Working Diagnosis:
The patient was diagnosised with a mild traumatic brain injury with associated transient immunosuppression leading to Herpes (VZV) Zoster Ophthalmicus.

Treatment:
For concussion treatment, the patient was started on gabapentin 300 milligrams three times a day for pain, ondansetron 4-8 milligrams as needed within the first 1-2 weeks of treatment, and was enrolled in both vestibular and cervical spine therapies. He was also started on over the counter diphenhydramine ointment and 25-50 milligram tablets as needed at night for itching.

His ophthalmology treatment consisted of erythromycin ointment and prednisone acetate 1 percent suspension.

Infectious Disease started the patient on acyclovir 800 mg four times a day for a 14 day course for his herpes zoster ophthalmicus.

Outcome:
By week two the patient had improvement in his photophobia, headache, and rash. His SCAT symptom score improved to 50, and the patient returned to school part time. At this time, he began low level exercise as tolerated.

At week three, he continued to have improvement in his symptoms with SCAT symptom score improved to 30.

At week 5, the patient scored a 0 SCAT symptom score and had transitioned back to full time school. Per the return to play protocol, he was cleared for non-contact sports.

Upon week 11 he was cleared by Infectious Disease and Ophthalmology for return to sports, but the patient had decided upon retirement from contact sports. Case Photo #3

Author's Comments:
Herpes Zoster is rare in children, having an incidence of 42:100,000 person years.(1) Herpes zoster ophthalmicus is considered an ophthalmologic emergency, as potential sequelae include severe chronic pain and vision loss. Traumatic brain injury and/or concussion as the stressor that causes reactivation of Varicella in the form of herpes zoster ophthalmicus has not been studied comprehensively although existing research does indicate that patients with traumatic brain injury have higher incidence of herpes zoster ophthalmicus and post herpetic neuralgia.(2-3) Further, existing case studies and research focuses on adult patients and research is limited on herpes zoster ophthalmicus activation in the setting of concussion in pediatric patients.

Typically, children that do present with Herpes Zoster do so due to immunosuppression, a developing immune system, or acquisition of the virus intrauterine.(4-9) Our case indicates perhaps that traumatic brain injury may cause a transient state of immunosuppression, mimicking states of immunosuppression in the first year of life. This idea has been briefly explored and existing research suggests that traumatic brain injury can cause transient peripheral immunosuppression.(10-11) The research on this association however is still developing and largely equivocal. This case also highlights the potential additive effect that concussion and Herpes Zoster may have on visual symptoms.

Lastly, our case indicates that Herpes Zoster may complicate and/or exacerbate concussion recovery. Another interesting note is that the patient did not have a prior chicken pox infection. Children with Varicella Zoster Virus infection, or chickenpox, during their first year of life develop Herpes Zoster, or shingles, over 9 times the rate as compared to children who have experienced Herpes Zoster infection after the first year of life.(12) The only exposure this patient had to Varicella was through a live vaccine he received several years prior. Patients with Varicella vaccination typically have very low rates of Varicella reactivation, with our patient being a rare exception.(13)

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