Nasal Herpes Simplex Infection: A Rare Pathway From Skin Lesion to Brain Involvement

Herpesvirus Infection of The Nose Tip: Causes, Diagnosis and Possible Intracranial Complications

nasal herpes infection, nose tip herpes, HSV-1, HSV-2, meningitis, encephalitis, Mollaret's, brain infection, CSF PCR, acyclovir

Herpes simplex viruses (HSV) are common DNA viruses in humans; HSV-1 is usually associated with orolabial (cold sore/cold sore) lesions, while HSV-2 is more commonly associated with genital lesions. Both types can rarely cause central nervous system (CNS) infections: HSV-1 is more frequently associated with encephalitis (brain parenchymal infection), while HSV-2 is associated with aseptic/lymphocytic meningitis and Mollaret's recurrent meningitis (a rare and chronic form of aseptic (nonbacterial) meningitis). These points are supported by extensive literature. Sometimes, diagnosis is made after a simple cold sore, starting with a burning, painful, and stinging sensation on the tip of the nose, with vesicles appearing at the center of the reddened areas, following a "typical herpes appearance."

The patient's images above and below show hyperemic lesions on the vesicular base of the tip of the nose. After the patient had not used any medication for a long time and had used topical cortisone cream, the lesions on the tip of the nose had transformed into purulent areas.

Nasal herpes: How does it occur and why is it important?

Herpes appearing in the nasal area or on the tip of the nose is most often due to HSV-1 reactivation. Trauma (e.g., scratching, cosmetic procedures, filler applications), surgical interventions, or disruption of local skin integrity can predispose the latent virus to reactivation and the formation of lesions on the facial/nasal skin. While nasal herpes is a rare presentation, both isolated nasal lesions and cases associated with intracranial complications have been reported in the literature.

Viral Reactivation and Cell Damage

Once the HSV-1 virus enters the body, it remains latent in the ganglia of the trigeminal nerve.

Conditions such as stress, fever, sunlight, nasal irritation, colds, surgery, or immunosuppression cause the virus to reactivate.

The activated virus travels along nerve fibers to the skin at the tip of the nose, where it infects epithelial cells.

Rapid viral replication occurs in infected cells, followed by lysis and the formation of a vesicle (fluid-filled blister).

As the cells within the vesicle die and the virus particles spread to surrounding tissue, the body's immune system sounds the alarm.

Neutrophils, macrophages, and lymphocytes arrive at the site.

During this process, classic signs of inflammation such as:

Redness (erythema)
Swelling (edema)
Increased temperature
Pain

Addition of a Secondary Bacterial Infection

The skin at the tip of the nose is thin and vulnerable to trauma.

When herpes blisters rupture, the skin barrier is disrupted, making it easier for bacteria to enter.

Bacteria, particularly Staphylococcus aureus or Streptococcus pyogenes, can colonize the wound.

In this case, the lesions become:

Inflamed, with yellow crusts,
Purulent (pus-filled),
Painful, and swollen.

This condition is called impetiginization, or secondary bacterial infection. In our patient, whose images I shared with you on this page, inflammatory areas appeared in herpes lesions after secondary bacterial infection.

Mechanisms of Spread from Nasal/Herpes Lesions to the CNS

HSV remains latent in cranial nerve ganglia, such as the trigeminal ganglion, after primary infection or reactivation. Upon reactivation, the virus can reach the central nervous system via perineural or retrograde axonal spread. Furthermore, local tissue trauma and inflammation can weaken barriers, providing an easier opportunity for spread. These mechanisms are theoretically explained and supported by some case series.

Reported Cases: Has meningitis or encephalitis developed after nasal/facial herpes?

Case reports supporting this association exist in the literature. For example, there are case reports of HSV-1 encephalitis following cosmetic filler application to the nasal area; such reports suggest that local procedures and trauma may trigger viral reactivation. Furthermore, articles describe cases with intranasal or nasal lesions and report complications (local necrosis, moderate or severe CNS symptoms). On the other hand, aseptic meningitis caused by HSV-2 (especially Mollaret-type recurrent meningitis) is more prominently associated with cases of genital origin, but herpesvirus spread from the face/head region to the CNS has also been demonstrated in exceptional cases.

Herpesviruses become latent in sensory neurons after primary infection; upon reactivation, they can spread along neuronal axons to diseased cells and surrounding tissue. The trigeminal nerve ganglion (Gasserian ganglion) of the face is the main latency site for HSV-1. It is theoretically possible to reach more central regions (meninges/encephalic tissues) via retrograde spread along the nerve pathway from lesions on the tip of the nose, nasal region, or lips, or via perineural spread mechanisms. While this mechanism is rare, there are some case series and cases reported in the literature.

Who is at Risk for Intracranial Spread/Complications Following Nasal Herpes Infection?

