Late onset DCR surgical site herpes zoster in an immunocompetent patient: A rare presentation.

A 30-year-old female presented to us with watering in right eye (RE) since 12 months. The best corrected visual acuity in both eyes was 20/20. Anterior segment was unremarkable in both eyes except that regurgitation on pressure over lacrimal sac area in RE was positive. A diagnosis of primary acquired nasolacrimal duct obstruction was made for which dacryocystorhinostomy (DCR) was advised and carried out uneventfully. HIV/HbsAg/HCV assays were negative. The patient was discharged with steroid-antibiotic combination drops, antibiotic ointment, systemic antibiotics, NSAIDs, and nasal decongestants. At 2-week follow-up, sutures were removed. After 2 weeks, the patient presented with painful swelling over the lacrimal sac area. The patient was continued on antibiotic eye ointment and tablet trypsin/chymotrypsin was added. After 1 week, a 3-mm single abscess was noted over the wound. The abscess suspected to be due to secondary bacterial infection was drained under aseptic precaution and oral antibiotic was re-started. Multiple abscesses were noted over the wound site after 1 week [Fig. 1]. The patient was started on intravenous cefotaxime (1 gram) BD for 3 days. Mantoux, chest X-ray, and sputum culture for AFB were negative. Coalescent vesicles were seen over the wound site after 3 days [Fig. 2]. Lacrimal irrigation in RE was patent. Gram stain, KOH mount, and Ziehl-Nielsen stain all were negative for pus collected from the site. Clinical impression of surgical site herpes zoster was made with dermatologist consult. The patient was started on tablet acyclovir (800 mg) 5 times a day and acyclovir cream (5%) over wound area. After 7 days, a dramatic decrease in the size and number of vesicles were observed [Fig. 3]. After 1 month of initiating anti-viral therapy, the wound site was completely healthy and no herpetic lesion was noted [Fig. 4].

Figure 1

Slit lamp photo depicting multiple vesicles around DCR wound

Figure 2

Slit lamp photo showing increase in size and number of vesicles

Figure 3

Slit lamp photo showing decrease in the size and number of vesicles after initiating antiviral therapy

Figure 4

Slit lamp photo depicting complete resolution of the lesion and a clean healed wound

Discussion

Herpes zoster was reported within scar of a recent facial operation.[1] Corticosteroid injections,[2] botulinum toxin injections,[3] radiotherapy,[4] and cryosurgery[5] can incite shingles.

Histopathology and viral culture/PCR were lacking to support our clinical diagnosis. The lack of DCR surgical site herpes zoster related reports make this case one of its kind and an eye opener for future references.

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Conflicts of interest

There are no conflicts of interest.