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Ophtalmic Herpes Zoster in Patient with Systemic Lupus

Erythematosus

Tania Jessica, Padmawati I. G. A. Dian Intan, Puspawati Ni Made Dwi

Department of Dermatology and Venereology, Medical Faculty of Udayana University/Sanglah Public Hospital, Bali,

Indonesia

Keywords: Ophtalmic herpes zoster, OHZ

Abstract: Ophtalmic herpes zoster (OHZ) might manifest as pain and cutaneous rash limited to periocular region, but

occular involvement have been reported in imunocompromised patients. We present a case report of

ophthalmic herpes zoster in a patient with systemic lupus erythematosus who receive immunosuppressive

therapies to add up to the literature about risk factors and management of OHZ. The diagnosis was

established by the findings from history, physical examination, and supporting examination. The

management of this was conducted collaboratively with Departments of Internal Medicine and

Opthtalmology. The prognosis of this case was dubious due to the higher risk of recurrency associated with

the ongoing immunosuppression therapy.

1 INTRODUCTION

Ophtalmic herpes zoster (OHZ)occurs in 10% to

20% of all herpes zoster cases. This condition might

manifest as pain and cutaneous rash limited to

periocular region, but 50%-72% cases have

demonstrated occular involvement with varied

clinical manifestation and degree of severity (Vrcek

et al, 2017). Several studies have reported the higher

rate of herpes zoster infection among

immunocompromised patients than the general

population, including patients with systemic lupus

erythematosus (SLE) who receive

immunosuppressive therapies (Cohen, 2013).

This

paper reports a case of ophthalmic herpes zoster in a

patient with SLE who underwent chemotherapy with

intraveonous cyclophosphamide to add up to the

literature about risk factors and management of

OHZ.

2 CASE

The patient was a 21-year-old Balinese Indonesian

female with SLE. She was consulted from the

Department of Internal Medicine with vesicles in the

right forehead and around patient’s right eye since

three days before consultation day. These painful

and non itchy vesicles initially appeared in the

forehead. They had been increasing in numbers,

some had coalesced, and furtherthese vesicles

extended to the patient’s right eye. The patient then

complained about red, watery, painful right eye and

trouble with opening it. These complains also

presented with fever. No medications had been

taken, including topical treatement. The patient had

a history of varicella during childhood.

The patient was currently receiving 500mg pulse

dose metilprednisolone within 250cc sodium

chloride 0.9% for 3 days, followed by intravenous

62.5mg metilprednisolone every 12 hours for 5 days,

then intravenous 62.5 mg metilprednisolone every

24 hours for, anda maintenance dose of 16 oral

prednisolones every 12hours. She had also received

one cycle of chemotherapy with 500 mg

cyclophosphamide within 250cc sodium chloride

0.9%.

During the examination, the patient demonstrated

normal vital sign, mild pain (visual analog

scale/VAS: 2), and right eye visual acuity of 6/15.

Vesicles and crusts presented in the edematous right

eyelid. The dermatological examination of the right

frontal region, right upperlid (in concordance with

the dermatome of the ophthalmic branch of the

trigeminal nerve) revealed efforescence of multiple

vesicles, some had coalesced and formed rounded

geographical bullaes with sizes ranging from 0.1 x

Jessica, T., Dian Intan, P. and Dwi, P.

Ophtalmic Herpes Zoster in Patient with Systemic Lupus Erythematosus.

DOI: 10.5220/0008157803770380

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 377-380

ISBN: 978-989-758-494-7

377

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0.2 cm to 0.5 x 0.8 cmabove the erythematous skin

surface, as illustrated in Figure 1.

Figure 1: Findings of dermatological state examination

day 1.

Complete blood count revealed lowered values

red blood cellsmeasure-ments and blood chemistry

demonstrated increasedvalues of liver enzyme tests,

blood urea nitrogen, and lowered albumin. The

Tzanck smear of specimen from scrapping of the

bullae base showed multinucleated giant cells.

The diagnosis of the patient was ophthalmic

herpes zoster that was in concordance with the

dermatome of trigeminal nerve’s ophthalmic branch.

She was treated with 800 mg oral acyclovir every 5

hours (day 1) for 10days, 500 mg oral paracetamol

tablet every 8 hours (if fever arose), oral vitamin B1,

B6, B12 tabletsevery 24 hours, 500 mg oral

mefenamic acid tablet every 8 hours (if required),1%

salicyl powder + 0.5% menthol applied in the

bullous lesions every 12 hours. The patient also

received explanations about her condition, planned

treatment, and possible complications. She was also

consulted to the Department of Ophtalmology who

subsequently diagnosed her with right ophthalmic

blepharoconjunctivitis and provided gentamycin eye

ointment every 8 hours and 1 drop of levofloxacin

and lyteers every 4 hours for the right eye. The

maintenance prednisolone dose was continued by

Department of Internal Medicine, and the second

cycle of cyclophosphamide chemotherapy was

delayed until the skin lesions had improved.

