Herpes Zoster: A Case Report of a Rare Ramification Leading to Secondary Infection

Abstract

The herpes virus causes herpes zoster (HZ) (shingles). It develops years later in elderly patients who were affected by the varicella-zoster virus in their childhood. The virus gets reactivated and typically localizes its symptoms to a particular dermatome. If left untreated, it can lead to dental complications, such as osteonecrosis, tooth exfoliation, periodontitis, calcified and devitalized pulps, periapical lesions, and root resorption, in addition to developmental irregularities, such as abnormally short roots and missing teeth. Here, we present the case of a 61-year-old male affected by a rare bacterial superinfection followed by an HZ infection. Our report aims at making clinicians aware of the various potential complications that can develop after an HZ infection.

Keywords: actinomycotic osteomyelitis; bacterial superinfection; herpes zoster; post-herpetic neuralgia; shingles.

Figure 1. Extraoral swelling.

Diffused extraoral swelling with scars limited to the left maxillary and mandibular division of the trigeminal nerve.

Figure 2. Multiple ulcers involving multiple areas of the oral cavity limited to the left trigeminal nerve distribution.

a: Ulcers involving the left retromolar region and the buccal mucosa. b: Ulcers involving the left side of the hard palate without crossing the midline. c: Ulcers involving the left side of the upper and lower lip.

Figure 3. Post-treatment.

a: Evidence of resolved scars with pigmentation. b: Evidence of resolved ulcers in the hard palate, upper lip, and lower lip. c: Evidence of resolved ulcers in the retromolar region and the buccal mucosa.

Figure 4. Evidence of gingival inflammation with pus discharge in relation to the 21, 22, 23 region.

Figure 5. Intraoral periapical radiograph and occlusal radiograph.

a: Intraoral periapical radiograph showing ill-defined periapical radiolucency with bone loss in relation to the 21, 22, 23 region. b: Occlusal radiograph revealing mixed radiopaque and radiolucent area superior to periapical radiolucency with altered trabeculae pattern in relation to the 21, 22, 23 region (red arrow).

Figure 6. Computerized tomography of the paranasal sinuses with three-dimensional reconstruction.

a: Three-dimensional reconstruction revealing bony erosion involving the left alveolar process. b: The sagittal view revealing bony erosion involving the left alveolar process and the hard palate involving the pre-molar region. c: The coronal view revealing fistula formation between the oral cavity and the maxillary sinus.

Figure 7. Histopathological picture.

a: The section shows connective tissue stroma with mixed inflammatory cell infiltration predominantly lymphocytes, plasma cells, and neutrophils surrounding numerous areas of bacterial colonies along with Splendore–Hoeppli phenomenon (red arrow). b: The section shows basophilic radiating filaments (blue arrow).

Figure 8. Intraoral image post-treatment with ceftriaxone 1 g.