Posttraumatic maxillary and ophthalmic herpes zoster in an immune-competent female – A unique presentation

Abstract

Herpes Zoster is a neuro-cutaneous disorder caused by reactivation of Varicella-Zoster Virus. A number of factors such as old age, psychological stress, low immune states, radiation exposure and physical trauma have been implicated for reactivation. Post traumatic herpes zoster involving maxillary and ophthalmic division of trigeminal nerve is very rare and has been reported in presence of Immune deficiency and following iatrogenic trauma (nerve block injection). We report a unique presentation of simultaneous ophthalmic and maxillary herpes zoster following a facial injury with a wooden stick in an immune-competent female.

A 55-year-old female patient from rural background presented to our ophthalmology outpatient department with complaints of redness, pain, watering, and blurring of vision in the right eye associated with erythema, pain, swelling, and vesicular eruptions over the right half of the face and buccal mucosa for 1 day. She had a history of an accidental trauma to the skin of the right cheek and nose with a wooden stick while working at home 3 days ago. This was followed by severe pain and swelling in the region, which reduced with analgesics. There was no history of any systemic illness, long-term medication use, or similar episode in the past. Upon inquiring, she did give a history of suffering from chicken pox infection in her early childhood. There was no history of dental caries or any dental procedure in the recent past. Her physical examination revealed swelling, erythema, and vesicular eruptions over the right side of the cheek and upper lip, along the right nasolabial fold and right side of the nose involving the tip. Few vesicles were also present over the right forehead [Figure 1a]. Oral cavity examination revealed erythema and vesicular eruptions over the right half of the buccal mucosa and palate [Figure 1b]. Ocular examination revealed visual acuity of 20/60 (OD) and 20/40 (OS) with edema over the right eyelids. Corneal sensations were slightly diminished in the right eye. Fluorescein-stained examination was unremarkable. Age-related cortical cataract with Grade 1 nuclear sclerosis was present in both eyes. Posterior segment evaluation was unremarkable in either eye.

Figure 1.

(a) Erythema-edema with vesicular eruption on the right side of the face. (b) Vesicular eruption over the right palate and buccal mucosa

A clinical diagnosis of posttraumatic right-sided trigeminal herpes zoster (HZ) with ophthalmic and maxillary branch involvement was made. The patient was started on topical eye drops moxifloxacin 0.5% and carboxymethylcellulose along with oral acyclovir 800 mg 5 times a day, cefuroxime 200 mg b.d, and multivitamins for 7 days. The patient was reviewed after 1 week and showed marked improvement in condition with reduction in erythema and swelling and scaling of vesicles [Figure 2a]. The buccal mucosa and palate looked healthier with disappearance of vesicles [Figure 2b]. Her blood investigations were normal with no evidence of immunosuppression. The patient was continued on antiviral medications and is due for follow-up.

Figure 2.

(a) Scaling of eruption with reduced edema over the face and eyelids. (b) Disappearance of vesicles from over the buccal mucosa and palate

HZ is caused by reactivation of the varicella-zoster virus following psychological stress, radiation exposure, underlying malignancy, immunosuppression, and physical trauma.[1] The exact pathophysiology of posttraumatic HZ is unknown, however a reflex hyperemia and irritation of the involved ganglion is proposed for viral reactivation.[2] Simultaneous involvement of both maxillary and ophthalmic divisions has been reported following accidental iatrogenic injury to both these divisions of trigeminal nerve and in the presence of immunosuppression.[3,4] Our case highlights a rare presentation of posttraumatic HZ involving the maxillary and ophthalmic divisions of the trigeminal nerve following facial injury by a wooden stick in an immunocompetent patient. Perhaps, a direct injury to multiple dermatomes over the face and extensive posttraumatic inflammation could be a reason for such extensive HZ in spite of lack of immunosuppression.

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Conflicts of interest

There are no conflicts of interest.