MULTIPLE ORO-FACIAL COMPLICATIONS OF HERPES ZOSTER INFECTION INAN ELDERLY: A CASE REPORT

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A.A Salami^1,2,3, T.O Mudasiru^4,6, I. Joseph^5,6, E.O Abe⁶, A.O Adisa⁶

1. Department of Oral and Maxillofacial Surgery, University College Hospital, Ibadan, Nigeria.
2. Faculty of Dentistry, University of Puthisastra, Phnom Penh, Cambodia.
3. Department of Public Health Dentistry, Manipal Academy of Higher Education, Manipal, India.
4. Department of Maxillofacial Surgery, Ahmadu Bello University Teaching Hospital, Shika-Zaria, Kaduna, Nigeria.
5. Department of Dental and Maxillofacial Surgery, Federal Teaching Hospital, Birnin Kebbi, Kebbi State, Nigeria.
6. Department of Oral Pathology/Medicine, University College Hospital, Ibadan, Nigeria.

Abstract

Introduction: Herpes zoster (HZ) is a viral disease with a global health burden which significantly impacts on the quality of life. HZ is caused by reactivation of the varicella-zoster virus and its complications are dependent on multiple factors like immune suppression, psychological stress, malnutrition, co-morbidities, duration of HZ infection and old age. Some of the complications include secondary bacterial infection, post-herpetic neuralgia, scarring, nerve palsy, and viral encephalitis. These complications could present as single or rarely as multiple entities in an individual.

Materials & Methods: We present a case of HZ infection affecting the mandibular division of trigeminal nerve in a 78-year-old widow. The patient presented with multiple complications including hyper- pigmented scarring, post herpetic neuralgia and chronic non-suppurative osteomyelitis of the left mandible. This case report highlights the presentation of multiple complications from HZ infection especially among the elderly.

Conclusion: Early diagnosis and prompt treatment of HZ infection are highly essential for reduced risk of complications.

Keywords: Herpes zoster; Chronic osteomyelitis; Post-herpetic neuralgia; Scarring

Introduction

Herpes zoster (HZ), also known as shingles is a viral infection caused by the reactivation of latent varicella zoster virus within the sensory dorsal root ganglia, cranial ganglia or autonomic ganglia due to depressed immunity, psychological stress or advancing age. It presents as a unilateral, localized, self-limiting, painful, erythematous maculopapular rash along the affected dermatome¹ HZ occurs mostly among the elderly and the incidence ranges from 3.9-11.8 per 1000 persons per year among individuals who are 65 years and older.² The reactivation of latent vaccine preventable varicella zoster virus (VZV) in the dorsal root ganglia causes herpes zoster which mostly affects the thoraco-lumbar dermatome. When the trigeminal nerve is affected, the ophthalmic division is mostly involved while the mandibular division is least affected.³ Though a self limiting disease, it may be associated with varying complications including postherpetic neuralgia, pigmentary changes, scarring in the form of hypertrophic or keloidal scars, secondary infections, acute retinal necrosis, blindness, cerebellar ataxia, Guillain-Barre syndrome, Ramsay-Hunt syndrome, meningoencephalitis, stroke, and myocarditis.^2,4 These complications may be single or in rare cases occur as multiple complications in an individual depending on severity of immune compromise and co-morbidity status.⁴

Postherpetic neuralgia (PHN) is one of the most common complications of HZ and it is a debilitating, neuropathic pain syndrome characterized by constant or intermittent burning, stabbing, shooting, electric shock-like pain which occur usually after resolution of herpes zoster.⁶ PHN persists in the area where the rash was once located, it continues more than 90 days after rash onset and could last for months or even years.⁷ PHN is considered the most debilitating sequelae of HZ as it impairs an individual’s quality of life across the four health domains which include physical, psychological, functional and social.¹ In PHN, the threshold of action potential of the affected nerve is lowered thus resulting in disproportionate and amplified responses to stimuli (hyperalgesia) and spontaneous discharge of pain even without any pain stimulus (allodynia).⁸ A meta-analysis revealed some risks associated with developing PHN following HZ infection as HIV/AIDS, immunosuppression, family history, older age, trauma, females, and presence of comorbidities like diabetes and rheumatoid arthritis9. The lifetime incidence of zoster is 30% and an estimated 12.5% of zoster patients aged 50 years develop PHN.10

Although HZ mostly affects the thoracolumbar dermatomes, the trigeminal nerve is affected in 13% of cases especially its ophthalmic division.³ The involvement of the mandibular division (herpes zoster mandibularis) or maxillary division is characterized by oral manifestations including internal resorption, tooth exfoliation and chronic osteomyelitis of the jaw.¹¹

We present the case of HZ infection (HZI) affecting the mandibular division of trigeminal nerve in a 78- year-old woman with multiple orofacial complications including PHN, chronic osteomyelitis of the jaw and hyperpigmented scarring of the affected region. This case report highlights the presence of multiple complications from HZI especially among the elderly. Therefore, early diagnosis and prompt treatment of HZ and its complications is highly desirable as studies have shown a faster resolution of HZ symptoms and its complications when treatment is initiated early.^4,5