Recurrent herpes infection showing a new facial phenotype: A case report

Abstract

BACKGROUND

Facial herpes is a common form of the herpes simplex virus-1 infection and usually presents as vesicles near the mouth, nose, and periocular sites. In contrast, we observed a new facial symptom of herpes on the entire face without vesicles.

CASE SUMMARY

A 33-year-old woman with a history of varicella infection and shingles since an early age presented with sarcoidosis of the entire face and neuralgia without oral lesions. The patient was prescribed antiviral treatment with valacyclovir and acyclovir cream. One day after drug administration, facial skin lesions and neurological pain improved. Herpes simplex without oral blisters can easily be misdiagnosed as pimples upon visual examination in an outpatient clinic.

CONCLUSION

As acute herpes simplex is accompanied by neuralgia, prompt diagnosis and prescription are necessary, considering the pathological history and health conditions.

Key Words: Facial herpes, Recurrent herpes infection, Cutaneous sarcoidosis, Herpes simplex virus, Herpes zoster, Varicella-zoster, Chicken pox, Immune system, Case report

Core Tip: Unlike common facial herpes, this case introduces a new pan-facial herpes symptom: Swollen redness on the patient’s entire face without herpetic vesicles. The patient had experienced recurrent infections with herpes simplex and herpes zoster viruses since the age of 7 years. On the visit day, the patient complained of headache and neuralgia; hence, a prompt antiviral prescription was advised based on the patient’s pathological history and current condition.

INTRODUCTION

In cases of fatigue and stress, people can be infected with herpes simplex virus-1 (HSV-1), which lies dormant in the nervous system[1]. It appears on the surface of the skin, especially in the face, nose, lips, and eyes. Orofacial herpes infection, also known as herpes labialis or cold sores, is caused by HSV-1 and commonly occurs as blisters or cold sores around the mouth and nose; it is rarely reported as a facial infection[2,3]. Many cases present with infections on the lip and near the mouth. Some rare cases have reported infections in the palate or nose caused by filler injection, eye infections known as herpes simplex ophthalmicus, and head infections known as herpes simplex encephalitis. Based on the specific visual characteristics of herpes, which are vesicular eruptions near the mouth and nose, most orofacial cases are first diagnosed through visual examination at an outpatient clinic. However, cases of facial HSV-1 infection are rarely identified and can be misdiagnosed as other dermatological diseases[4-6]. Here, we present the case of a 33-year-old female HSV-1 who was misdiagnosed.

CASE PRESENTATION

Chief complaints

A 33-year-old healthy woman complained of neuralgia that started at the periocular site and severe headache.

History of present illness

On that day, she visited two clinics and was misdiagnosed with urticaria and pimples. She then visited a third clinic. Considering the recent three consecutive days of her health condition (lack of sleep and physical burden), pan-facial herpes symptoms seemed to result in a weakened immune system, as manifested by cutaneous sarcoidosis.

History of past illness

She had a prescription history of antiviral drugs (14 days) for herpetic symptoms on the left forehead, assuming herpes encephalitis, from 2018 to 2019.

Personal and family history

According to the patient’s clinical history (Figure 1), the first herpes virus infection was varicella zoster at seven years of age. The second varicella zoster infection occurred when she was 18 years old and preparing for a national exam; she was diagnosed with shingles on the right side of her arm and abdomen with large multiple vesicles. When she was under a lot of stress at 29 years of age, unusual right-sided headaches often occurred on the same side as the prior skin rash, right side of her upper forehead, and blisters on her fingers. She was prescribed antiviral medication twice for suspected herpes zoster encephalitis symptoms between 2018 and 2019.

Figure 1 History of Varicella-zoster infection and herpes simplex virus in a 33-year-old woman.

Physical examination

Numerous small pimples covered the patient’s face, and the bilateral eyelids and cheeks were swollen (Figure 2A). However, few blisters or vesicles such as cold sore were identified on the face, and none were near the mouth, palate, or nose. Because of the numerous pimple-like redness, small vesicles at periocular sites are rarely distinguished from other skin diseases, such as acne and urticaria. When the patient washed and cleaned the lesions, multiple tiny vesicles, formed under the bilateral periocular sites, were observed.

