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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 32  |  Issue : 4  |  Page : 417-420

Herpes zoster of trigeminal distribution - A case series


Department of Oral Medicine and Radiology, Government Dental College and Hospital, Aurangabad, Maharashtra, India

Date of Submission08-May-2020
Date of Decision18-Oct-2020
Date of Acceptance24-Oct-2020
Date of Web Publication28-Dec-2020

Correspondence Address:
Dr. Anka Sharma
Department of Oral Medicine and Radiology, Government Dental College and Hospital, Aurangabad, 431 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_86_20

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   Abstract 


Herpes Zoster (HZ) is an acute vesiculobullous condition affecting dermatomes supplied by cranial or extracranial nerves. It is caused by reactivation of varicella zoster virus (VZV) in a patient with a history of chickenpox. Usually, a single dermatome is affected and the patient presents with erythema, burning pain, and vesicular eruptions in the affected segment. Antivirals like acyclovir are the mainstay of treatment. This manuscript discusses three cases affecting the three branches of the trigeminal nerve. The first (a 36-year-old male), second (a 59-year-old male), and the third case (a 50-year-old male) are affected by HZ involving the maxillary, mandibular and ophthalmic-maxillary dermatomes, respectively.

Keywords: Herpes zoster, trigeminal nerve, varicella zoster virus


How to cite this article:
Sharma A, Pagare JS, Kasat VO, Parate AR. Herpes zoster of trigeminal distribution - A case series. J Indian Acad Oral Med Radiol 2020;32:417-20

How to cite this URL:
Sharma A, Pagare JS, Kasat VO, Parate AR. Herpes zoster of trigeminal distribution - A case series. J Indian Acad Oral Med Radiol [serial online] 2020 [cited 2021 Jan 17];32:417-20. Available from: https://www.jiaomr.in/text.asp?2020/32/4/417/305281




   Introduction Top


Herpes Zoster (HZ) is an acute, infectious disease of viral origin affecting both cranial as well as extracranial nerves. It is caused by reactivation of varicella zoster virus (VZV) in an individual with a history of chickenpox.[1] After the primary infection (chickenpox), VZV travels in a retrograde manner and resides in the ganglion of the affected nerve, only to reactivate later, causing vesiculobullous lesions.[2],[3] HZ frequently affects the trigeminal nerve (CNV), and hence, is routinely encountered by a dentist. This manuscript describes a series of three cases of HZ affecting the three branches of CNV and their management.


   Case Reports Top


Case 1

A 36-year-old male presented with the chief complaint of pain and swelling on the left side of the face for seven days. The pain was sharp, radiating and preceded by a burning sensation. The swelling was followed by multiple, smaller eruptions (since 2 days) that itched and if scratched, released fluid. The patient recently had a change in the working hours of his job (night shift) which he was finding difficult to adapt to. He had a history of chickenpox in the past. Dental history was inconclusive.

On extraoral examination, a diffuse, reddish-pink swelling was evident on the left side of the face with multiple erosions [Figure 1]a. Few vesicles were seen over the upper lip near the midline. Intraorally, crops of multiple pinpoint ulcers, covered with grayish-white pseudomembrane were evident, strictly restricted to the left side of the hard palate [Figure 1]b.
Figure 1: (a). Diffuse, reddish-pink swelling on left side of the face along the distribution of maxillary nerve. Yellowish exudate evident at left nasolabial sulcus. (b). Crops of multiple pinpoint ulcers, covered with grayish-white pseudomembrane strictly restricted to the left side of the palate. (c). Follow up visit. Erythema on the face has resolved. Scabbing present at multiple sites. (d). Follow up visit. Ulcers are in healing phase

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A clinical diagnosis of HZ involving the maxillary nerve (CNV2) was formed.

