|Year : 2017 | Volume
| Issue : 1 | Page : 38-40
Multidermatomal herpes zoster ophthalmicus in an immunocompetent male
Shobhana Dube1, Pratyush Ranjan2, V Rajshekhar3
1 Department of Ophthalmology, Career Institute of Medical Sciences and Hospital, Lucknow, Uttar Pradesh, India
2 Department of Ophthalmology, Vardhman Mahavir Medical College, Safdarjung Hospital, New Delhi, India
3 Department of Ophthalmology, Heritage Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
|Date of Submission||28-Jan-2016|
|Date of Acceptance||25-Aug-2016|
|Date of Web Publication||6-Dec-2016|
Department of Ophthalmology, Heritage Institute of Medical Sciences, Varanasi, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Herpes zoster (HZ) is caused by varicella zoster virus, which most commonly affects the thoracic (45%), cervical (23%), and trigeminal nerve (15%). Multidermatomal involvement is rare in an immunocompetent patient. We report an unusual case of HZ ophthalmicus involving all three divisions of trigeminal nerve including the superficial cervical plexus in an immunocompetent male. We recommend in such situation patient should be followed up to ensure earlier tests were not done during the window period.
Keywords: Herpes zoster, immunocompetent, multidermatomal, superficial cervical plexus, trigeminal nerve
|How to cite this article:|
Dube S, Ranjan P, Rajshekhar V. Multidermatomal herpes zoster ophthalmicus in an immunocompetent male. J Clin Ophthalmol Res 2017;5:38-40
|How to cite this URL:|
Dube S, Ranjan P, Rajshekhar V. Multidermatomal herpes zoster ophthalmicus in an immunocompetent male. J Clin Ophthalmol Res [serial online] 2017 [cited 2022 Jun 27];5:38-40. Available from: https://www.jcor.in/text.asp?2017/5/1/38/195308
Herpes zoster (HZ) also known as Shingles is an extremely painful and incapacitating acute infectious viral disease caused by reactivation of dormant deoxyribonucleic acid (DNA) neurotrophic varicella zoster virus (VZV). It mainly affects elderly individuals.
The most commonly affected dermatomes are the thoracic (45%), cervical (23%), and trigeminal (15%). The ophthalmic division of the trigeminal nerve is affected about twenty times more often than the 2 nd and 3 rd divisions of the nerve. Multidermatomal involvement is rare in immunocompetent persons with less than thirty cases reported so far.
| Case Report|| |
A 55-year-old male presented with pustular, vesicular, and maculopapular eruptions over the right half of face. The lesions initially began on the right upper lip approximately 10 days back with pain and burning sensation. He was treated by his family physician but the situation worsened after which he was referred to us. The lesions involved the whole right side of the face, right forehead, right external ear, and right side of the neck [Figure 1]. The whole right side of face was extremely edematous. He did not give any history of similar lesions or any other major illness. Ophthalmic examination revealed conjunctival congestion in the right eye with lid edema. Rest of the ocular examination did not reveal any abnormalities. After the edema subsided, both eyes revealed decreased corneal sensation.
|Figure 1: The lesions involving the whole right side of the face, right forehead, right external ear, and right side of neck|
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Ear, nose, and throat examination revealed similar eruptions over the right pinna with no other positive ear, nose, and throat involvement.
General physical examination of the patient was normal, and his vitals were stable.
Routine laboratory investigations such as complete hemogram, blood sugar, urine microscopy, and serum electrolytes were within normal limits. Spot and enzyme-linked immunosorbent assay tests for human immunodeficiency virus were negative.
Serological testing for VZV immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies were strongly positive. VZV IgG was 100.19 U/mL (normal <8 U/mL) and VZV IgM was 52.80 U/L (normal <8 U/mL).
