Disseminated Herpes Zoster Ophthalmicus in an Immunocompetent 8-Year Old Boy
A previously healthy 8-year old boy presented with a five-day history of right sided headache and a four day history of a vesicular rash on the ipsilateral forehead, eye lid and nose. There was associated pain and swelling of the areas involved. The rash later progressed to involve the ipsilateral side of the scalp while the facial swelling spread to the contralateral side of the face (). Three days after the onset of the facial rash, a vesicular rash was noticed on the chest, back, upper and lower limbs. There was associated fever and generalized headache. Review of systems was negative. There was a past history of a febrile exanthematous illness suggestive of chicken pox at 3 years of age and his parents and siblings had similar illness at about the same time. There was no history of recurrent illnesses, intake of neither steroids nor cytotoxic drugs. A history of contact with individuals with varicella infection was uncertain but the child had been attending school before his illness. He presented during an ongoing chicken pox outbreak as evidenced by an increased number of cases observed within and outside the hospital setting.\nAt presentation, he was acutely ill looking, febrile with an axillary temperature of 39.6°C. He had coalesced pustulo-bullous crusting lesions on the right peri-orbital and frontal areas, extending upwards into the temperoparietal region of the scalp on the ipsilateral side and downwards to the right nostril, in keeping with involvement of the ophthalmic branch of the trigeminal nerve. There was associated gross facial edema involving both periorbital areas and extending to the chin and submandibular region. The swelling on the right side of the face was crepitant, suggestive of subcutaneous emphysema. Both eyes were tightly shut with copious discharge. He had right-sided pre-auricular, posterior auricular, submandibular and cervical lymphadenopathy. His weight was 33.5 kg (90th percentile) and his height was 128 cm (50th percentile). He had disseminated lesions on the trunk and extremities except spared the soles and palms. There were umbilicated vesicles on erythematous base with some crusting of some of the lesions ().\nOther systems were essentially normal. A diagnosis of herpes zoster ophthalmicus with suspected secondary bacterial infection was made.\nHis hematocrit was 38%, the white cell count was normal at presentation. HIV antibody test was non-reactive. His random plasma glucose was 123 mg/dL. Serology for varicella antibodies could not be carried out until 6weeks after and was reported as positive for varicella immunoglobulin (Ig) G and negative for IgM. Viral cultures and polymerase chain reaction (PCR) were not available.\nHe was admitted and nursed in isolation and was managed by both the pediatric infectious diseases unit in conjunction with the ophthalmologists. He was tolerating oral fluids and feeds fairly well and commenced on oral acyclovir at 20 mg/kg five times a day (the intravenous form was not available), acyclovir eye ointment and drops, regular ocular toileting with 0.9% saline and dexamethasone eye drops on account of chemosis observed on eye examination. A full eye examination was not possible at this point as it was difficult to prise the lids open. He received in addition, intravenous flucloxacillin, ceftriaxone and metronidazole on account of the bilateral periorbital cellulitis. Topical acyclovir was applied to the lesions on the frontal region.\nWithin 24 h of oral acyclovir treatment, new skin lesions ceased to appear. He improved remarkably over the next week (). The pustules became ulcerated and gradually healed. Fever and facial edema gradually resolved. He was able to open both eyes and had no problems with vision. He was discharged home with acyclovir ointment application after having completed a week of systemic acyclovir use and antibiotics. Follow-up at six weeks showed residual ptosis of the left eye () without evidence of Bell’s palsy or other neurological findings that may be in keeping with a complication including Ramsay-Hunt or Trigeminal herpes zoster. A slit-lamp examination of the eye did not reveal any significant corneal scarring and ophthalmoscopy did not show any intraocular lesion (). Visual acuity was normal.