December 2015

Patient information:

The patient, a 29-year old otherwise healthy female, presents with a chief complaint of a facial rash.

History of Present Illness

The patient reported the first occurrence of a facial skin rash on November 1st. It was localized toon three areas on the right side of the face only: supra-orbital area (25mm), forehead (15mm), and upper eyelid (5mm). The skin lesions were pruritic and associated with erythema, were slightly raised, and did not cross the midline. No vesicles or pustules could be identified.

The patient had a flu shot two days prior to the onset of the rash, and reported stress levels of moderate to high due to work-related activities. One day prior to the occurrence of the skin lesions, she reported a mild scalp on the right side. It was sensitive to touch and when combing her hair. Lesions were also preceded by an intermittent burning and tingling sensation on the facial skin area and associated dermatome (scalp).

Treatment History

On the first day of noticing the lesions (November 1st; Fig 1), the patient went to an Urgent Care (UC) facility. A physician assistant diagnosed the rash as contact dermatitis (most likely a reaction to an unknown insect bite). A topical corticosteroid was prescribed (Triamcinolone topical cream 0.025%, bid).

Figure 1: Patient at initial presentation demonstrating localized erythema of the skin.

On the second day (November 2nd; Fig 2), since the lesions were not improving, the patient discussed her case with an acquaintance, an ER physician, who suspected the lesion to be . She was advised to seek another UC for a second opinion. At the UC, a physician concurred with a diagnosis of contact dermatitis, and considered shingles as an “improbable differential diagnosis”. The patient was prescribed an oral corticosteroid (Methylprednisolone – Medrol, 1 pack as directed), and recommended to stop using the topical cream.

Figure 2: Patient 48 hours after noticing the lesions and 24 hours after topical application of Triamcinolone cream.

24 hours after taking Medrol without any improvement, the patient went to a third UC for evaluation (Fig 3). She was then diagnosed with shingles due to the clinical presentation of the skin lesions. Tissue scraping was not advised, due to the classical presentation. The patient was advised to stop both oral and topical corticosteroids, and was prescribed an antiviral medication (Valacyclovir 1000mg PO q8h x7days). The physician was also concerned about possible involvement of the eye (herpes zoster ophthalmicus). Therefore, he recommended a same-day consultation with an ophthalmologist.

Figure 3: Patient 72 hrs after noticing the lesions and 24 hrs after oral corticosteroid intake (Medrol Pack). Notice cluster of vesicles surrounding erythema of skin extending to the medial canthus of the eye (arrow).

The clinical examination by an ophthalmologist was within normal limits, and the cornea was not affected. It was recommended to follow-up in 7 days or sooner, if needed. The patient was also advised to stay home due to a risk of contamination.

Two days after the patient was diagnosed with shingles, she woke up with noticeable swelling of both upper and lower eyelids. A small area of erythema was also present in the left side of the nose. The same ophthalmologist evaluated her and explained that the swelling can be attributed to dermatitis, and not related to any possible lesions in the eye. A 1-week follow-up appointment was scheduled.

Figure 4: Patient 5 days after noticing the lesions and 2 days after being diagnosed with shingles presenting with swelling of upper and lower eyelids. At this point, the patient was on Valacyclovir for 2 days. Notice crusting of facial vesicles.

During the one-week follow-up with the same ophthalmologist, the lesions were healing according to the expected progression of shingles (lesions ruptured and crusted over). No other symptoms were associated. No further follow-up was recommended.

Figure 5: Patient at one-week follow-up (Valacyclovir intake for 7 days). Notice further crusting of facial vesicles.

Figure 6 demonstrates resolution of the lesions at 30 days. Patient does not report any postherpetic neuralgia.

Figure 6: Patient at 30 days following appearance of the skin rash.

The patient described in this report presented with pain of sudden onset followed by a rash in a dermatomal distribution consistent with herpes zoster.

Following primary infection with varicella-zoster manifested clinically as chickenpox, the virus is transported via sensory nerves to the dorsal root ganglia where it establishes latency. Predisposing factors for reactivation manifested as herpes zoster (shingles) include among others, immunosuppression, emotional or physical stress, dental manipulation and substance abuse. Herpes zoster most commonly affects older individuals presumable because of a decrease in cell-mediated immunity1,2.

The three clinical phases of herpes zoster are: prodrome, acute, and chronic. The prodromal phase is characterized by sensory phenomena including pain, itching, or paresthesia affecting one or more dermatomes. Depending on the location, the pain may mimic among others, headache, cardiac pain, and appendicitis. Other less common symptoms include myalgia, photophobia and fever. The prodromal phase is due to initial viral replication and of the ganglion 2.

