A Healthy 2.5-Year-Old Boy With Herpes Zoster Ophthalmicus as Primary Presentation.

Abstract

Herpes zoster ophthalmicus (HZO) has already been reported in young healthy children, most of them with a history of chickenpox or varicella zoster virus (VZV) vaccination [1–10].We present a case of HZO in a previously healthy 2.5-year-old boy. To our knowledge, our case report is the first publication in which both serological analyses showed VZV seroconversion and polymerase chain reaction (PCR)-confirmed VZV DNA in the fluid from the patient’s vesicular rash. History and Clinical Examination A 2.5-year-old boy presented with acute onset of a vesicular rash involving the left forehead with swelling and erythema of the left upper eyelid since day 1. The patient had previously always been healthy, and, more specifically, he had never had any clinical manifestations of varicella or herpes simplex virus (HSV) infections and had never received a vaccine against varicella. The mother had developed chickenpox during childhood and was known to experience recurrent herpes labialis. An older brother had developed varicella at the time of birth of the patient after a normal pregnancy and full-term normal delivery. Our patient did not develop any rash or fever at that time. Further family history was unremarkable. The clinical examination revealed a subfebrile temperature (peak 38.3°C), but other vital signs were normal. The rash was vesicular, covered with golden yellow crusts, and distributed according to the ophthalmic division of the left trigeminal nerve (forehead and periocular). Inspection of the left eye showed marked erythema and swelling of the upper eyelid. Hutchinson’s sign, a predictor of ocular inflammation and corneal sensory denervation, was absent. Eye movements and visual acuity were normal. Macroscopic inspection of the anterior segment of the eye did not show any fluorescein staining of the corneal epithelium. There were no signs of ocular complications. Further clinical examination was unremarkable. Because of a clinical suspicion of HZO with bacterial superinfection (impetigo), the patient empirically received intravenous and topical acyclovir and intravenous flucloxacillin. Laboratory Investigations At admission, hematological investigation revealed a white blood cell count of 4.9 × 10 3 cells/μL (reference range, 5.5–15.5 × 10 3 cells/μL). Basic biochemical (sodium, potassium, chloride, bicarbonate, anion gap, bilirubin, serum glutamic pyruvic transaminase, and serum glutamic oxaloacetic transaminase) and basic immunological tests (immunoglobulin [Ig]G, IgG subclasses, IgM, IgA, complement C3 and C4 levels) showed no abnormalities. The C-reactive protein level was normal. Serological analyses for VZV and HSV were performed. Both VZV, anti-VZV IgM and anti-VZV IgG (Liaison VZV IgM and IgG kit; DiaSorin, Saluggia, Italy), and HSV, anti-HSV IgM and anti-HSV IgG (Enzygnost assay on BEP 2000 Advance System; Siemens, Erlangen, Germany), antibodies were negative. Fluid from the vesicular rash was collected, and real-time PCR (DNA extraction with NucliSENS easyMAG nucleic acid extractor [bioMerieux SA, Marcy l’Etoile, France] and real-time PCR with Affigene VZV tracer kit [Cepheid, Bouwel, Belgium] on the Rotor-gene 6000 [Qiagen, Venlo, Netherlands]) for the detection of VZV DNA was positive. Culture from an ESwab (Becton, Dickinson and Company, Erembodegem, Belgium) (forehead and upper eyelid) confirmed secondary bacterial infection with Staphylococcus aureus. Six days after initial serologic analyses, anti-VZV IgM and anti-VZV