Ibrahim A, Ahmed M, Conway R, Carey JJ Risk of infection with methotrexate therapy in inflammatory diseases: a systematic review and meta-analysis. J Clin Med. 2018; 8 https://doi.org/10.3390/jcm8010015
Pupic-Bakrač A, Pupić-Bakrač J, Gabrić I Herpes zoster opthalmicus-related ophthalmoplegia: anatomical, pathogenetic, and therapeutic perspectives. J Craniofac Surg. 2022; 33:2463-2467 https://doi.org/10.1097/SCS.0000000000008631
This is a case report of a patient seen on the dental emergency clinic that describes ophthalmic shingles reactivation soon after a tooth extraction with the potential to have led to a misdiagnosis of the condition. This can potentially have serious consequences, including effects on vision. This case report emphasizes the importance of a thorough history and careful examination when a patient presents in an urgent setting.
CPD/Clinical Relevance:
The importance of a thorough history and careful examination is highlighted.
Article
A 50-year-old female patient presented post-operatively at the dental emergency clinic with a significant facial swelling affecting her left upper cheek and peri-orbital area. Relevant medical history included treatment for long-standing rheumatoid arthritis with methotrexate.
The patient had initially attended 9 days prior for an extraction of the UL6 owing to irreversible pulpitis, and then again 5 days post-operatively because of the worsening pain. At this point, the suppuration from the socket led to a diagnosis of a post-operative infection, and which was managed with socket irrigation and oral antibiotics.
On the third visit to the clinic, 9 days post-extraction (and therefore, 4 days after starting antibiotics), the patient complained of swelling around her eye, which had been getting worse for a few days and the eye was now difficult to open (Figure 1). She also complained of ‘spots which have stuff coming out of them’ on the face, referring to a clear discharge. The patient felt sure that the extraction had caused the swelling.
Figure 1. Timeline of the patient's presentations to the dental emergency clinic.
The patient's vital signs were measured and recorded on a National Early Warning Scale 2 (NEWS2) chart. NEWS2 is a scoring system for monitoring a patient's physiological parameters (such as blood pressure and oxygen saturation). This allows healthcare professionals to be alerted of any deterioration promptly. It is a departmental protocol to initiate NEWS2 for patients who present with a facial swelling, or who feel systemically unwell, in order to identify acutely unwell patients. The patient's results were within normal range for all six physiological parameters that are measured. Her tympanic temperature was 37.4°C.
Extra-orally, the patient's left eye was swollen and closed at rest (Figure 2). An eye examination was carried out by prying the eyelids open with gentle finger pressure. The eye mobility was unaffected on testing the cranial nerves, with no diplopia or proptosis. Visual acuity testing was assessed using a Snellen chart and was normal for the patient.
Figure 2. Extra-oral photograph showing swelling affecting the left peri-orbital area.
There was a vesicular rash present with a crusted appearance that affected the left forehead (Figure 3), extending just onto the scalp (Figure 4).
Figure 3. Vesicular rash with some scabbing seen on left forehead.Figure 4. Extension of vesicular rash onto scalp.
Intra-oral examination revealed a healing socket in the UL6 area, with no evidence of suppuration or intra-oral vesicles.
Owing to the distribution of the vesicles and swelling, a diagnosis of herpes zoster ophthalmicus (HZO) also known as ophthalmic shingles was made. This condition is caused by reactivation of latent varicella zoster virus (VZV), also known as human herpes virus-3 (HHV-3) within the ophthalmic division of the trigeminal nerve. The diagnosis was made on clinical findings, although confirmation with a swab of the vesicles to test for the presence of HHV-3 could also have been carried out.
The patient was prescribed oral aciclovir (800 mg five times a day for 7 days) and, owing to the risk to the eye, was also seen by the eye casualty clinic as a precaution. She was discharged by that clinic without follow-up, but was advised to re-attend if she noticed any changes to visual acuity, any onset of diplopia or redness of the eye.
Discussion
This case highlights the importance of thoroughly explaining to the patient that correlation, or in fact even coincidence, does not equal causation. The patient was sure her post-operative pain was directly caused by the infected tooth socket. It was explained to the patient that the swelling had been caused by the herpetic reactivation, which was a result of her being run down, and not directly due to the extraction. However, the patient's initial dental pain had affected her ability to eat and sleep, as has the post-operative tooth socket infection on day 5. Therefore, overall, these events has contributed to the patient feeling run down, which potentially predisposed her to herpetic reactivation. Additionally, the methotrexate medication for the treatment of the patient's rheumatoid arthritis is an immunosuppressant, and may increase the risk of infection and reactivation of the HHV-3.1
Conclusion
Herpes zoster ophthalmicus is a serious condition with the potential for long-term repercussions, including permanent ophthalmoplegia (paralysis or weakness of the eye muscles).2 To reduce the chance of long-term complications, it is important that antiviral treatment is initiated promptly. Furthermore, prompt referral to ophthalmology should be completed to ensure the patient is followed up and treated should any complications arise. Examples of complications include keratitis, uveitis, iritis, corneal ulceration, permanent lid ptosis and post-herpetic neuralgia, all of which have the potential to worsen vision.3 Any misattribution of symptoms exclusively to a dental cause in this case therefore could have had a serious impact on the patient's health.
