The Case Files

Abstract

Figure: Intraoral lesions on left half of the hard and soft palates without extension across the midline.FigureFigureAn 89-year-old woman presented to the emergency department with three days of painful swallowing and oral blisters. She first noticed intraoral blisters two days before presentation, with blisters on the upper lip occurring the following day. She was only able to swallow small amounts of liquids. Her exam revealed multiple vesicular lesions on the left upper lip and nares and multiple vesicular lesions extending from the midline of the hard and soft palates laterally to the left to the edge of the palate. (See images.) Given the dermatomal distribution and herpetiform appearance of the lesions, we diagnosed oral varicella zoster involving the greater palatine branch of the V2 distribution. The patient was started on oral valacyclovir 1000 mg three times daily, and was given viscous lidocaine swish-and-spit to decrease the oral pain in the emergency department. She was admitted for further pain management and IV fluids.Figure: Manifestation of the rash on the left upper lip and left nares.Oral herpes zoster is caused by the varicella zoster virus, which initially causes chicken pox and persists in the ganglia of trigeminal nerve. It is reactivated after immunity to the virus decreases, typically because of aging or immunosuppression. (Mayo Clin Proc 2009;84[3]:274.) Antiviral treatment initiated within 72 hours has proven to decrease duration of rash and the severity of pain, and corticosteroid trials have shown variable results, but prednisone in combination with acyclovir has been shown to reduce pain. (Am Fam Physician 2000;61[8]:2437.) Vaccination has been shown to reduce incidence by 51 percent so prevention through immunization may be the key. (N Engl J Med 2005;352[22]:2271.)