Purpose

Objectives: To report a rare presentation of herpes zoster ophthalmicus presenting with dacryoadenitis preceding the cutaneous eruption, mimicking preseptal cellulitis in a young postpartum patient.

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Methods

Methods: Single case review with clinical examination, orbital imaging, broad immunology workup and viral PCR/serology.

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Results

Results: A 39-year-old woman, four weeks postpartum, presented with one week of headache and progressive left upper lid swelling and erythema, associated with pain. She presented with progression after five days of treatment for presumed preseptal cellulitis with oral Co-Amoxiclav, and subsequent intravenous Ceftriaxone by our emergency care colleagues. There was no improvement and CT orbital imaging was requested which demonstrated lacrimal gland enlargement consistent with dacryoadenitis and excluded orbital cellulitis. A vesicular rash subsequently developed over the left forehead and temple one week later.

Oculoplastic assessment showed upper lid swelling with an S-sign, vesicular eruption in the first trigeminal division, inferior punctate epitheliopathy, full motility, stable acuity and a quiet anterior chamber, with no intraocular involvement on dilated fundoscopy examination. There was no proptosis. Immunology blood workup included ACE, syphilis, HIV, ANA, ANCA, ESR, CRP, rheumatoid factor, TFTs, TSH-receptor antibody, IgG4 and other immunoglobulins, were negative.

The ocular surface swab was negative for herpes simplex and positive for varicella-zoster virus by PCR. Serum VZV IgG was elevated, in keeping with prior varicella and supporting reactivation. Aciclovir 800 mg five times daily with ocular surface lubrication produced significant improvement within days.

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Conclusion

Conclusions: Herpes zoster ophthalmicus very rarely presents with dacryoadenitis as the initial feature, mimicking preseptal cellulitis and delaying antiviral treatment. HZO should be included in the differential of acute orbital inflammation. Ocular surface PCR with a structured workup confirms the diagnosis and enables appropriate treatment.

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Additional Authors

First name	Last name	Base Hospital / Institution
Fiona	Jazayeri	Buckinghamshire Healthcare NHS Trust

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