Case 2

A 59-year-old male presented with multiple small, itchy eruptions on the lower lip for three days, accompanied by severe burning sensation and pain in the mouth. He had a dental appointment three days back after which the symptoms appeared. He denied any episode of chickenpox in childhood. On extra-oral examination, multiple fluid-filled vesicles were noted on the left side of the lower one-third of the face and lower lip [Figure 2]a. Intra-orally, multiple small ulcers with irregular margins and erythematous halo were present on the left side of floor of the mouth and labial mucosa [Figure 2]b. A clinical diagnosis of HZ involving the mandibular nerve (CNV3) was formed.
Figure 2: (a). Multiple, small vesicles seen on the lower half of the face. Note that a few have coalesced. (b). Few pinpoint and one large ulcer evident on the floor of mouth in the anterior region. (c). Follow-up visit. Multiple scabs present over the lower lip. Also note few hypopigmented areas. (d). Follow-up visit. The ulcers have healed completely

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Case 3

A 50-year-old male presented with complaint of pain in the upper front tooth and swelling of the right side of the face for four days. The pain was sharp, shooting, and radiating in nature. He had a history of a similar episode in the past, which subsided on taking medications from a local practitioner. However, this time, it was followed by eruption of multiple, small, fluid-filled eruptions on the right side of the face, accompanied by excessive itching. Scratching led a few to burst open, exuding fluid from them. Medical history was inconclusive and he denied any episode of chickenpox in childhood.

On extra-oral examination, few fluid-filled vesicles were evident on the right half of the forehead, temporal region [Figure 3]a, malar region, and upper lip [Figure 3]b. Intraorally, 13 was carious (distal) and severely attrited [Figure 3]c. It was tender on percussion. The right upper vestibule was slightly obliterated and tender on palpation. Orthopantomograph (OPG) revealed proximal caries and periapical lesion in relation to 13.
Figure 3: (a). Multiple, small vesicles seen on the right half of the forehead. Note that a few have coalesced. (b). Multiple, small vesicles seen on the right half of the face (infraorbital and malar region). A scab is also evident on the upper lip. (c). Severely attrited 13. The tooth had distal caries (not evident in the image). (d). Follow-up visit. Multiple scabs present over the right half of the face

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A clinicoradiographic diagnosis of phoenix abscess with 13 and HZ involving ophthalmic (CNV1) and maxillary nerve (CNV2) was established.

Therapeutic intervention

All the cases were advocated tablet valacyclovir 1000mg t.i.d for 10 days and topical anesthetic gel for intra-oral application. Case 3 was prescribed tablet amoxycillin-clavulanic acid 625 mg b.i.d and tablet aceclofenac-serratiopeptidase combination t.i.d for five days in addition to valacyclovir and was referred for endodontic management of 13.

Follow-up and outcomes

All the three patients after one week follow-up were relieved of pain, showed scabbing of the vesicles and healing of the ulcers [Figure 1]c, [Figure 1]d, [Figure 2]c, [Figure 2]d, and [Figure 3]d. Case 1 and 2 reported itching in the scabs and were prescribed topical calamine lotion. The patient in case 3 was scheduled for root canal treatment.

The patients were followed up for two years without any recurrence or complications.


   Discussion Top


The primary infection by VZV (chickenpox) is usually mild or occurs at a very young age and thus, the patient may not recollect previous episode of chickenpox. The patients in case 2 and 3 also denied history of chickenpox. HZ is quite prevalent in the Asia-Pacific region and is known to have a female predilection. Incidence of HZ increases significantly over 40 years of age and peaks at 70–80 years.[4] In the present case series only one patient was less than 40 years (Case 1).

Waning cell-mediated immunity (CMI) has been considered as the major etiology for HZ.[4] Occasionally, HZ has been reported in healthy immunocompetent individuals. Ashi A et al., reported HZ in a 13-year-old immunocompetent child. The authors could not elicit the exact cause but suggested in-utero exposure to the virus as the etiology.[5] In the present case series, stress due to change in working hours, dental procedure, and toothache appeared to be the reason of reduced CMI.

