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CASE REPORT
Year : 1996  |  Volume : 44  |  Issue : 1  |  Page : 40-42

Bilateral and multifocal generalized eruptions in herpes zoster ophthalmicus: Case report


Department of Ophthalmology, King George's Medical College, Lucknow, India

Correspondence Address:
Rajiv Nath
Department of Ophthalmology, King George's Medical College, Lucknow
India
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Source of Support: None, Conflict of Interest: None


PMID: 8828306

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How to cite this article:
Nath R. Bilateral and multifocal generalized eruptions in herpes zoster ophthalmicus: Case report. Indian J Ophthalmol 1996;44:40-2

How to cite this URL:
Nath R. Bilateral and multifocal generalized eruptions in herpes zoster ophthalmicus: Case report. Indian J Ophthalmol [serial online] 1996 [cited 2020 Jun 4];44:40-2. Available from: http://www.ijo.in/text.asp?1996/44/1/40/24606

Herpes Zoster is an infection caused by the varicella-zoster virus. This virus is identical to the chicken pox virus antigenically. However, it has never been reported to have presented with generalized eruptions like chicken pox. It affects the sensory ganglia and results in maculo-papular rashes along the course of the concerned sensory nerve.[1] Herpes zoster ophthalmicus (HZO) is a condition where the ophthalmic division of the trigeminal nerve is affected; and the reservoir of the viruses is in the Gasserian ganglion. HZO is considered to be strictly unilateral disease. Although the periorbital oedema can spread to the other side, there have been scant reports of eruptions being found on the other side,[2] and there has been no report of presence of generalized eruptions in any form. This is a case report where the eruptions were present not only on the other side of scalp, forehead, bridge of nose, but few eruptions were also present along the ipsilateral intercostal areas on back of chest, and contralateral forearm.


  Case report Top


A 60 year old male presented with a 5 day history of severe pain on left side of forehead, followed on next day, by eruptions in that area and elsewhere. He also complained of inability to open the left eye. There was history suggestive of eruptive fever believed to be chicken pox during childhood. There was no other significant aspect in present, past, family, or personal history.

On general examination, the cardiovascular, respiratory, abdominal, musculoskeletal, and central nervous systems did not reveal any significant feature. There was no lymphadenopathy, and no finding suggestive of Acquired Immune Deficiency Syndrome (AIDS). There were maculo-papular rashes on the left side of scalp and forehead along the distribution of supraorbital and supratrochlear divisions of the ophthalmic branch of trigeminal nerve; eruptions on the whole of the left side of nose including the ala corresponding to the nasociliary division. Few eruptions were also present on the left upper lid. There was severe lid oedema which was extending to the other side as well [Figure - 1]. There were similar but fewer lesions on the other (right) side of forehead, scalp, and bridge of nose [Figure - 2]. These lesions on contralateral side were few, discrete, round, and had a dark central area of necrosis. They were similar in size, shape, and colour to those on the left side. On careful examination, similar rash at the same stage of development was found on the lateral side of right forearm [Figure - 3], and on the left intercostal areas on the back [Figure - 4]. All these lesions were similar to those at the main site of involvement. The patient reported that these lesions had developed with the primary disease, and all these sites had moderate to severe burning pain, but less severe compared to pain around the left eye. Apart from eruptions, there was ptosis of left upper lid, and limitation of movement of the left eye in all directions except adduction. In the left eye, the cornea was insensitive, the pupil was not reacting to direct light, vitreous was hazy, and the optic disc margins were blurred. Vision in that eye was finger counting very close to face, with an impaired projection of rays in all directions. Examination of right eyeball did not reveal any abnormality.

On investigations, he was found to be non-diabetic with normal blood chemistry and cell counts. The patient refused to get investigated for AIDS. He was prescribed oral prednisolone 40 mg daily in single dose therapy, and topical application of acyclovir and steroids on affected areas of skin, and topical acyclovir and gentamicin for the left eye. The patient was unable to afford the cost of treatment of oral acyclovir.

The skin oedema started subsiding, and lesions flattened in 4 days. The crusts separated out in 5 to 7 days, at all the sites of eruption. Oral steroids were withdrawn after 2 weeks. The movement of left eyeball recovered fully. The vitreous haze cleared, but the visual acuity in left eye did not improve due to optic atrophy. The patient reported 3 weeks later with severe anterior uveitis in the left eye, and post herpetic neuralgia of the left side of the face. He was treated with topical steroids and oral carbamazepine. He became asymptomatic in a week, but returned again after 3 months with a total cataract in the left eye. There was no evidence of active anterior uveitis, and an extracapsular cataract extraction was done. Intraocular lens implantation was not done because of the possibility of complications in the event of a recurrence of anterior uveitis, and also because of poor prognosis in presence of optic atrophy. The postoperative period was uneventful, and surprisingly the visual acuity was 6/36 with appropriate aphakic correction. Later, 8 weeks after surgery, he presented with severe neuroparalytic keratitis with superadded fungal keratitis in the left eye. He was treated with topical natamycin, atropine, and ciprofloxacin. A lateral tarsorrhaphy was done. The corneal ulcer healed, leaving a large, dense and vascularized scar occupying central 75% of the corneal surface.


  Discussion Top


HZO has been reported to be associated with systemic complications such as encephalitis,[3] ipsilateral or contralateral hemiplegia,[4] delayed cerebral infarction and meningoencephalitis,[5] more so in immuno-compromised patients such as those receiving immuno-suppresive drugs or suffering from AIDS.[6] Although this patient suffered from a severe form of illness, he did not develop any of these systemic complications. Blood investigations did not reveal diabetes mellitus or immunosuppresion. He could not be investigated for AIDS, but he has been on follow-up for one year, and there has been no clinical manifestation of AIDS till now. The unique feature of this case was the bilateral association with multifocality of eruptions, which to our knowledge has not been reported earlier. Herpes zoster virus is considered antigenically similar to chicken pox virus. However the eruptions in the former remain localized along the path of a sensory nerve, while in latter, the eruptions are generalized. In this case, the multifocal and generalized pattern of eruptions clinically corroborate the association of herpes zoster infection with chicken pox.

 
  References Top

1.
Harding SP, Lipton JR. Natural history of Herpes zoster ophthalmicus: predictors of postherpetic neuralgia and ocular involvement. Br J Ophthalmol. 71:353-8, 1987.  Back to cited text no. 1
    
2.
Yamada K, Hayasaka S, Yamamoto Y, et al. Cutaneous eruptions with or without ocular complications in patients with herpes zoster involving trigeminal nerve. Graefes Arch Clin Exp Ophthalmol. 228:1-4, 1990.  Back to cited text no. 2
    
3.
Barnes DW, Whitley RJ. CNS diseases associated with varicella zoster virus and herpes simplex virus infection. Pathogenesis and current therapy. Neurol Clinic. 4:265-83, 1986.  Back to cited text no. 3
    
4.
Szpakowa G, Tarnowska-Dziduszko E, Kryst-Widzgowska T.Two cases of ophthalmic infection followed by hemiplegia. Neurol Neurochir Pol. 25:95-1000, 1991.  Back to cited text no. 4
    
5.
Freedman MS, Mcdonald RD. Herpes zoster ophthalmicus with delayed cerebral infarction and meningoencephalitis. Can J Neurol Sci. 14:312-4, 1987.  Back to cited text no. 5
    
6.
Kestelyn P, Stevens AM, Bakkers E et al. Severe herpes zoster ophthalmicus in young africans adults: a marker for HTLV-III seropositivity. Br J Ophthalmol. 71:806-9, 1987.  Back to cited text no. 6
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]



 

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