Disseminated herpes zoster misdiagnosed as orbital complication of acute sinusitis

Several articles were reported about orbital and nasal involvement of disseminated herpes zoster (DHZ) such as herpes ophthalmicus and Hutchinson's sign. In contrast, there is a lack of information about DHZ accompanied by orbital and nasal involvement in elderly immunocompetent patient and nasal mucosal change in healing period. We experienced an immunocompetent 71-year-old female patient who was misdiagnosed with preseptal orbital cellulitis initially. The swollen mucosa was noticed endoscopically and initial CT revealed the mild soft tissue density in left maxillary and ethmoid sinus radiologically. Noticeable dissemination of zoster vesicles was revealed and intravenous acyclovir was administered in a negative pressure room until shingles improved. Lately, adhesive crusting disrupted the chondromucosa and nasal septal perforation occurred. Interestingly, the perforation size tended to decrease spontaneously. There was no other complication except an asymptomatic small nasoseptal perforation during the nine-month follow-up period. DHZ can occur in the immunocompetent elderly patient and manifest initially as solely acute sinusitis complicated by preseptal cellulitis, without any classic cutaneous lesions. Septal perforation can also occur as a result of disseminated herpes zoster.