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      Shingles as the underlying cause of orbital myositis in an adolescent: A case report

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          Abstract

          Purpose

          Orbital myositis is characterized by pain with eye movements, gaze restriction, diplopia, and enlargement of extraocular muscles on imaging. Varicella zoster virus (VZV) is an extremely rare cause of the disease in the elderly and has never been reported in a patient younger than forty-five years old such as the adolescent described herein. We present this case to raise awareness of an entity that will likely become more prevalent due to current vaccine strategies.

          Observation

          We present the case of a 13-year-old girl with VZV-associated orbital myositis and meningitis that had a quick and complete recovery following IV acyclovir and oral steroids.

          Conclusions and importance

          In conclusion, orbital myositis is an extremely rare complication of facial VZV infections. Our case highlights the importance of prompt detection and treatment in the pediatric population.

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          Most cited references 11

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          Factors associated with age of onset of herpes zoster ophthalmicus.

          The aim of this study was to evaluate factors associated with the age of onset of herpes zoster ophthalmicus (HZO) in the era of varicella vaccination.
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            An unusual presentation of herpes zoster ophthalmicus: orbital myositis preceding vesicular eruption.

            To present a case of orbital myositis associated with herpes zoster ophthalmicus. Observational case report. A 47-year-old woman with acute retrobulbar eye pain and diplopia preceding the vesicular rash of herpes zoster ophthalmicus was evaluated and treated. Magnetic resonance imaging showed enlargement and enhancement of extraocular muscles consistent with an inflammatory myopathy. Following acyclovir and prednisone treatment, all symptoms resolved, and neuralgia did not develop. Herpes zoster may cause symptoms and signs of orbital myositis before eruption of cutaneous skin lesions and thus should be considered in the differential diagnosis of an acute orbital myositis.
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              Orbital apex syndrome: an unusual complication of herpes zoster ophthalmicus

              Background Herpes zoster ophthalmicus is defined as herpes zoster involvement of the ophthalmic division of the trigeminal nerve. Ocular involvement occurs in 20–70% of patients with herpes zoster ophthalmicus and may include blepharitis, keratoconjunctivitis, iritis, scleritis, and acute retinal necrosis. Orbital apex syndrome is a rare but severe ocular complication of herpes zoster ophthalmicus. We present here the first reported case of herpes zoster ophthalmicus complicated by orbital apex syndrome in a patient from Taiwan. Case presentation A 78-year-old man initially presented with patchy erythema and herpetiform vesicles on his left forehead and upper eyelid. He subsequently developed left-sided ocular complications including reduced visual acuity, anisocoria, ptosis, and complete ophthalmoplegia. Orbital magnetic resonance imaging (MRI) was performed on day 6 of admission to search for signs of the common causes of orbital apex syndrome such as hemorrhage, neoplasm, and cavernous sinus thrombosis. The MRI showed only orbital myositis and enhancement of the retro-orbital optic nerve sheath. The patient was diagnosed with herpes zoster ophthalmicus complicated by orbital apex syndrome. Although the ocular complications partially resolved after systemic antiviral therapy for 15 days and steroid therapy tapered over 12 weeks, there was residual limitation of abduction and paralysis of the left upper eyelid at follow-up at 180 days after the onset of symptoms. The orbital MRI findings at 180 days showed no significant changes compared with the MRI findings on day 6 of admission. Conclusions Primary care physicians should be aware of this rare but potentially sight-threatening complication of herpes zoster ophthalmicus. The appropriate therapy for orbital apex syndrome due to herpes zoster ophthalmicus and the potential outcomes of this condition require further investigation.
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                Author and article information

                Contributors
                Journal
                Am J Ophthalmol Case Rep
                Am J Ophthalmol Case Rep
                American Journal of Ophthalmology Case Reports
                Elsevier
                2451-9936
                30 December 2016
                April 2017
                30 December 2016
                : 5
                : 111-113
                Affiliations
                Department of Ophthalmology, University of Utah, Salt Lake City, UT 84112, USA
                Author notes
                []Corresponding author. Christopher.conrady@ 123456hsc.utah.edu
                Article
                S2451-9936(16)30155-4
                10.1016/j.ajoc.2016.12.016
                5758027

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                Categories
                Case report

                varicella zoster, orbital myositis, pediatric

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