HZ has characteristic clinical features that can be grouped into three categories: prodromal, acute, and chronic. Lesions are typically unilateral and do not cross the midline. The thoracic segment is most commonly affected, followed by trigeminal, lumbar, and cervical segments. In the trigeminal distribution, the ophthalmic branch is most commonly affected. Usually, HZ involves a single dermatome, but adjacent dermatomes have been affected in 20% cases[2] (similar to case 3 whereby both ophthalmic and maxillary division were involved). Recurrence of HZ, though rare has been reported in 2.3 to 8% cases.[6] None of our patients had recurrence.

Treatment of HZ can be categorized as pharmacological and non-pharmacological. The non-pharmacological management includes isolation of the patients (till the active lesions heal), dietary modifications, and open dressing of the skin lesions till the scabbing occurs. Within the pharmacological management [Table 1], acyclovir (guanosine analog) has been considered as the drug of choice. However, it has a poor patient compliance (due to five times a day regime). In a cochrane review, Mustafa et al., found that valacyclovir (prodrug of acyclovir) 1000 mg three times a day, famciclovir (prodrug of penciclovir) 500 mg three times a day, and brivudin (125 mg once daily) were more bioavailable than acyclovir and yielded superior results in HZ management.[7]
Table 1: Pharmacological management of HZ

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HZ if not treated well in time is known to cause a wide array of complications of which post herpetic neuralgia (PHN) is the most dreaded one. Dental complications like osteomyelitis are uncommon but have been reported with local factors like periodontitis and caries acting as aggravating factors.[8],[9] None of the patients in the case series reported any complication during the follow-up period.


   Conclusion Top


HZ affecting the trigeminal nerve is commonly encountered by the dental fraternity. It has striking clinical features and hence, the diagnosis is usually clinical. However, if not managed well in time, HZ can lead to chronic complications like PHN, reducing the quality of life in patients. This case series emphasizes that an early diagnosis and prompt management with guanosine analogs go a long way in preventing complications and morbidity in patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Mario RND. Herpes zoster and postherpetic neuralgia: Diagnosis and therapeutic considerations. Altern Med Rev 2006;11:102-13.  Back to cited text no. 1
    
2.
Sampathkumar P, Drage LA, Martin DP. Herpes zoster (shingles) and postherpetic neuralgia. Mayo Clin Proc 2009;84:274-80.  Back to cited text no. 2
    
3.
Hambleton S, Gershon AA. Preventing varicella-zoster disease. Clin Microbiol Rev 2005;18:70-80.  Back to cited text no. 3
    
4.
Chen LK, Arai H, Chen LY, Chou MY, Chou MY, Djauzi S, Dong B, et al. Looking back to move forward: A twenty-year audit of herpes zoster in Asia-Pacific. BMC Infect Dis 2017;17:213.  Back to cited text no. 4
    
5.
Ashi A, Ali A, Alzahrani M, Ali J, Albar R. Herpes zoster eruption in an otherwise healthy child: A case report. Cureus 2019;11:e5194.  Back to cited text no. 5
    
6.
Jeong SK, Kim IH. Recurrence rate of herpes zoster during the previous decade. Korean J Dermatol 2012;50:287-9.  Back to cited text no. 6
    
7.
Mustafa MB, Arduino PG, Porter SR. Varicella zoster virus: Review of its management. J Oral Pathol Med 2009;38:673-88.  Back to cited text no. 7
    
8.
Wright WE, Davis ML, Geffen DB, Martin SE, Nelson MJ, Straus SE. Alveolar bone necrosis and tooth loss. A rare complication associated with herpes zoster infection of the fifth cranial nerve. Oral Surg Oral Med Oral Pathol 1983;56:39-46.  Back to cited text no. 8
    
9.
Gupta S, Sreenivasan V, Patil PB. Dental complications of herpes zoster: Two case reports and review of literature. Indian J Dent Res 2015;26:214-9.  Back to cited text no. 9
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