Keywords
Herpes zoster; Vesicular rash; Brainstem cranial nerve nuclei; Brainstem radiculitis; Valcyclovir
Abstract
Ramsay hunt syndrome arises from a constellation of cranial nerve involvement, commonly facial nerve and trigeminal nerve along with erythematous rash in ear/ over the eye secondary to Varicella Zoster Virus (VZV) reactivation. We describe an unusual presentation of herpes zoster in an immunocompetent individual with several brainstem nuclei involvement mimicking a brain stem stroke. This presentation is termed as brain stem radiculitis.
Introduction
VZV is commonly dormant in the dorsal root ganglions and cranial nerve nuclei and when a person is immunocompromised it leads to reactivation causing a localized vesicular rash called herpes zoster. The most common cranial nerves involved are V (Trigeminal) and VII (Facial nerve).
Case Report
A 63 year old male presented with stroke like symptoms with right facial droop, hoarseness of voice and difficulty of swallowing of one day duration. Prior to these symptoms he had a three day history of right ear pain for which he was taking antibiotics. His past medical history was significant for hypertension.
On examination he was afebrile, vitals were with in normal limits, ear pinna was inflamed, and a vesicular rash was noted in external canal of right ear, first and second divisions of trigeminal nerve on the right side. Cranial nerve exam revealed right lower motor neuron type facial palsy, hypersensitivity to touch in all divisions of trigeminal nerve on right side, decreased hearing on right side. No other motor deficits or gait difficulties or ataxia was noted. Laryngoscope exam revealed hypo mobility of right vocal cord, audiometry showed profound right side sensorineural hearing loss. Barium swallow evaluation demonstrated right pharyngeal wall weakness. He was diagnosed with Ramsay hunt syndrome with extensive brain stem nuclei involvement and treated with Valcyclovir 1000mg three times daily for seven days and steroids
With extensive speech rehabilitation, after 6 months patient can tolerate mechanical soft diet, his voice is almost back to baseline and is working on getting a cochlear implant.
Conclusion
Herpes zoster can present in immunocompetent individuals with extensive brain stem involvement mimicking a brainstem stroke. As it is an inflammatory infectious process, the term “Brainstem radiculitis” is appropriate. Accurate diagnosis and treatment with antiviral agents can minimize complications. Rarely, it can cause permanent damage like in our patient who lost function of his auditory nerve and has to get a cochlear implant.
Acknowledgement
No funding sources. Thank you to Dept. of Neurology, University of Missouri, Columbia.
Citation
Yerram SR. Brainstem Radiculitis - A Complication of Post Herpes Zoster infection. SM J Neurol Neurosci. 2017; 3(1): 1009.