The risk of CNS complications increases in conditions that disrupt local barriers, such as immunodeficiency, primary severe HSV infection (especially in neonates), trauma, or craniofacial surgery/head trauma. However, HSV meningitis can also occur in immunocompetent individuals; therefore, clinical evaluation cannot be limited solely to the underlying immune status.

Although HSV (especially HSV-1) spread from infection in the tip of the nose or facial area to the brain (intracranial) is quite rare, it carries high mortality and morbidity when it occurs.

Without treatment, mortality in HSV-1 encephalitis is ≈70–80%.

With early IV acyclovir treatment, mortality is reduced to 10–20%.

This table summarizes the mortality rates of HSV-1 encephalitis (which can occur when infection spreads from the tip of the nose to the brain, for example) depending on the treatment.

Clinical findings and when should we suspect it?

If a patient with a herpes lesion on the tip of the nose develops sudden and severe headache, fever, photophobia, neck stiffness, altered consciousness, seizures, or neurological focal findings, CNS involvement (meningitis/encephalitis/meningoencephalitis) should be considered. This risk may be particularly increased in those with a recent history of nasal trauma, surgery, or cosmetic procedures.

Numerous case reports of CNS involvement by HSV-1 or HSV-2 exist in the literature. Important studies include the release and PCR detection of HSV-1 DNA in Mollaret-type meningitis; in addition, cases of aseptic meningitis/meningoencephalitis due to HSV-1 have been reported. Cases reporting rare presentations of HSV associated with lesions located on the tip of the nose (e.g., a case reporting infraorbital neuralgia with an HSV lesion on the tip of the nose; cases developing systemic or intracranial symptoms following nasal lesions) have been published. These publications indicate that a nasal/facial lesion does not always directly follow meningitis, but may occasionally be a source of CNS involvement. When these symptoms occur, prompt evaluation and appropriate diagnostic tests are necessary.

Diagnosis of Nasal Herpes—which tests guide the way?

Neurological evaluation and brain imaging (MRI is preferred) should be performed first. Cerebrospinal fluid (CSF) analysis and a PCR test to detect HSV DNA in CSF are the gold standards for definitive diagnosis. Lymphocytic pleocytosis and a mild protein increase in CSF may suggest a viral course, but PCR provides a specific diagnosis. Furthermore, a swab sample taken from the facial lesion can be used to determine the type (HSV-1 vs. HSV-2), providing a clinical correlation. Early-stage samples have higher diagnostic sensitivity.

Treatment and Follow-up

Initiating intravenous acyclovir without delay is crucial if HSV meningitis/encephalitis is suspected; early antiviral treatment reduces morbidity and mortality. The duration of treatment is determined by clinical response, CSF results, and imaging findings. Immunosuppressed patients, neonates, or those with severe neurological involvement require more aggressive monitoring and treatment. Prophylactic oral antivirals are also considered in those with a history of recurrent aseptic meningitis (e.g., the approaches discussed in recurrent Mollaret).

Practical implications — clinical approach recommendations

New onset neurological symptoms in patients with active herpes lesions on the tip of the nose or nasal region should be evaluated urgently.

Caution should be increased if there is a history of recent procedures such as nasal surgery, fillings, or trauma.

CSF PCR testing for HSV and simultaneous facial swab typing are useful.

When in doubt, early initiation of intravenous acyclovir/valacyclovir/famciclovir is safer than a wait-and-see approach.

Herpes lesions on the tip of the nose alone do not frequently result in intracranial infection (meningitis/encephalitis); however, rarely, especially in the presence of triggers such as trauma/surgery or immune deficiency, the virus can reach the central nervous system via the nerve pathway and cause meningitis or encephalitis. Case reports and case series demonstrating this association exist in the literature; clinicians should intervene with rapid diagnosis and early antiviral treatment in the presence of appropriate symptoms.

I wanted to share with you a nice video on YouTube about this subject prepared by Dr. Betsy Grunch. Thank you for sharing. Unfortunately, as emphasized in the video, "Despite the availability of antiviral therapy, herpes simplex encephalitis continues to cause substantial illness and death in both adults and children".

Did you know that herpes can get in your brain? Doctor explains herpes encephalitis - video

Herpes Simplex Virus Encephalitis — clinical presentation and discussion video on the subject

You can click on the search result link to read other articles about herpes virus infection prepared by Dr. Murat Enoz and published on this website (you can access other articles by clicking "more posts" under the opened link) >> https://www.ent-istanbul.com/search?q=herpes+virus+infection

Herpes Simplex Virus (HSV-1 and HSV-2) Animation Video

This video provides animations explaining the infection process, pathogenesis, diagnosis, and treatment of herpes simplex viruses (HSV-1 and HSV-2). It also provides information about the development of cold sores on facial areas such as the tip of the nose.

Source links >>

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon

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