The patient was started on oral acyclovir (Acivir, Cipla) 800 mg five times a day and oral diclofenac (Voveran SR, Novartis) 100 mg twice daily along with daily cleaning of skin and application of topical framycetin (Soframycin) ointments over skin lesions. Topical moxifloxacin 0.5% four times a day, ointment ganciclovir 0.15% three times a day, and carboxymethylcellulose 1% eye drops 6-8 times in a day were also started. The lesions crusted and the patient showed recovery within a week. The oral antivirals were continued for another 1 week till all active lesion subsided, Voveran SR was stopped at 1 week. Topical drops were continued till 3 weeks [Figure 2].
|Figure 2: The lesions crusted and the patient showed recovery within a week|
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| Discussion|| |
In HZ, a few lesions (typically <20) can normally appear adjacent to the affected dermatome. More extensive skin involvement of several adjacent dermatomes is called multidermatomal zoster, whereas spread to a nonadjacent dermatome is known as zoster duplex unilateralis or bilateralis. 
VZV-specific cell-mediated immunity (CMI) is required to halt the virus reactivation. During young adulthood, VZV-specific CMI is robust which explains the infrequent occurrence in this age group, with aging, the VZV-specific CMI declines, especially after the age of 60. This decline in CMI correlates with increased incidence of HZ in the elderly population. Humoral immunity does not appear to protect against reactivation of VZV. In contrast, patients with T-cell deficiency, such as HIV patients and bone marrow transplant recipients, can present with severe cutaneous and visceral disseminated disease. 
Among immunocompetent patients, zoster is considered a self-limited, localized infection commonly complicated by postherpetic neuralgia and it has been reported to present with subconjunctival hemorrhage, vesicular conjunctivitis, corneal hypoesthesia, epithelial and stromal keratitis, anterior uveitis, keratouveitis, Iris atrophy, pupillary distortion, ocular hypertension, glaucoma, neurotrophic keratopathy, oculomotor nerve palsy, optic neuritis,  acute dacryoadenitis  orbital abscess,  orbital apex syndrome,  and it has been reported to be extending up to soft palate. 
Diagnosis is made clinically, but specialized tests are used in difficult situations like ours. Tzanck smear assay is a pretreatment microscopic examination of scrapings from the base of a cutaneous lesion and is stained with either giemsa wright, hematoxylin and eosin or papanicolaou stain. It has low sensitivity and is influenced by stage of lesion. The fresh vesicle is more likely to result in positive tzanck smear. Furthermore, it cannot differentiate between specific infections induced by herpes simplex virus (HSV)-1, HSV-2, or VZV. In our case, the patient reported to our outpatient department late with some pretreatment, so tzanck smear was not preferred.
Serological testing is useful for identifying acute infections. Detecting VZV DNA by polymerase chain reaction, VZV IgG, and IgM antibodies to VZV in serum are confirmatory. IgG and IgM antibodies both usually appear within 5 days of the rash. IgM disappears in 2-4 weeks whereas IgG antibody usually persists for an indeterminate time. A positive IgG result indicates immunity or past exposure to VZV whereas positive IgM results indicate recent infection.
Direct fluorescent antibody test directly detects the HSV1/2 or VZV antigen using fluorescein-tagged antibodies. Sensitivity is 50%-100% with 100% specificity.  Viral culture is time-consuming, labor intensive requires experienced expertise, specialized facilities, and its results depend on subjective interpretations. Nucleic acid amplification test requires specialized facilities.
In our case, serological testing for IgG and IgM antibodies were done and it was strongly positive in the patient, thereby, confirming the diagnosis of HZ infection despite confusing clinical manifestation.
Multidermatomal involvement is rare in immunocompetent persons, till now only less than thirty cases have been reported in literature.
We recommend that immune status must be ascertained quickly if atypical involvement is seen and oral or parenteral antiviral drugs should be started as quickly as possible to prevent complications. Eyes should be carefully and regularly examined to rule out any involvement at the earliest. For the purpose of rapid diagnosis and initiation of appropriate therapy, clinicians should be aware of these more atypical presentations of VZV infection even in immunocompetent persons.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]