Herpes Reactivation Following Posterior Fossa Surgery: A Case Series

Abstract

Herpes reactivation following posterior fossa surgery is an underrecognized but clinically significant complication. This case series describes three patients who developed herpes labialis within 3 to 4 days after posterior fossa surgery involving the trigeminal nerve. Surgical stress, direct nerve manipulation, and perioperative corticosteroid use likely contributed to reactivation. Prompt diagnosis and early antiviral therapy with acyclovir led to complete resolution in all cases. These findings highlight the need for greater awareness, early recognition, and potential prophylactic antiviral use in high-risk neurosurgical procedures to prevent herpes-related complications.

 

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Keywords

herpes virus - herpes reactivation - posterior fossa surgery - herpes labialis - acyclovir

Introduction

Traditionally associated with trigeminal nerve activation, herpes simplex virus 1 (HSV-1) and herpes zoster infections have long intrigued researchers and clinicians. While HSV-1 typically manifests mildly in infancy or early childhood before establishing a dormant presence within the trigeminal ganglion, the onset of herpes zoster, commonly known as chickenpox, occurs in a similar timeframe. Despite their dormancy, both viruses can reactivate due to various triggers, ranging from hormonal fluctuations to neurosurgical interventions like microsurgical decompression of the trigeminal nerve root. Reactivation can lead to complications ranging from mild herpes labialis to potentially serious sequelae such as keratoconjunctivitis, meningitis, or encephalitis if unrecognized or untreated.

To emphasize the importance of postoperative herpes reactivation following posterior fossa surgery and discuss the potential role for antiviral prophylaxis in selected high-risk neurosurgical patients, our series sheds light on this phenomenon observed in three patients who underwent similar procedure. These individuals subsequently experienced herpes labialis.

 

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Case 1

A 37-year-old female presented with complaints of persistent headache, diminished vision, and decreased hearing, prompting medical evaluation. Following thorough assessment, she was diagnosed with a right cerebellopontine (CP) angle tumor ([Fig. 1A]). The decision was made to proceed with retromastoid suboccipital craniotomy and excision to address the lesion. Intraoperatively, a soft greenish vascular mass lesion attached to the trigeminal nerve was identified. The surgical procedure proceeded uneventfully, and the patient was extubated following surgery and transferred to the ward for postoperative care.

Fig. 1 (A) Magnetic resonance imaging (MRI) showing a. right cerebellopontine lesion of case 1, (B) right cerebellopontine schwannoma of case 2, and (C) left trigeminal schwannoma extending toward pons of case 3.

On the third day postsurgery, the patient developed oral sores on the right angle of her mouth, specifically on the lower lip ([Fig. 2A]). Dermatology consultation was sought to address this new symptom, which was diagnosed clinically as herpes labialis by them and tablet acyclovir was prescribed. Following initiation of antiviral therapy, the oral sores subsided significantly, and the patient's condition improved. After a few additional days of observation, during which no further complications arose, the patient was discharged with no residual complaints.

Fig. 2 Herpes simplex virus (HSV) lesion. (A) Case 1 with lesion in the lower lips. (B) Case 2 with lesion in the upper lip. (C) Case 3 with lesion predominantly on the lower lip.

 

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Case 2

A 30-year-old female presented with complaints of diminished hearing, leading to further evaluation and the diagnosis of a right CP angle meningioma ([Fig. 1B]) extending toward Meckel's cave. Elective surgery was scheduled to address the tumor, and intraoperative findings revealed a soft to firm greyish-white lesion attached to the seventh and eighth cranial nerves in the right CP angle. The surgical procedure proceeded without complications, and the patient was extubated on the operating table before being transferred to the recovery area.

On the fourth day postsurgery, the patient developed nodular sores on the upper border of the right angle of her lip ([Fig. 2B]). Dermatology consultation was sought, and a diagnosis of herpes labialis was confirmed clinically. Treatment with acyclovir was initiated, resulting in the resolution of the lesions. Following this improvement, the patient was discharged from the hospital without any further issues.

 

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Case 3

A 35-year-old male presented with complaints of headache and diminished hearing, prompting medical evaluation and subsequent diagnosis of a left trigeminal space-occupying lesion ([Fig. 1C]). Surgery was planned to address the tumor, and retromastoid suboccipital craniotomy and excision were performed. Intraoperative findings revealed a soft to firm greyish mass lesion attached to the seventh and eighth cranial nerves in the left CP angle. The surgical procedure was uneventful, except for the need for two units of packed cell transfusion.

