Facial Swelling and Rash Following Tooth Extraction Hyungjoo Ham, MD1, Christopher E. Uy, MD2, and Dawn DeWitt, MD, MSc1 1
Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; 2Division of Neurology, UBC, Vancouver, British Columbia, Canada.
J Gen Intern Med DOI: 10.1007/s11606-015-3443-y © Society of General Internal Medicine 2015
HIV-negative, non-diabetic man develA noped88-year-old, right facial pain, swelling and redness one day after right upper molar extraction. Despite outpatient therapy with amoxicillin and valacyclovir, he developed serous drainage and swelling of the right eyelid. The next day he presented with extensive right facial erythema, edema, patches of crusting and black eschar, but no vesicles, in the V2 distribution (Fig. 1). Oral examination showed small vesicles and ulcers on the right hard and soft palates (Fig. 2). Lesion distribution was sharply demarcated at the midline. Swabs showed co-infection with herpes simplex virus type 1 (HSV1), varicella-zoster virus (VZV) and methicillinsensitive Staphylococcus aureus. Ophthalmologic consultation excluded corneal involvement. The patient received intravenous acyclovir and antibiotics. Three weeks later, his facial and palatal lesions had resolved.
Fig. 2 Vesicles and ulcers on the right hard and soft palates
In immune-competent patients, concurrent reactivation with VZV and HSV is rare in the same cutaneous site. Co-infection cases tend to be more severe than single-infection cases, are more common in the elderly, and demonstrate a predilection for head involvement.1 In our patient, co-reactivation in a vulnerable area was further complicated by bacterial superinfection which was unresponsive to initial outpatient treatment. Awareness of the possibility and severity of co-infection may facilitate earlier diagnosis and appropriate interventions.
Conflict of Interest: The authors declare that they do not have a conflict of interest. Corresponding Author: Dawn DeWitt, MD, MSc; Department of MedicineUniversity of British Columbia, DHCC 10th Floor, 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9, Canada (e-mail: [email protected]).
REFERENCE Fig. 1 Patches of crusting and black eschar on an erythematous base in the right V2 distribution
1. Giehl KA, Müller-Sander E, Rottenkolber M, Degitz K, Volkenandt M, Berking C. Identification and characterization of 20 immunocompetent patients with simultaneous varicella zoster and herpes simplex virus infection. J Eur Acad Dermatol Venereol. 2008;22:722–8.
Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; 2Division of Neurology, UBC, Vancouver, British Columbia, Canada.
J Gen Intern Med DOI: 10.1007/s11606-015-3443-y © Society of General Internal Medicine 2015
HIV-negative, non-diabetic man develA noped88-year-old, right facial pain, swelling and redness one day after right upper molar extraction. Despite outpatient therapy with amoxicillin and valacyclovir, he developed serous drainage and swelling of the right eyelid. The next day he presented with extensive right facial erythema, edema, patches of crusting and black eschar, but no vesicles, in the V2 distribution (Fig. 1). Oral examination showed small vesicles and ulcers on the right hard and soft palates (Fig. 2). Lesion distribution was sharply demarcated at the midline. Swabs showed co-infection with herpes simplex virus type 1 (HSV1), varicella-zoster virus (VZV) and methicillinsensitive Staphylococcus aureus. Ophthalmologic consultation excluded corneal involvement. The patient received intravenous acyclovir and antibiotics. Three weeks later, his facial and palatal lesions had resolved.
Fig. 2 Vesicles and ulcers on the right hard and soft palates
In immune-competent patients, concurrent reactivation with VZV and HSV is rare in the same cutaneous site. Co-infection cases tend to be more severe than single-infection cases, are more common in the elderly, and demonstrate a predilection for head involvement.1 In our patient, co-reactivation in a vulnerable area was further complicated by bacterial superinfection which was unresponsive to initial outpatient treatment. Awareness of the possibility and severity of co-infection may facilitate earlier diagnosis and appropriate interventions.
Conflict of Interest: The authors declare that they do not have a conflict of interest. Corresponding Author: Dawn DeWitt, MD, MSc; Department of MedicineUniversity of British Columbia, DHCC 10th Floor, 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9, Canada (e-mail: [email protected]).
REFERENCE Fig. 1 Patches of crusting and black eschar on an erythematous base in the right V2 distribution
1. Giehl KA, Müller-Sander E, Rottenkolber M, Degitz K, Volkenandt M, Berking C. Identification and characterization of 20 immunocompetent patients with simultaneous varicella zoster and herpes simplex virus infection. J Eur Acad Dermatol Venereol. 2008;22:722–8.