The acute phase is characterized by appearance of patchy erythema, occasionally with induration, in a dermatomal distribution. A classic finding is that of grouped vesicles on an erythematous base stopping abruptly due to dermatomal distribution. An uncommon presentation is that of dermatomal pain without rash (zoster sine herpete)3. Almost all adults experience pain, which can be severe in nature. Although symptoms tend to resolve in 10-15 days, complete healing of the lesions may require up to one month.

Herpes zoster of the trigeminal nerve with involvement of the ophthalmic (V1), maxillary (V2) or mandibular (V3) is of particular interest to dental health care providers. Oral lesions occur with trigeminal involvement, often extend to the midline, and are accompanied by skin lesions overlying the affected quadrant. The teeth in the area may develop pulpitis with subsequent pulpal . Rarely, jaw osteonecrosis can occur 4-6.

Ocular involvement, present in 10-25% of trigeminal involvement, can cause blindness. If lesions extend to the tip of the nose (Hutchinson sign), referral to ophthalmologist is required due to involvement of the nasociliary branch of the trigeminal nerve and an increased risk of severe ocular infection 7,8.

The differential diagnosis for our patient included contact dermatitis. Although contact dermatitis presents as a localized rash accompanied by pain, the pain and the rash usually occur simultaneously whereas sensory phenomena precede the rash in herpes zoster. Furthermore, contact dermatitis is not dermatome-restricted 9.

The chronic phase observed in approximately 15% of patients, is characterized by persistent or recurrent pain lasting 30 or more days after acute infection. This postherpetic neuralgia commonly resolves within one year with half the patients experiencing resolution after 2 months 10.

The diagnosis of herpes zoster is based on history and physical findings. Laboratory tests including direct fluorescent antibody testing, polymerase chain reaction or Tzanck smear of vesicular fluid are reserved for severely immunocompromised patients lacking classical clinical features 11.

Herpes zoster usually resolves without intervention and conservative therapy consisting of nonsteroidal anti- inflammatory drugs and calamine solution is recommended. For postherpetic neuralgia, narcotic and nonnarcotic , neuroactive agents and anticonvulsant medications are recommended 11.

Prompt antiviral therapy (acyclovir, valacyclovir, famciclovir) may decrease the length of time of new lesions and the days of acute discomfort. These medications can also be supplemented with systemic corticosteroids 12.

Zostavax, a live attenuated herpes zoster vaccine, was introduced in 2005 and is approved for use in patients 50 years or older13,14. Studies of Zostavax in older adults demonstrate significant decrease in herpes zoster incidence (50-70%) and 67% decrease in postherpetic neuralgia. This vaccine is not recommended for immunocompromised patients due to the fact that it contains a live, attenuated virus.

References:

1. Mueller NH, Gilden DH, Cohrs RJ, Mahalingam R, Nagel MA. Varicella zoster virus infection: clinical features, molecular pathogenesis of disease, and latency. Neurol Clin 2008;26:675-97, viii.

2. Dworkin RH, Johnson RW, Breuer J, et al. Recommendations for the management of herpes zoster. Clin Infect Dis 2007;44 Suppl 1:S1-26.

3. Kennedy PG. Zoster sine herpete: it would be rash to ignore it. Neurology 2011;76:416-7.

4.Talebzadeh B, Rahimi S, Abdollahi AA, Nouroloyuni A, Asghari V. Varicella Zoster Virus and Internal Root Resorption: A Case Report. J Endod 2015;41:1375-81.

5. Jain MK, Manjunath KS, Jagadish SN. Unusual oral complications of herpes zoster infection: report of a case and review of literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:e37-41.

6. Ramchandani PL, Mellor TK. Herpes zoster associated with and periapical lesions. Br J Oral Maxillofac Surg 2007;45:71-3.

7. Weinberg JM. Herpes zoster: epidemiology, natural history, and common complications. J Am Acad Dermatol 2007;57:S130-5.

8. Shaikh S, Ta CN. Evaluation and management of herpes zoster ophthalmicus. Am Fam Physician 2002;66:1723- 30.

9. Carlisle RT, Digiovanni J. Differential Diagnosis of the Swollen Red Eyelid. Am Fam Physician 2015;92:106-12.

10. Johnson RW. Herpes zoster and postherpetic neuralgia. Expert Rev Vaccines 2010;9:21-6.

11. Ramdass P, Mullick S, Farber HF. Viral Skin Diseases. Prim Care 2015;42:517-67.

12. McDonald EM, de Kock J, Ram FS. Antivirals for management of herpes zoster including ophthalmicus: a systematic review of high-quality randomized controlled trials. Antivir Ther 2012;17:255-64.

13. Oxman MN, Levin MJ, Johnson GR, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med 2005;352:2271-84.

14. Holcomb K, Weinberg JM. A novel vaccine (Zostavax) to prevent herpes zoster and postherpetic neuralgia. J Drugs Dermatol 2006;5:863-6.