Zoster Neuropathy: Rare Diagnosis in Atypical Facial Pain not Responding to Treatment

Case Study: Case with atypical facial pain: We report the case of a 15-year-old boy with a one-sided, sudden initiating and in attacks (duration from minutes to hours) proceeding headache and facial pain. He described it as piercing, strong (NRS 8/10), localized behind the right eye and in the right forehead with tearing and light sensitivity, responding on ibuprofen and resting/sleeping. There was no history of migraine, just occasional slight tension headache. Ophthalmologic (intraocular pressure and optic nerve) and neurologic examination, cMRI, and CSF investigation were normal. EEG showed unspecific occipital deceleration.

Differential Diagnosis: We considered diverse facial pain syndromes as cluster headache, SUNA-syndrome, and paroxysmal hemicrania. Diagnostic criteria for trigeminal nerve neuralgia were not convenient and features for trigeminal nerve neuropathy were lacking.

Diagnosis: A second ophthalmologic investigation (3 days later) showed single vesicles below the right upper lid, so a herpetic blepharoconjunctivitis was probable. Serum antibodies (IgM) against varicella zoster virus could subsequently be detected. Treatment with intravenous acyclovir and cefuroxime was followed.

Treatment of Pain and Course: We tried at first oxygen, then sumatriptan, both without having effect on pain and autonomic symptoms, piritramide relieved pain hardly.

In course, worsening and more lasting pain Tramadol was not effective but oxycodone/naloxone in combination with gabapentin and amitriptyline in escalating doses. Carbamazepine was not well tolerated, but oxcarbazepine was. He responded well to twice done nerve block anesthesia at right supraorbital nerve with ropivacaine.

Medication could be gradually reduced along 9 weeks (at first oxycodone and at last gabapentin) without relapse of pain or autonomous symptoms.

Conclusion: Herpes zoster with few or without vesicles (Zoster without Zoster) should be considered in atypical pain or unknown etiology, also in children and adolescents. Treatment may be difficult and take some trials, but should be initiated rapidly and forced.

Keywords: diagnosis of atypical facial pain, Zoster neuropathy, nerve block anesthesia.