A 70-year-old man presented with a two day history of facial edema, vesicular rash and burning pain along the left lower jaw. Three days before the outbreak of the rash, the patient complained of glossodynia, otalgia and pain in the lower half of the face. Clinical examination revealed no neurologic deficits, meningeal signs or lymphadenopathy. The vesicular rash was scattered along the dermatome innervated by the madibular division of the trigeminal nerve. There was no facial palsy or hearing loss observed. On oral examination, the vesicular lesions were also present along the anterior two thirds of the left half of his tongue.
A clinical diagnosis of herpes zoster madibularis was made. Herpes zoster is a viral infection that occurs with the reactivation of varicella zoster virus. The infection is usually self-limiting but painful. Symptoms typically appear with pain and vesicular eruption after a time period of 2 to 3 days. Classical clinical findings include a vesicular rash and pain along the affected dermatome. Treatment is given within 72 hours of the onset of symptoms and includes anti-viral medication valacyclovir, famciclovir and acyclovir.
The acute viral disease mostly affects individuals aged 60-70 years and older than 80 years. The infection is as a result of the reactivation of varicella zoster virus that remained dormant in the root ganglion of trigeminal nerve after clinical manifestation of chicken pox. Additionally, younger patients with immunosuppression are also more susceptible to the infection.
Enterovirus and herpes simplex virus were considered to be less likely considering the distribution of the rash. The patient was treated with acyclovir, nystatin, analgesic agents (including gabapentin) and an antibiotic agent for bacterial superinfection.
However, a month after the facial rash improved, the patient complained of postherpetic neuralgia in the innervated dermatome.
Postherpetic neuraligia is the most common complication of shingles that causes a burning pain that lasts along the nerve fibres and skin that lasts long after the rash has disappeared. Moreover, the 70-year-old patient complained of moderate to severe pain for approximately 4 months after resolution of the rash. The pain subsided after this time.
The patient was asymptomatic after 6 months of the resolution of the rash and had stopped taking gabapentin.
References
Afonso, T., & Pires, R. (2016). Herpes zoster mandibularis. New England Journal of Medicine, 375(4), 369-369.