On the third day postsurgery, the patient developed nodular lesions on the upper border of his right lip ([Fig. 2C]). Dermatology consultation confirmed the diagnosis of herpes labialis clinically, and treatment with acyclovir was initiated. The patient responded well to antiviral therapy, and the lesions resolved without further complications. Subsequently, the patient was discharged from the hospital in stable condition.

 

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Discussion

Herpes reactivation following posterior fossa surgery is a clinically significant complication that needs more recognition. Surgical stress, direct trigeminal nerve manipulation, and perioperative corticosteroid use likely trigger this reactivation.

Similar case of herpes zoster infection precipitated by surgical manipulation of the trigeminal nerve root during an attempted microvascular decompression procedure was reported by Mansour et al.[1] Previous studies have shown herpes reactivation in up to one-fifth of patients after microvascular decompression of the trigeminal nerve,[2] with prior herpes labialis and reoperation as key risk factors. While herpes labialis is the most common manifestation of herpes reactivation, other severe complications such as keratoconjunctivitis and meningitis[2] [3] can also occur, which prompt us to be even more vigilant. In this series, all three patients developed herpes labialis within 3 to 4 days postsurgery, supporting the link between trigeminal nerve handling and herpes reactivation.

Prompt diagnosis and early antiviral therapy with acyclovir led to quick symptom resolution in all cases. Clinicians should remain vigilant for postoperative oral lesions and initiate early treatment to prevent complications like keratoconjunctivitis and encephalitis.[4] Proactive screening and possible antiviral prophylaxis[5] in high-risk cases may improve outcomes. Schädelin et al[6] in their study found herpes labialis occurred in only 1 of 14 patients who received acyclovir, compared to 12 of 16 in the placebo group, highlighting its effectiveness in preventing herpes reactivation. This series underscores the need for increased awareness and structured management of herpes reactivation in neurosurgical practice. Jaques et al[7] reported postoperative HSV as a rare but serious complication of neurosurgery, with significant diagnostic challenges due to variable presentations. They emphasized the importance of early antiviral therapy and advocated prophylactic treatment in patients with prior HSV undergoing neurosurgical procedures. Recent literature identifies several risk factors for HSV-1 reactivation following trigeminal surgeries, including direct mechanical stimulation of the trigeminal ganglion, longer operative time, and low preoperative HSV-1 immunoglobulin G antibody titers. Surgical techniques involving more intense ganglion handling, such as partial sensory rhizotomy and percutaneous balloon compression, carry a higher risk compared to microvascular decompression.[8]

In our cases, clinical diagnosis of herpes labialis was made by dermatology consultation based on characteristic vesicular lesions and perilabial distribution. In severe, atypical, or disseminated cases, confirmation with polymerase chain reaction from vesicular swabs can be done.

 

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Conclusion

Herpes reactivation following posterior fossa surgery is a clinically relevant complication that warrants greater recognition. This case series highlights herpes reactivation as a clinically relevant and underrecognized complication following posterior fossa surgeries involving the trigeminal nerve. Early diagnosis and prompt antiviral therapy ensured quick resolution without complications. Increased awareness, early recognition of symptoms, and timely intervention are essential to improve patient outcomes and prevent severe complications.

 

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Conflict of Interest

None declared.

• References

• 1 Mansour N, Kaliaperumal C, Choudhari KA. Facial herpes zoster infection precipitated by surgical manipulation of the trigeminal nerve during exploration of the posterior fossa: a case report. J Med Case Rep 2009; 3: 7813
• 2 Kikuchi A, Ishizaki S, Yokosako S, Kasuya H, Kubota Y. Clinical features of herpes simplex virus reactivation after microvascular decompression for trigeminal neuralgia: experience of 200 patients and a literature review. Surg Neurol Int 2022; 13: 371
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• 4 Arduino PG, Porter SR. Herpes simplex virus type 1 infection: overview on relevant clinico-pathological features. J Oral Pathol Med 2008; 37 (02) 107-121
• 5 Simms HN, Dunn LT. Herpes zoster of the trigeminal nerve following microvascular decompression. Br J Neurosurg 2006; 20 (06) 423-426
• 6 Schädelin J, Schilt HU, Rohner M. Preventive therapy of herpes labialis associated with trigeminal surgery. Am J Med 1988; 85 (2A): 46-48
• 7 Jaques DA, Bagetakou S, L'Huillier AG. et al. Herpes simplex encephalitis as a complication of neurosurgical procedures: report of 3 cases and review of the literature. Virol J 2016; 13: 83
• 8 Zhen X, Xu X, Shao X. et al. Risk factors of herpes simplex virus reactivation after surgery for primary trigeminal neuralgia. J Neurovirol 2022; 28 (03) 367-373

Publikationsverlauf

Artikel online veröffentlicht:
21. August 2025