Necrodestructive herpes zoster.

Herpes Zoster (HZ) is a self-limiting viral infection of skin and mucosa caused by Varicella zoster virus. Cutaneous lesions of HZ usually heal without any scarring and hyper/hypopigmentation. Though, post-inflammatory depigmentation and deep scarring can occur in immunocompromised or HIV positive individuals. The present report is of a elderly immunocompetent female who had HZ involving the ophthalmic division (including nasociliary branch) of trigeminal nerve. The lesions over nose caused mutilating scarring resulting in complete obstruction of the right anterior nare.

Introduction

Herpes zoster (HZ), also called shingles, is the consequence of the reactivation of latent varicella zoster virus from the dorsal root ganglia. This virus, belonging to the Herpesviridae family, leads to a group of painful blisters over the area of the dermatome. Cutaneous lesions of HZ usually heal without any scarring and hyper/hypopigmentation. Necrodestrucutve HZ is a well-described entity in immunocompromised or HIV-positive individuals.[12] We report here a case of elderly immunocompetent female who had HZ affecting the ophthalmic division (including the nasociliary branch) of the trigeminal nerve. Lesions over the nose healed with mutilating scarring that caused complete obstruction of the anterior nare. To the best of our knowledge, the presentation of necrodestructive HZ along with the distribution of the nasociliary nerve causing impairment and cosmetic disfigurement in an immunocompetent patient is the first case report in the medical literature.

Case Report

A 66-year-old female, referred by the department of medicine, presented with fluid-filled lesions on the right side of the face following intense pain. She was unable to open the right eye. Dermatological examination revealed multiple grouped papules and vesicles on the erythematous base covering the right side of the forehead, the upper eyelid, and the side of the bridge of nose, nasal aperture, and vestibule. Tzanck smear from vesicular lesions revealed multiple multinucleated giant cells. On ophthalmic examination, there was edema of right upper lid along with conjunctival congestion and corneal clouding. General physical examination was normal. Systemic examination revealed no organomegaly or lymphadenopathy. Routine investigations were within the normal limits. A diagnosis of HZ ophthalmicus was made, and the patient was prescribed oral acyclovir 800 mg 5 times a day for 7 days along with anti-inflammatory agents, topical silver sulfadiazine cream, and eye drops. Two days later, she developed superficial punctate keratitis showing positive fluorescein staining. Slit lamp examination revealed changes of senile cataract. Fundus examination was normal. On follow-up at 1 week, corneal edema subsided completely, conjunctival congestion markedly decreased, and she was able to easily open the eyes. Skin lesions began to crust and showed early signs of healing. The patient was given amitriptyline 25 mg twice daily and carbamazepine 200 mg thrice daily to relieve neuralgic pain. Two weeks after the onset of eruption, lesions on the right side of the forehead and the right eyelid had healed, but there was crust formation along with deep ulcerative lesions on the right nasal aperture. The formation of the ulcerative lesions prompted us to do a complete workup of the patient to check her immunological status, which we had not done at the initial presentation as HZ is common in elderly and we did not suspect any kind of immunosuppression. Her past history did not reveal any such history of similar lesions, radiotherapy, blood transfusion, antitubercular treatment, chemotherapy, surgery, and chronic medical treatment. Pus swab for culture and sensitivity from the ulcerative lesions showed normal flora. Repeat complete hemogram, blood glucose, erythrocytesedimentation rate, and skiagram of the chest were done. Additionally, mantoux test, venereal disease research laboratory test (VDRL), and ultrasonography of the abdomen were done, but they did not reveal any abnormality. The patient was seronegative to HIV-1 and HIV-2. A diagnosis of necrodestructive HZ was made. After about 6 weeks, lesions on the entire affected area healed with depressed superficial scarring along with hyper- and hypopigmented macular lesions, but the patient had extensive scarring on the right side of the anterior nare. She was unable to breathe from the right side due to almost complete obstruction of the right anterior nare [Figure 1]. A small plastic tube was inserted inside the right anterior nare to keep the nasal passage patent. On repeated follow-ups, there was no improvement in the obstruction of nasal aperture. The patient was then referred for plastic surgery for reconstruction.

Figure 1

Mutilating scarring over the right anterior nare, which causes almost complete obstruction

Discussion

Complications in HZ may be due to multiple mechanisms involved including viral spread, nerve damage, ischemic vasculitis, and the rate of inflammatory granulomatous reactions. The rate of complications is high in the cases of lymphoma and other malignancies, diseases causing immunosuppression including HIV.[1-3] The extent of scarring in HZ may also depend on the depth of the involvement. The main brunt of the disease in our case was on the nasociliary branch of the ophthalmic division of the trigeminal nerve. The nasociliary nerve is not always involved in ophthalamic HZ. The involvement of the tip of the nose supplied by the nasociliary branch has been thought to be a clinical predictor of the ocular involvement called Hutchinson's sign.[4] The destruction of alveolar processes of maxillary bone, falling of teeth, and the formation of the oroantral fistula has been reported previously in an immunocompetent HZ patient along with the involvement of ophthalmic and maxillary divisions of the trigeminal nerve.[5] The presentation of necrodestructive HZ in our patient, who was proved immunocompetent on laboratory investigations, raises an important question: Can old age be considered as an immunocompromised state? The administration of early systemic steroids along with antiviral drugs can prevent such type of complications. Steroids also help to decrease the rate of postherpetic neuralgia and scarring. It is suggested that steroids act by eliminating the edema, avoid immunological reactions, and reduce proliferative formation.[6] Steroids could not be given in our patient because of the risk of development of corneal ulcer. Such a type of mutilating scarring due to HZ involvement of the nasocilary nerve in an immunocompetent patient, which completely obstructed the anterior nare causing cosmetic disfigurement and functional impairment, is the first case report in the medical literature. Young patients with similar scarring should be evaluated for the cause of immunosuppression, including HIV.