Herpes zoster - Oral Mucosal Lesion
Clinically, herpes zoster usually has a prodromal phase characterized by neuralgia. Fever, malaise, and headache are normally present 1-4 days before formation of cutaneous or mucosal lesions. As the virus travels down the nerve, the pain intensifies and has been described as burning, tingling, itching, boring, prickly, or knife-like. The pain develops in the area of epithelium innervated by the affected sensory nerve (dermatome).
The first, second, or third division of the trigeminal nerve may be involved, and oral lesions would be associated with the same affected cutaneous or intraoral region innervated by the latter two divisions. The oral lesions can present on either keratinized or non-keratinized oral mucosa and classically terminate at the midline. Like varicella, the individual lesions present as 1-4 mm vesicles, which usually rupture to form shallow ulcerations. In the maxilla, devitalization of teeth and bony necrosis are possible in the affected area.
The involved skin develops clusters of vesicles set on an erythematous base. Within 3-4 days, the vesicles become pustular and ulcerate, with crusts developing after 7-10 days. The lesions tend to follow the path of the affected nerve and terminate at the midline. The exanthem typically resolves within 2-3 weeks in otherwise healthy individuals.
Ocular involvement is not unusual and can be significant, including permanent blindness. If the tip of the nose is involved, this is a sign that the nasociliary branch of the fifth cranial nerve is involved, suggesting the potential for ocular infection. In these cases, referral to an ophthalmologist is mandatory.
A major concern after a zoster outbreak is the postherpetic neuralgia (PHN), defined as pain and neuropathic symptoms that persist in a dermatome one month beyond resolution of the rash. Risk factors for PHN include older age, female sex, presence of a prodrome, and greater rash severity and acute pain. Postherpetic neuralgia can be intractable and debilitating, and prevention is an important goal.
Cerebrovascular accidents, peripheral motor neuropathies, neurogenic bladder, and diaphragmatic paralysis have been associated with zoster. Herpes zoster encephalitis usually appears in the first 2 weeks after the onset of lesions and it has a 10%-20% mortality rate. Lesions may also be at risk for bacterial superinfection. In extreme cases, necrotizing fasciitis may occur.
B02.9 – Zoster without complications
4740000 – Zoster
- Ramsay-Hunt syndrome – Dissemination can occur, particularly in the immunocompromised. This syndrome consists of vertigo, ipsilateral facial weakness, and deafness (with auditory nerve involvement). Involvement of the nasociliary branch of the ophthalmic nerve increases the risk of ocular complications such as conjunctivitis, lid ulcerations, keratitis, glaucoma, optic neuritis, optic atrophy, and panophthalmitis.
- Herpes simplex virus (HSV) – Lesions may cross the midline and present with similar shallow ulcerations but with more focal involvement. They present extraorally on the skin or vermilion zone of the lip (herpes labialis) and intraorally on the gingiva and hard palate and dorsum of tongue.
- Aphthous ulcer (canker sore) – Presents as single or multiple painful intraoral ulcerations limited to movable, nonkeratinized mucosa. They may have a unilateral distribution but will not be found on the hard palate or attached gingiva.
- Herpangina – Ulcers are generally located in the posterior oral cavity and oropharynx; with fever and malaise typical for a viral infection.
- Hand-foot-and-mouth disease – Patients present with involvement of the hands and feet; with fever and malaise.
- Pemphigus vulgaris – Bilateral ulcerations that do not correspond to the distribution of the nerve.
- Paraneoplastic pemphigus – Severe ulcerations of the oral cavity, bilateral, with hemorrhagic scabs of the lips and concomitant underlying malignancy.
- Necrotizing sialometaplasia – Unilateral single ulcer of the hard or soft palate resulting from ischemia, with a specific histopathology.