What is the diagnosis and treatment for a patient presenting with a herpes-like lesion periorbital (around the eye) with lymph node involvement and cold-like symptoms?

Periorbital Herpes Simplex with Systemic Symptoms: Diagnosis and Treatment

This presentation is consistent with primary or recurrent herpes simplex virus (HSV) infection with periorbital involvement, and requires immediate oral antiviral therapy with valacyclovir or famciclovir to prevent serious ocular complications including keratitis, corneal scarring, and vision loss.

Clinical Diagnosis

The constellation of periorbital herpes-like lesions, preauricular lymphadenopathy, and cold-like symptoms is highly characteristic of HSV infection:

• Unilateral presentation with vesicular or ulcerative periorbital lesions strongly suggests HSV, particularly when accompanied by palpable preauricular lymph node 1
• Systemic symptoms including cold-like symptoms and lymphadenopathy are common, especially in primary HSV infection 2
• Vesicular eyelid lesions are pathognomonic when present and require urgent evaluation for corneal involvement 1

Critical assessment needed: Examine the cornea with fluorescein staining for dendritic lesions, as HSV keratitis can rapidly progress to vision-threatening complications including stromal keratitis, corneal scarring, perforation, and uveitis 1, 2.

Immediate Treatment Protocol

Oral Antiviral Therapy (First-Line)

Valacyclovir is the preferred treatment due to superior bioavailability and convenient dosing:

• For periorbital HSV with potential ocular involvement: Valacyclovir 1 gram three times daily for 7-10 days 2, 3
• Alternative: Famciclovir 500 mg three times daily for 7 days 2
• For immunocompromised patients: Consider IV acyclovir if severe or disseminated disease 2

Timing is critical: Initiate therapy immediately upon clinical diagnosis—do not wait for laboratory confirmation, as treatment efficacy decreases significantly after 72 hours from symptom onset 3, 4.

Why Oral Over Topical

Topical antivirals alone are not recommended for periorbital HSV because:

• They cannot reach the site of viral reactivation in the sensory ganglia 2
• They provide inadequate drug levels for preventing ocular complications 2
• Oral therapy is required to prevent progression to keratitis and other serious complications 2, 1

Ophthalmologic Evaluation

Urgent ophthalmology referral is mandatory for:

• Any patient with periorbital HSV lesions to rule out corneal involvement 1
• Presence of dendritic corneal lesions on fluorescein examination 2, 1
• Visual symptoms, eye pain, or photophobia 2

The condition can progress to epithelial keratitis, stromal keratitis, endotheliitis, corneal scarring, and permanent vision loss if not promptly treated 1, 2.

Adjunctive Management

• Supportive care: Maintain adequate hydration during antiviral therapy 3
• Topical antibiotics: May be considered to prevent secondary bacterial infection of vesicular lesions, though not routinely necessary 2
• Pain management: Oral analgesics as needed for discomfort 2
• Avoid topical corticosteroids unless specifically directed by ophthalmology, as they can worsen HSV keratitis 2

Special Populations

Immunocompromised Patients

• Require more aggressive treatment with consideration for IV acyclovir (especially if CD4+ <100 cells/µL) 2
• Higher risk for chronic ulcerations, dissemination, and acyclovir-resistant virus 2
• May need prolonged therapy beyond standard 7-10 day course 2

Pediatric Patients

• Neonates require immediate systemic evaluation as HSV can be life-threatening 2
• Prompt pediatric consultation mandatory for any infant with periorbital HSV 2

Critical Pitfalls to Avoid

1. Delaying treatment: Waiting for laboratory confirmation significantly reduces treatment efficacy—treat based on clinical diagnosis 3, 4
2. Using topical antivirals alone: Inadequate for preventing ocular complications 2
3. Missing corneal involvement: Always examine with fluorescein; dendritic lesions require immediate ophthalmology involvement 1, 2
4. Inadequate follow-up: Patients need reassessment within 48-72 hours to ensure response and rule out complications 2, 1

Expected Course

• Without treatment: Self-limited resolution in 7-10 days in immunocompetent patients, but with significant risk of ocular complications 1, 5
• With treatment: Faster resolution of lesions, reduced viral shedding, and decreased risk of complications when initiated early 2, 3
• Recurrence risk: HSV establishes latency and can reactivate with triggers including stress, UV exposure, fever, or immunosuppression 2, 1