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Journal Français d'Ophtalmologie
Volume 40, n° 7
pages e255-e256 (septembre 2017)
Doi : 10.1016/j.jfo.2016.07.030
Lettres à l'éditeur

Orbital cellulitis due to ophthalmic herpes zoster in an immunocompetent child: A case report
Cellulite orbitaire secondaire à un zona ophtalmique chez un enfant immunocompétent : à propos d’un cas
 

S. El Hamichi , R. Messaoudi, B. Moujahid, A. Alsubari, N. El Ouatassi, K. Reda, A. Oubaaz
 Service d’ophtalomogie, hôpital militaire d’instruction Mohammed V, Rabat, Morocco 

Corresponding author. BP 5142, 93000 Tetouan, Morocco.
Introduction

Varicella zoster virus (VZV) is a human neurotrophic alpha herpes virus [1]. The primary infection of this virus causes varicella. Herpes zoster is caused by reactivation of the dormant virus in immunosuppressive conditions [2]. Neurological complications due to VZV are uncommon when the patient is immunocompetent. In the literature, only a few cases were reported, and they most usually involved either adult or senior patients [3, 4]. The occurrence in immunocompetent children is rarely reported [5].

Orbital cellulitis is the major infection of the ocular adnexal and orbital tissues, and is potentially sight and life threatening.

Our case represents the association of two conditions: orbital cellulitis and VZV reactivation, requiring urgent investigation and treatment to prevent the severe complications of both.

Case report

A thirteen-year-old male arrived at the emergency room for left periorbital edema, pain and erythema with fever evolving within the previous 24hours. Three days before, the parents had noticed the appearance of maculopapular skin lesions, which quickly transformed into vesicles localized on the forehead. No other symptoms were reported. The patient's medical history revealed a varicella infection at the age of two, which was not treated with any antiviral therapy or vaccination at that time.

Examination at admission showed a temperature of 38.3°C with unremarkable vital signs, with edema, ptosis and redness of the left eyelid, causing difficulty opening the eye. Herpetiform vesicles were limited to the territory of the ophthalmic branch of the trigeminal nerve V1 (Figure 1).



Figure 1


Figure 1. 

Preseptal cellulitis (edema, ptosis and redness of the left eyelid) with herpetiform vesicles on the territory of the trigeminal nerve V1.

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The ophthalmic examination did not show any exophthalmia. There was no loss of visual acuity or limitation of ocular movement or elevated intraocular pression (14mmHg). The biomicroscopy of the anterior segment with a fundus examination were normal.

Given the clinical and paraclinical data, we diagnosed a cellulitis resulting from ophthalmic zoster lesions in an immunocompetent boy.

The orbito-cerebral scanner revealed a preseptal cellulitis: grade 1 of Chandler classification (Figure 2). The routine laboratory examination including hemogramma (1700 lymphocytes/μL), blood ionogramma were within the normal limits. The results of immunological screening for HIV were unremarkable. The C-reactive protein was increased (95mg/L).



Figure 2


Figure 2. 

Tomodensitometry showing a grade 1 Chandler orbital cellulitis (equivalent to preseptal cellulitis where the infection is anterior to the orbital septum).

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The patient was then hospitalized in the ophthalmology department. The treatment was based on the antiviral therapy: oral valaciclovir (3g per day for 7days) and local fucidine dermathological ointment. General corticosteroids were also added 48hours after the initial treatment.

The patient's temperature was back to normal 24hours after treatment; swelling and redness disappeared 48hours after treatment. The patient was discharged with daily follow-ups. The recovery was complete after 10 days (Figure 3).



Figure 3


Figure 3. 

Patient follow-up 10 days after valaciclovir treatment with almost complete recovery.

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Discussion

Elderly and immunocompromised patients are usually the ones affected by herpes zoster. Decreasing cell-mediated immunity is considered the main factor of the increased risk of herpes zoster [6, 7]. This could explain the few number of cases reported of immunocompetent children [1, 3].

The results of the biological tests of this patient were normal, though a normal immune system does not completely protect from VZV reactivation.

VZV is generally considered to be self-limiting [8]. However, a localized infection may disseminate throughout the orbital tissues and cause an orbital cellulitis [9].

Orbital cellulitis rarely causes complete loss of vision if treated in a timely fashion. It is commonly due to sinusitis, or dacryocystis and less frequently associated with cutaneous infection. For simplification, Chandler classified the disease into five categories and emphasized the possibility of fatality due to cavernous sinus thrombosis and intracranial abscess [10].

Conclusion

Orbital cellulitis frequently appears in children, though the cause can be unusual. The reactivation of varicella zoster virus should be considered in immunocompetent children, it could have many aspects. This fact raises questions about the mechanism to explain this issue.

Disclosure of interest

The authors declare that they have no competing interest.

References

Pahud B.A., Glaser C.A., Dekker C.L., Arvin A.M., Schmid D.S. Varicella zoster disease of the central nervous system: epidemiological, clinical, and laboratory features 10 years after the introduction of the varicella vaccine J Infect Dis 2011 ;  39 : 316-32310.1093/infdis/jiq066 [cross-ref]
Yoshiki Miyachi M.D., Yoshiaki Yoshikawa M.D., Miki Tanioka M.D. Bilateral disseminated herpes zoster in an immunocompetent host Dermatol Online J 2016 ;  19 : 13
Han J.Y., Hanson D.C., Way S.S. Herpes zoster and meningitis due to reactivation of varicella vaccine virus in an immunocompetent child Pediatr Infect Dis J 2011 ;  39 : 266-26810.1097/INF.0b013e3181f63cf9 [cross-ref]
Nahdi I., Boukoum H., Ben N., Salem A.B.M. Detection of herpes simplex virus (1 and 2), varicella-zoster virus, cytomegalovirus, human herpesvirus 6 and enterovirus in immunocompetent Tunisian patients with acute neuromeningeal disorder J Med Virol 2012 ;  39 : 282-28910.1002/jmv.23192 [cross-ref]
Archana Singal, Shilpa Mehta, Deepika, Pandhi Herpes zoster with dissemination Indian Pediatr 2006 ;  43 : 353-356
Gilden D., Nagel M.A., Cohrs R.J., Mahalingam R. The variegate neurological manifestations of varicella zoster virus infection Curr Neurol Neurosci Rep 2013 ;  39 : 374 [cross-ref]
Nagel M.A., Gilden D. Complications of varicella zoster virus reactivation Curr Treat Options Neurol 2013 ;  39 : 439-453 [cross-ref]
Lee K.G., Cheng M.O. Varicella-zoster infection with secondary bacteremia and extensive facial abscesses Med J Malaysia 2012 ;  67 : 529
Bullok J.D., Fleishman J.A. Orbital cellulitis following dental extraction Trans Am Ophthalmol Soc 1984 ;  82 : 111-133
Chandler J.R., Langenbrunner D.J., Stevens E.R. The pathogenesis of orbital complications in acute sinusitis Laryngoscope 1970 ;  80 : 1414-1428 [cross-ref]



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