Further follow up on day 11 revealed that the

bullae had resolved and left erosions on the

erythematous skin surface partially covered by dark

brown crusts. No new lesions nor fever were

reported, and the pain improved.

Acyclovir and paracetamol were no longer

administered but the mefenamic acid and vitamin

tablets were resumed. Fifteen minutes open dressing

with 0.9% Sodium cchloride 0,9% was conducted

every 8 hours on the erosive lesions, and 2% Sodium

Fusidate cream was applied to the lesion every 12

hours afterwards. The patient also continued to

receive levofloxacin and lyteers drops.

The examination on day 18 revealed that much

of the lesions had dried (Figure 2). No pain, no

itchiness, no new lesions, and no fever were

encountered. The mefenamic acid was no longer

administered while vitamin tablets, open dressing

with 0.9% sodium chloride, and the application of

2% Sodium Fusidate cream was continued. The

Department of Ophtalmology stopped the

administration of levofloxacin drop, but continued

the lyteers and added gentamycin eye ointment

every 8 hours.

Figure 2: Findings of dermatological state examination

day 18.

3 DISCUSSION

Cutaneous manifestation of SLE presents in 75%

patients and serves as an early sign in about quarter

of the cases (Kuhn et al, 2013).

These patients have

11-23 higher risk for infection than the general

population, and herpes zoster is the most common

viral infection encountered (Sayeeda et al, 2010).

Herpes zoster infection might present in the form of

ophthalmic herpes zoster (OHZ) marked by the

occurrence of inflammation in the eye, intraneural,

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and perineural of the sensory nerve. OHZ frequently

presents with dermal eruptions that are in

concordance with the dermatome, but occular

involvement is uncommon.

An imminulogical study in patient with SLE

showed a breakdown of cell mediated immune,

delayed of hypersensitivity reaction, and hyperactive

humoral immune system. The side effect from high

dose corticosteroids therapy and other

immunosuppresive agents alsocan decrease host

resistency to some infections. The activity of

disesase, nephritis lupus, and positive Sm-antibody

have been reported as risk factors of herpes zoster in

SLE (

Leroux, 2016).

This case reported a 21-year-old female with

SLE who was consulted from the Department of

Internal Medicine due to the emergence of vesicles

in the right forehead and around the patient’s right

eye. This patient was also under treatment oh high

dose and long term therapy with immunosuppresive

agents such as cyclophosphamide and

corticosteroids.

The diagnosis of OHZ was then established

from the history, physical examination, and

supporting examination. This patient presented with

effloresence of multiple vesicles, some of them had

coalesced and formed bullaes on the erythematous

skin of right frontal region and right upper lid (in

concordance with the dermatome of the ophthalmic

branch of the trigeminal nerve). These clinical

features were in concordance with the diagnosis of

OHZ (Vrcek et al, 2017). In addition, the Tzanck

smear with Giemsa staining revealed multinucleated

giant cells. Other modalities to establish the

diagnosis might include the histopathological

examination, viral culture, polymerase Chain

Reaction (PCR), and serological tests (

Schmader and

Oxman, 2012

However, due to the possibly longer

duration to obtain results and cost effectiveness

consideration, these test were not conducted in the

patient.

The management of OHZ is similar to the herpes

zoster infection in general, but additional eye

management should be conducted. The management

should attempt to decrease viral replications,

accelerate recovery, relieve pain, and prevent

complications (Dail and Makes, 2002). This includes

the main therapy with antivirals, added with

supporting therapies such as analgetics and topical

therapies both for the skin and the eye (Dworkin et

al, 2007). The patient in the case received 800 mg

acyclovir ever 5 hours for 10 days, added with oral

mefenamic and vitamins B1, B6, B12.Open dressing

and sodium fusidate cream were provided for the

skin treatment, while gentamycin eye ointment and

lyteeers were provided for the eye.

The prognosis of OHZ is generally favorable, but

patients older than 70 years old or who are

immunocompromised are at higher risk of

recurrence (Armando et al, 2015). The most

common complication of herpes zoster infection is

post herpetic neuralgia. In 9% cases, this pain might

last for a period that ranges from 4 weeks to 10

years. In this case report, the patient was a 21-year-

old female who showed improvement after

collaborative treatments. However, due to the

ongoing immunosuppression therapy for her SLE,

her prognosis was dubious, with a higher risk of

recurrent herpes zoster infection than the general

population.

4 CONCLUSION

This case report presented the occurrence of

opthtalmic herpes zoster in a patient with SLE. The

diagnosis was established by the findings from

history, physical examination, and supporting

examination. The management of this was

conducted collaboratively according to the available

recommendations. The prognosis of this case was

dubious due to the higher risk of recurrency

associated with the ongoing immunosuppression

therapy.

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