Facial herpes zoster in an infant with nutritional rickets complicated by pneumonia and stomatitis: a case report and review

Background. Shingles in infants is a rare condition caused by intrauterine exposure to the varicella-zoster virus (VZV). Nutritional rickets due to vitamin D deficiency is associated with impaired immune function, potentially predisposing to viral reactivation and severe complications. Case report. We describe an 11.5-month-old infant who developed facial herpes zoster one month after contact with an older sibling with varicella. The disease began with fever, localized vesicular rash on the left cheek, vesicles with crusts and painful cervical lymphadenitis, later progressed to gingivostomatitis and bacterial pneumonia on a background of vitamin D avitaminosis and deficiency/nutritional rickets. Laboratory investigations revealed marked vitamin D deficiency (25(OH)D = 5.3 ng/mL), hypocalcemia, and elevated alkaline phosphatase, consistent with nutritional rickets. Chest radiography confirmed bilateral pneumonia with signs of rickets. Treatment included intravenous amoxicillin-clavulanate for 5 days, oral acyclovir (20 mg/kg/day for 5 days), vitamin D3 supplementation (4000 IU/day), oral calcium, oxygen therapy, and symptomatic care. The patient improved rapidly and was discharged after 7 days. At 13 months follow-up, the child remained symptom-free. Conclusions. This case highlights the potential for severe complications of herpes zoster in infants with profound vitamin D deficiency and rickets, emphasizing the importance of early recognition and intervention. The severe vitamin D deficiency clinically expressed by rickets, in a child with HZ in the first year of life can lead to quite severe complications such as bacterial pneumonia and aphthous gingivostomatitis.