Herpes zoster affecting all three divisions of trigeminal nerve in an immunocompetent male: a rare presentation.

Sir,

Herpes zoster is a neurocutaneous viral infection caused by Varicella zoster virus. It is characterized by unilateral radicular pain and vesicular eruptions limited to a single dermatome innervated by a single spinal or cranial sensory ganglion.[1] Multi-dermatomal involvement is rare in immunocompetent patients.[2] We report an unusual case of involvement of ophthalmic, mandibular and maxillary branches of the trigeminal nerve in an immunocompetent male, which is extremely rare.

A 28-year-old male with no pre-morbid illness presented with the multiple fluid filled lesions over the left half of the face for 3 days. The lesions began in the left upper lip and progressed within a span of 3 days to involve entire left half of the face. He also had a burning sensation and pain over the lesions. He did not give any history of similar lesions in the past or any immunosuppressed state.

General physical examination of the patient was normal and his vitals were stable. Cutaneous examination revealed edema of the left half of the face. Multiple grouped vesicles on an erythematous base were seen over left upper lip, tip of nose, left temporal region, left cheek, and left side of the hard palate [Figure 1]. Ear examination revealed vesicles over left pinna, anterior wall of external auditory canal and anterior part of the tympanic membrane. There was mild conductive hearing loss with no involvement of facial nerve. Ophthalmic examination of left eye revealed mild conjunctival congestion. Lids, cornea, anterior chamber, vitreous, and retina were within normal limits. Right eye was within normal limits. The distribution of lesions corresponded to the left ophthalmic (V1), maxillary (V2), and mandibular (V3) branches of the trigeminal nerve.

Figure 1

Multiple grouped vesicles distributed along ophthalmic, maxillary, and mandibular division of Trigeminal nerve

His laboratory investigations such as random blood glucose levels and complete hemogram were within normal limits. ELISA for human immunodeficiency virus was negative. Tzanck smear showed multinucleated giant cells [Figure 2]. Patient was started on 1 g valacyclovir orally 3 times a day and systemic and topical antibiotics. The lesions crusted and the patient recovered [Figure 3] within 5 days of treatment with recovery of conductive hearing loss and conjunctival congestion.

Figure 2

Tzanck smear showing multinucleate giant cell (H and E, ×40)

Figure 3

Lesions resolved after treatment

Herpes zoster is caused by Varicella zoster virus an alpha herpes virus. The primary infection of varicella includes viremia and a widespread eruption. The virus remains latent for many years in the sensory nerve ganglion cells.[3] Herpes zoster is a result of reactivation of this residual latent virus, which may be triggered by trauma, sunburn, stress, and old age.[1]

Pain and paresthesia in the involved dermatome occurs 2-3 days prior to the development of closely grouped red papules. These rapidly become vesicular and pustular in a continuous or interrupted band in the area of the dermatome. Mucus membrane of the affected dermatome may be involved.[3]

The frequency of zoster in thoracic dermatomes is 53%, cranial nerves is 20%, trigeminal including ophthalmic is 15%, cervical dermatomes is 4-20%, and lumbosacral is 11%.[13] Multi-dermatomal involvement is rare in immunocompetent persons.[2] The relative frequency of ophthalmic herpes zoster increases with age.[13] Eye is involved in 30-40% of patients with ophthalmic zoster.[4] Our patient had only conjunctival congestion.

Vesicles on the tip or side of the nose indicate involvement of nasociliary branch of the ophthalmic division of the trigeminal nerve called “Hutchison's sign.”[3] This sign was not positive in our patient, though vesicles were present on the tip of the nose. Zoster of the maxillary division produces vesicles on the uvula and tonsillar area. Vesicles appear on the anterior part of the tongue, floor of the mouth, and buccal mucus membrane when mandibular nerve is involved.[3] The 2nd and 3rd divisions of the trigeminal nerve are rarely involved.[5] In spite of extensive search of the literature, we were unable to obtain any report of a case involving all 3 divisions of the trigeminal nerve. This is a case, probably first of its kind with involvement of ophthalmic, maxillary and mandibular divisions of the trigeminal nerve in an immunocompetent male.

Tzanck smear shows multinucleated giant cells and epithelial cells containing intranuclear inclusion bodies, which aids in diagnosis.[4] Detection of Varicella zoster virus (VZV) antigen by direct fluorescent antibody staining of a smear or of VZV DNA by Polymerase chain reaction (PCR) or culture helps to confirm the diagnosis.[3] Tzanck smear was positive in our patient. Confirmatory tests could not be performed due to lack of availability of these tests in our set up.

Antivirals like acyclovir 800 mg 5 times a day or valcyclovir 1 g 3 times a day are the treatment of choice.[1] Our patient received tab valacyclovir to which he responded rapidly and the vesicles crusted and healed within 5 days of initiation of treatment.