 years old patient was seen for a pain of the right side of the face and a complete immobility of the eyeball . the diagnosis of v1 shingles with a pan uveitis , and a paralysis of iii , iv and vi nerves was made . the patiants hiv status was positive and cd4 cell count was 150 cells / mm . after two months of evolution under art with a cd4 count of 850 cells /mm , the symptomatology was quickly complicated by significant inflammation causing a phtisis bulbi . cd4 cells count is an important indicator in the hiv / aids therapy . in some major forms of iris , momentary pause of anti retroviral treatment is sometimes necessary . infection with varicella zoster virus ( vzv ) , which is a member of the herpes virus family , is relatively common . in general , in childhood vzv causes chickenpox , and in adults it recurs to cause shingles . after the signs and symptoms of chickenpox resolve , vzv goes into a state of latent infection inside nerve cells ( 1 ) . however , as the immune system weakens with age , vzv can become reactivated , resulting in shingles . shingles is most commonly seen in people over the age of 50 . however , there are cases when the immune system becomes weakened , such as hiv / aids context that can allow the reactivation of vzv leading to shingles even in younger patient ( 1 , 2 ) . if immunological weakness is important , usually when the cd4 cell count is less than 100 cells / mm , the risk of inflammatory reactions in the first three months after initiating antiretroviral treatment ( art ) is very high . we report the first documented case of iris and v1shingles , associated with a combined paralysis of three oculomotor nerves in a 40 year old hiv patient at the university hospital of brazzaville . a 40 years old patient was seen for a pain of the right side of the face evolving for nearly a week . he described the pain as burning electrical discharge encompassing the eye , the ear and the cheek . the review noted : 
 bullous and necrotic lesions along the path of the right v1 ( figure 1);hutchinson 's sign : presence of the above described lesions at the tip of the nose , right eyelid ptosis;complete ophthalmoplegia : right eye was fixed in the primary position regardless of the direction taken by the left eye ( fig . 2 and 3);anterior granulomatous uveitis ; andintra ocular pressure ( iop ) : 25 mmhg.the review of the left eye was normal ( iop = 12 mmhg ) . bullous and necrotic lesions along the path of the right v1 ( figure 1 ) ; hutchinson 's sign : presence of the above described lesions at the tip of the nose , complete ophthalmoplegia : right eye was fixed in the primary position regardless of the direction taken by the left eye ( fig . 2 and 3 ) ; anterior granulomatous uveitis ; and intra ocular pressure ( iop ) : 25 mmhg . right iii nerve paralysis ( eyelid ptosis ) and right v1 shingles with hutchinson 's sign in hiv patient paralysis of rights iii , iv nerves and right v1 shingles in hiv patient right vi nerve paralysis and right v1 shingles in hiv patient the hiv serology was positive with a cd4 cell count equal to 150 / mm . an art had been introduced ( lamivudine , zidovudine , and nevirapine).the treatment of uveitis was as follow : 
 valaciclovir oral route 1000 mg : three time a day one week;acetazolamide oral route 250 mg twice a day one week;atropine 1% eye drops twice a day two weeks ; 
  valaciclovir oral route 1000 mg : three time a day one week ; acetazolamide oral route 250 mg twice a day one week ; atropine 1% eye drops twice a day two weeks ; corticosteroids eye drops in decreasing doses were introduced one week after the beginning of treatment for a month . for the balance of blood potassium , the evolution was favorable in the first month , marked by the disappearance of pain , healing of skin lesions and normalization of iop . for no apparent reason , the situation completely changed at the beginning of the second month . the installation of a non - granulomatous pan uveitis that had evolved rapidly in three weeks in a state of blindness due to a phtisis bulbi . the goal of antiretroviral ( arv ) therapy in hiv / aids is immune reconstitution . however , an aberrant manifestation of this effect sometimes occurs . iris also known as immune restoration disease . this syndrome is usually accompanied by an increase in cd4 cell count and/or a rapid decrease in viral load . although most cases of iris occur in patients who have low cd4 counts and high viral load levels when arv therapy is initiated , iris can occur at any cd4 count ( 4 , 5 ) . the time of presentation is usually within the first four to eight weeks after initiation of arv therapy . after immune reconstitution , inflammatory reactions to many pathogens have been described , including mycobacterium , fungi , virus and bacteria . iris that involves worsening of some malignancies , including kaposi 's sarcoma and autoimmune phenomena have also been documented ( 6 ) . epidemiologic data regarding iris are variable and depend largely on the incidence and types of infections that patients have at the time of initiation of arv therapy . although one common aspect of iris cases is a significant increase in cd4 cells after initiation of arv therapy in patients who has low cd4 cells prior to treatment . patients who develop iris may have preexisting perturbations in their t - regulatory cell profile . the proinflammatory and regulatory responses , such as cytokine imbalances , may significantly contribute to onset of this syndrome , particulary when arv treatment is very active against hiv ( 4 ) . iris may also be more severe in patients with a higher burden of organism , which also suggests that antigen load may play a role ( 6 , 7 ) . the etiologic diagnosis of iris is based on clinical judgment , and multiple diagnoses can be present . the somewhat characteristic presentations of many opportunistc infections may aid in the diagnosis of iris . in case of vzv infection , it may act vzv reactivation after initiation of arv therapy or a worsening of symptoms ( 37 ) . prevention of complications associated with iris involves careful monitoring , particularly in patients with low cd4 counts and a past or current history of co - infections . after initiating arv therapy , clinicians should be alert to the possibility of iris as cd4 cell counts are restored . clinicians should initiate symptomatic treatment and supportive care for patients with iris . in severe cases , clinicians should consider prescribing prednisone 12 mg / kg or equivalent for one to two weeks . except in severe cases , arv therapy should not be interrupted in patients with iris ( 7 ) . in connection with multiple oculomotor nerves damage in young subjects , two other differential diagnoses can be mentioned : multiple sclerosis and tolosa - hunt 's syndrome . the tolosa - hunt 's syndrome is characterized by retroorbital pain and in the v1 territory , sometimes associated with an apex syndrome without change of cd4 cell count ( 8) . multiple sclerosis is characterized by chronic multiple paralysis , also without change of cd4 cell count ( 9 ) .
backgroundin countries with high prevalence of hiv / aids infection , particularly in black africa , shingles is one of the main opportunistic infections during immunosuppression due to aids in young patients . if immunological weakness is important , usually when the cd4 cell count is less than 100 cells / mm3 , the risk of inflammatory reactions in the first three months after initiating of antiretroviral treatment ( art ) is very high . 
 this inflammatory reaction is called immune reconstitution inflammatory syndrome ( iris ) . 
 this observation reports the first documented case of iris with v1 shingles in a young hiv patient at university hospital of brazzaville.case detailsa 40 years old patient was seen for a pain of the right side of the face and a complete immobility of the eyeball . 
 the diagnosis of v1 shingles with a pan uveitis , and a paralysis of iii , iv and vi nerves was made . 
 the patiants hiv status was positive and cd4 cell count was 150 cells / mm3 . 
 after two months of evolution under art with a cd4 count of 850 cells /mm3 , the symptomatology was quickly complicated by significant inflammation causing a phtisis bulbi.conclusioncd4 cells count is an important indicator in the hiv / aids therapy . in some major forms of iris , momentary pause of anti retroviral treatment 
 is sometimes necessary .