October 10, 2016
4 min read

Painful, vesicular facial rash, red left eye in 10-year-old male

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James H. Brien

A 10-year-old male presents with a painful vesicular rash on his face and a red left eye. The onset was 3 days earlier, when he complained to his mother that his brother had hit him in the eye, which was followed by some itching of the left side of his face and eye. The next day the eye was erythematous with some discharge, and he was seen by his primary and diagnosed with “pink eye” and prescribed gentamicin ophthalmic drops.

In spite of this treatment, the eye worsened, and he began noticing some bumps on his face. He was taken to the local hospital ED where his eye was found to be swollen, which he preferred to keep closed, and he also had a painful rash over the left side of his face. He was admitted for further evaluation and management.

Figure 1. Notable swelling of the left eyelids.

Source: Brien JH

Figure 2. Notable swelling of the left eyelids.

Source: Brien JH

Figure 3. Erythema of the conjunctiva.

Source: Brien JH

The patient’s past medical history is significant for having type 1 diabetes mellitus for 1 year with very poor control (HbA1c level always > 10%), resulting in several prior hospitalizations, including a pediatric ICU stay for severe diabetic ketoacidosis. His immunizations are reported to be up-to-date, but no documentation could be found; his parents do not think he has ever had chickenpox. His family history is a bit chaotic with an older sibling who also has poorly controlled type 1 diabetes mellitus, but no one else has had a rash or been sick recently.

Examination revealed a normal-appearing, 10-year-old male with multiple fluid-filled lesions, with a few ulcerated and crusting lesions on his face and swelling of the left eyelids and erythema of the conjunctiva (Figures 1-3). The rest of his exam is normal, including all cranial nerve function. Admitting lab tests were normal except for his nonfasting glucose of more than 200 mg/dL. A sample of a lesion for herpes simplex virus and varicella PCR and routine culture are pending.


Case Discussion

Figure 4. Involvement of nasociliary branch of the ophthalmic nerve.

Source: Brien JH

Figure 5. Herpes simplex virus.

Source: Brien JH

This is a fairly good history and picture of a child with facial shingles, or varicella zoster of the face and left eye (B), involving the ophthalmic (V1) branch of the trigeminal nerve (CN V) — probably provoked by his poorly controlled type 1 diabetes. I was always taught that if the nasociliary branch of the ophthalmic nerve was involved (Figure 4), the chance of eye involvement was higher; as this case demonstrates of course, that is not a foolproof rule. Additionally, it is a common observation that the varicella zoster virus tends to reactivate during times of immunologic stress, and certainly, chronic diabetic ketoacidosis can fit that category.

Some might argue that we do not need a varicella PCR to make the diagnosis, and that may be true. In some cases, however, a small patch of vesicles may be caused by either herpes simplex or varicella virus and look the same. Since the treatment is different, with higher dosing for varicella virus than herpes simplex, it may help to know. The management of zoster ophthalmicus is with systemic antiviral therapy as topical does not work, as it does with herpes. However, ophthalmologists will usually treat zoster of the eye with topical steroids as well as medication for pain, such as scopolamine drops. As there can be significant damage to the eye, involvement of ophthalmology is always recommended.

Figure 6. Poison ivy dermatitis.

Source: Brien JH

Figure 7. Example of Rhinocerebral mucormycosis.

Source: Williams B

Another reason to know whether the skin and eye infection is varicella or herpes is that the treatment of the eye might include a topical antiviral agent such as trifluridine if due to herpes simplex. One other treatment recommendation we should keep in mind is that ophthalmologists recommend using either topical therapy or systemic therapy for herpes ophthalmicus; however, for the neonate, both are recommended according to the Red Book, which may differ from the advice of an ophthalmologist not familiar with the neonate.

Ramsay Hunt syndrome (named for James Ramsay Hunt, 1872-1937) arises when zoster occurs in the geniculate ganglion of the facial nerve (CN VII), with ipsilateral facial pain and paralysis with hearing loss or tinnitus. This condition was discussed in the January 2013 column of What’s Your Diagnosis?; see that column for the full details.

Cutaneous herpes with conjunctivitis could certainly resemble zoster (Figure 5, a case of HSV), if not for the fairly sharp line of demarcation of the dermatome. However, if the rash of zoster were a bit less, it may look just like a patch of cutaneous herpes zoster ophthalmicus.

Contact dermatitis can take on a wide variety of appearances, including a vesicular rash. One of the differences is the lack of dermatomal pattern (Figure 6, a patient with severe poison ivy dermatitis).

One last word about poorly controlled type 1 diabetes: This is the setting for other “opportunistic” infections, a classic example of which is the invasive fungal infection, Rhinocerebral mucormycosis (Figure 7, courtesy of Basil Williams, DO) that appeared in the What’s Your Diagnosis? column of December 1994.

Reminder: It’s time to get your high-risk patients, such as those with diabetes, to come in for their annual influenza immunization. Get one yourself while you are at it.

Disclosure: Brien reports no relevant financial disclosures.