Herpes Zoster after Reconstruction for Head and Neck Cancer

Abstract

Sir: Patients with cancers of the head and neck are at significant risk for herpes zoster.1 The morbidity of zoster in this region can be severe, including encephalitis, blindness, deafness, and refractory neuralgia.2 Prompt initiation of antiviral therapy significantly reduces the risk of morbidity; however, establishing the diagnosis of zoster can be difficult after reconstruction. Tissue rearrangement and mobilization of distant tissues can distort or efface classic dermatomes, hindering identification of zoster. Surgeons performing reconstruction for head and neck cancer must be aware of postoperative zoster and take measures to guard against associated morbidities. A 68 year-old man presented with painful rash on the right side of his face (Fig. 1). His history included reconstruction of a right cheek defect after wide excision of squamous cell carcinoma. The patient was admitted for wound care and empiric antimicrobial coverage including acyclovir (10 mg/kg intravenously every 8 hours). Polymerase chain reaction and immunofluorescence data from lesion scrapings confirmed the diagnosis of zoster. By the third hospital day, the patient had marked resolution of his symptoms and was discharged on oral acyclovir.Fig. 1.: (Above) A 68-year-old man with a history of recurrent squamous cell carcinoma of the right cheek after head and neck reconstruction with free anterolateral thigh flap (black arrowheads), pedicled trapezius myocutaneous flap (white arrowheads), and local tissue rearrangement. (Below) Six months after completing reconstruction, the patient presented with unilateral facial pain, a vesicular rash in the distribution of the trigeminal nerve (V1 and V2 branches), and soft-tissue ulceration. Flap tissue was relatively spared from involvement, even though it is contiguous with the area of cutaneous lesions.We have observed an additional five cases of zoster in 350 head and neck reconstructions at our institution, yielding an incidence of 1.7 percent. In our series, the diagnosis of zoster was frequently hindered by dermatome distortion from tissue rearrangement, coexisting radiation dermatitis, suspicion of recurrent cancer, and misdiagnosis as bacterial infection. Islands of flap tissue typically remained unaffected, whereas surrounding native tissues demonstrated characteristic cutaneous lesions. More than 90 percent of U.S. adults carry latent varicella zoster virus and are at risk for herpes zoster.3 Factors associated with varicella zoster virus reactivation are age older than 50 years, tumor-induced defects in cell-mediated immunity,4 and surgical intervention. Head and neck cancer patients frequently meet all of these criteria, and should be considered to be at high risk for zoster. Antiviral therapy with oral acyclovir, valacyclovir, or famciclovir should be initiated within 72 hours of clinical presentation to maximize benefits of treatment.5 For immunocompromised patients and patients with complicated presentations such as herpes zoster ophthalmicus, intravenous acyclovir should be initiated and converted to an oral agent after evidence of disease regression. Herpes zoster is a highly morbid condition that can be triggered by therapy for head and neck cancer. As the diagnosis of zoster can be difficult in the postreconstructive period, a high index of suspicion and close attention for a history of neuropathic pain preceding cutaneous lesions are crucial to facilitate prompt initiation of therapy. When managing postoperative soft-tissue infections in this population, zoster should be included in the differential diagnosis, and empiric antivirals should be considered to minimize the potential for severe complications. Pranay M. Parikh, M.D. Steven P. Davison, M.D., D.D.S. Department of Plastic Surgery Georgetown University Hospital Washington, D.C. DISCLOSURE Neither of the authors has any conflicts of interest to disclose.