Varicella-Zoster Virus Reactivation Masquerading as Granuloma Faciale

Abstract

Background Varicella-zoster virus (VZV) typically presents as a dermatomal eruption of vesicles following a prodrome of burning pain. Atypical presentations may complicate diagnosis, especially when histopathologic features mimic inflammatory dermatoses.

Case Presentation A 38-year-old man presented with a one-week history of an erythematous, edematous plaque over the left glabella and periorbital region, associated with headache. Initial evaluation favored preseptal cellulitis, and imaging showed soft tissue thickening. Despite broad-spectrum antibiotics, the rash persisted. Skin biopsy revealed a dense perivascular and periadnexal lymphohistiocytic infiltrate with plasma cells and rare eosinophils, favoring granuloma faciale. Despite biopsy findings, empiric antiviral therapy was initiated given clinical suspicion for herpes zoster. VZV PCR ultimately returned positive. The patient completed a course of oral valacyclovir with resolution of symptoms.

Discussion This case illustrates an unusual presentation of VZV, histologically mimicking granuloma faciale without classic viral cytopathic changes. While granulomatous reactions are more often associated with chronic postherpetic changes, concurrent granulomatous inflammation during acute VZV reactivation is rare. Early consideration of VZV in atypical facial eruptions and the use of molecular testing are crucial to avoid diagnostic delays.

Conclusion Clinicians should maintain a high index of suspicion for VZV in atypical facial rashes, even when initial clinical and histopathologic findings suggest alternative diagnoses. Early PCR testing can facilitate prompt treatment and improve outcomes.