안와 염증이 피부 병변에 선행하여 나타난 눈대상포진 1예
An Unusual Case of Orbital Inflammation Preceding Herpes Zoster Ophthalmicus
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목적: 안와 염증 및 시신경주위염이 피부 병변에 선행하여 나타난 눈대상포진 1예를 보고하고자 한다. 증례요약: 담낭암과 고혈압의 병력을 가진 84세 여자 환자가 갑자기 발생한 좌안 주위 발적 및 부종, 경미한 불편감으로 의뢰되었다. 최대교정시력 양안 0.8, 동공 반사는 정상이었으며, 압통 및 안구돌출이나 안구운동제한은 없었다. 세극등검사상 미만성 결막 충혈과 결막 부종 외 전방 및 유리체, 시신경유두와 망막은 정상소견을 보였다. 2일간의 항생제 투여에도 악화되어 자기공명영상을 시행하였고, 좌측눈물샘, 시신경수초 및 안와 지방의 염증이 확인되었다. 스테로이드 추가 투여 2일 뒤에도 호전을 보이지 않던 중 코 끝, 좌측 안와 주위 피부, 좌측 두피에 수포성 발진과 좌안의 거짓가지모양각막염이 발생하였고, 눈대상포진으로 진단되었다. 항바이러스제 투여 1일 뒤부터 결막 충혈 및 결막 부종이 감소하고 각막염은 호전되었으나, 시력저하, 동공확대 및 대광반사 소실이 발생하였고, 수개월 후에도 완전히 호전되지 않았다. 결론: 눈대상포진은 드물게 안와 염증 및 시신경주위염 형태로 선행 발현될 수 있으므로, 안와 염증이 전형적인 치료에 반응이 없을 경우 감별진단으로 고려해야 할 것으로 생각된다.
Abstract
Purpose: To present a case of orbital inflammation and optic perineuritis preceding vesicular eruption in herpes zoster ophthalmicus (HZO). Case summary: An 84-year-old woman with a history of gall bladder cancer and hypertension complained of left periorbital erythematous edema and discomfort. On examination, visual acuity was 20/25 bilaterally; no tenderness, proptosis or ophthalmoplegia was observed. Pupils were equal, round, and reactive to light without relative afferent pupillary defects. Slit-lamp examination revealed severe conjunctival injection and chemosis without keratitis or uveitis. The remainder of the ocular examination was unremarkable. Magnetic resonance imaging confirmed left-sided preseptal swelling with an enlarged left lacrimal gland, high signal intensity of the retrobulbar fat and optic nerve sheath. Systemic antibiotic therapy with steroids was started under a presumed diagnosis of idiopathic orbital inflammatory disease, but the clinical presentation was unresolved. After 2 days, vesicular lesions confined to the first division of the trigeminal nerve and pseudodendritic keratitis developed on the left side leading to a diagnosis of HZO. Treatment with acyclovir immediately resolved anterior segment inflammation and periorbital edema. While on therapy, visual acuity deteriorated to 20/125 and the pupil became dilated and unresponsive to light over a few days. All signs and symptoms of acute orbitopathy and postherpetic neuralgia had resolved 3 months later with the exception of pupil abnormality and visual acuity. Conclusions: HZO may present with symptoms and signs of orbital inflammation and optic perineuritis even in the absence of a vesicular rash. Thus, HZO should be considered in the differential diagnosis of unexplained acute orbital syndromes.
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