Saturday, June 16, 2007

The Mask


Every day one sees something unique: either a new disorder or a singular variant of common process. A 90 yo woman was seen yesterday 3 - 4 week after the onset of Herpes zoster of the second division of the trigeminal nerve. She was left with an impressive escar covering a large portion of the dermatome. It was relatively easy to debride most of the escar off. No anesthesia was necessary. I'll affix a follow-up photo when I see her back. Follow-up care was with cool compresses and Silvadene cream.

This woman lives alone, drives her own car and is the family matriarch. Hopefully, the zoster will not derail her.

The above photo is a bit out of focus. My fault.


Same Patient -- Three days later. Note involvement of nasal tip. 2nd branch of trigeminal but with nasal tip involvement (and patient had sorneal ulcer!) indicating perhaps involvement of nasociliary branch of trigeminal (which should not happen) -- aberrant innvervation? She seems much brighter today and not complaining of much pain.

Six Weeks Later

The patient's skin has healed nicely but she has persistent numbness around left ala and left naso-labial fold. Also lancinating episodic pain and resultant depression. A neurologist has put her on Neurontin which I do not feel is helpful. Post-herpetic neuralgia is a complex disorder and I think there's a huge "illness behavior" component. I don't think pharmacotherapy is the answer. Nonetheless, I gave her EMLA cream to use.

1 comment:

  1. I have never seen such severe herpes zoster on the face - I had a patient with zoster with severe secondary infection at L2, 3 dermatome.

    In my practice, we would send culture and sensitivity, screen for diabetes and treat with oral antibiotics too eg cefuroxime.

    This is really impressive!!


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