Figure 2 The improvement of facial herpes before and after 16 hours of antiviral treatment. A: Before treatment, 1 day after reactivation of facial herpes; B: The second day, 16 hours after treatment taking valaciclovir and acyclovir cream.

Laboratory examinations

In this urgent situation, medication was prescribed based on the patient's herpes history without a polymerase chain reaction (PCR) examination.

FINAL DIAGNOSIS

Considering the patient’s pathological history, current health condition, and chief complaint, HSV-1 with a new form of facial herpes was suspected.

TREATMENT

Antiviral treatment was prescribed on the first day of treatment (Figure 3): Valtmax (Valaciclovir HCl Sesquihydrate) tablets (500 mg) three times a day for two days and acyclovir cream every 5 hours for two days.

Figure 3 Progression of weakened immune system conditions and facial herpes symptoms occurred in the healthy female patient. The day: The day facial herpes occurred, day + 1: One day after facial herpes occurred, the first day of drug prescription and antiviral drug and cream treatment, day + 2: Two days after facial herpes occurred, the second day of antiviral drug treatment and applying the cream.

OUTCOME AND FOLLOW-UP

On the second day of treatment (treatment day 2 in Figure 3), pan-facial herpetic symptoms disappeared (Figure 2B).

DISCUSSION

Facial HSV-1 is uncommon and can be easily misdiagnosed when vesicles are not present near the mouth[4-6]. The foremost option to accurately diagnose herpes virus subspecies in the clinic is PCR[7-10]. However, this test has a major limitation: In the case of small clinics in South Korea, it takes about 2-3 days from testing to receiving the results, which often results in patients not receiving prescriptions on time. Another delay in the timely treatment of herpes is the involvement of different departments based on the physical region affected: For example, dermatology for skin symptoms, otorhinolaryngology for nose and mouth herpetic lesions, ophthalmology for ocular lesions, dentistry for oral lesions, and neurology for infection of the facial nerve and neuralgia. Under these circumstances, patients with a long history and having several different presentations of herpes and varicella-zoster infections are difficult to accurately diagnose. Therefore, in this case, the diagnosis based on the history of herpes was more accurate because of the new facial presentation of herpes.

Whereas one symptom of herpes, recurrent cold sore, is well-known, recurrent infection of varicella zoster virus has been rarely reported. In one study, Heskel and Hanifin[11] reported “recurrent zoster,” misdiagnosed cases of herpes symptoms that appeared on the entire face of patients who had experienced recurrent herpes infections previously. Yamauchi et al[12] reported the recurrence of cutaneous sarcoidosis after herpes zoster infection. Similarly, Chovatiya and Silverberg[13] studied the association between herpes zoster and chronic inflammatory skin diseases in patients, including sarcoidosis (adjusted odds: 1.52), psoriasis (4.78), pemphigus (1.77), mycosis fungoides (3.79), dermatomyositis (7.31), systemic sclerosis (1.92), and cutaneous lupus erythematosus (1.94). Those studies and our case suggest that herpes zoster can vary in dermatological symptoms when a person is immuno-compromised. Still, recurrent infections or variations in the herpes virus have rarely been reported in longitudinal studies, and this is the first case of a new symptom on the face of a person with a long history of recurrent cross-infection between HSV-1 and varicella zoster virus. This case report is consistent with previous cases that imply that the long-term morbidity of varicella zoster virus could lead to unexpected physical symptoms of HSV-1.

CONCLUSION

This case demonstrated that those who experienced herpes zoster could be recurrently and acutely infected with a new form of HSV-1 and show inflammatory skin rash, such as cutaneous sarcoidosis, that is visually unlike commonly known herpetic symptoms. Facial herpes is often accompanied by neuralgia or headache and requires prompt antiviral treatment to prevent the development of severe nervous system diseases. In future studies, the association between acute inflammatory skin rashes such as cutaneous sarcoidosis and herpes subtypes should be studied using molecular tests.