Vigilance saves vision: Beating herpes zoster ophthalmicus in B-cell acute lymphoblastic leukemia

Herpes zoster ophthalmicus (HZO) represents a significant risk to vision due to the reactivation of the varicella-zoster virus (VZV), in general, and among immune-compromised individuals like leukemia on chemotherapy, in particular. We report on a 21-year-old woman who was diagnosed with B-cell acute lymphoblastic leukemia and was receiving chemotherapy for 2 months. She presented with signs of conjunctival injection, a vesicular rash on the right side of her upper face (along the trigeminal ophthalmic division, V1), and acute discomfort around the eye for a duration of 7 days, occurring just 15 days after completing her consolidation therapy [Figure 1]. Due to underlying immune suppression, a high index of suspicion of HZO was maintained, and intravenous acyclovir (along with local lubricant in consultation with the ophthalmologist) was initiated promptly. This resulted in lesions being crusted within a week, and ocular examination at follow-up indicated no corneal involvement, uveitis, or residual visual deficit [Figure 2].

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Figure 1:

Initial presentation of herpes zoster ophthalmicus showing blister-like vesicular rash on the right side of the forehead, eyelid, scalp along V1 nerve, and periorbital edema.

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Figure 2:

Two weeks post-therapy, the lesions crusted-off without any residual visual damage.

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The increased susceptibility to VZV reactivation is prevalent in leukemias mostly due to compromised cell-mediated immunity. A little delay in initiating appropriate treatment often leads to keratitis, neurotrophic ulcers, or permanent vision impairment. This instance underscores the importance of early detection of dermatomal rashes in immunocompromised persons to decrease complications.