Chickenpox and the geniculate ganglion: facial nerve palsy, Ramsay Hunt syndrome and acyclovir treatment

Ramsay Hunt syndrome and concurrent varicella-zoster virus meningitis in Denmark: A nationwide cohort study

Ramsay Hunt syndrome (RHS) is a manifestation of reactivated varicella-zoster virus (VZV) from the geniculate ganglion. Data on clinical features and outcomes of patients with RHS and concurrent VZV meningitis (henceforth RHS meningitis) are limited. Thus, we conducted a nationwide population-based cohort study of all adults hospitalized for RHS meningitis at the departments of infectious diseases in Denmark from 2015 to 2020. Patients with VZV meningitis without cranial nerve palsies were included for comparison. In total, 37 patients with RHS meningitis (mean annual incidence: 1.6/1 000 000 adults) and 162 with VZV meningitis without cranial nerve palsies were included. In RHS meningitis, the median age was 52 years (interquartile range: 35-64), and in addition to peripheral facial nerve palsy (100%), dizziness (46%), and hearing loss (35%) were common symptoms. The triad of headache, neck stiffness, and photophobia/hyperacusis was less common in RHS meningitis than in VZV meningitis without cranial nerve palsies (0/27 [0%] vs. 24/143 [17%]; p = 0.02). At 30 days after discharge, 18/36 (50%) patients with RHS meningitis had persistent peripheral facial nerve palsy, with no statistically significant difference between those treated with and without adjuvant glucocorticoids (6/16 [38%] vs. 12/20 [60%]; p = 0.18). Additional sequelae of RHS meningitis included dizziness (29%), neuralgia (14%), tinnitus/hyperacusis (11%), hearing loss (9%), headache (9%), fatigue (6%), and concentration difficulties (3%). In conclusion, clinical features and outcomes of RHS meningitis were primarily related to cranial neuropathies.

Bilateral asymmetrical herpes-zoster with Ramsay hunt syndrome in an immunocompetent adult

Background

Bilateral herpes zoster (BHZ) is an atypical presentation of herpes zoster (HZ), with few cases reported before. Ramsay Hunt syndrome (RHS) is an uncommon complication of VZV infection. Cases of BHZ with RHS in immunocompetent adults have been reported rarely.

Case presentation

We described an immunocompetent adult who suffered from left-sided thoracic herpes zoster and contralateral RHS simultaneously, and summarizes the characteristics of BHZ.

Conclusions

Cases of BHZ with RHS in immunocompetent adults have not been reported previously. Antivirus - glucocorticoid combination therapy showed a good effect in this case.

Ramsay Hunt syndrome in a girl with acute lymphoblastic leukemia during maintenance therapy

A 5-year-old girl with precursor B-cell acute lymphoblastic leukemia developed peripheral-type right facial palsy and very faint erythema on her right pinna during maintenance therapy. Acyclovir was started for possible zoster infection. The following day, vesicles appeared and a diagnosis of Ramsay Hunt syndrome was made. Prednisolone was started on day 5 after onset. Her facial palsy recovered within 6 months. Ramsay Hunt syndrome is a rare cause of facial palsy in patients with acute lymphoblastic leukemia, and this is the first case report. Preemptive therapy with acyclovir before the development of vesicles should help the patient recover from facial palsy.

Favorable Outcome of Ramsay Hunt Syndrome under Dexamethasone

A 20-year-old student under chronic stress developed a painful reddish left ear, vesicles on the left ear, severe left-sided peripheral facial-nerve palsy, and hypoesthesia of the left upper lip, after exposure to a ventilator. Ramsay Hunt syndrome was diagnosed. Instead of prednisolone she received dexamethasone (40 mg/d) but nonetheless recovered completely after 12 weeks.

Ramsay Hunt syndrome

Ramsay Hunt syndrome is a special form of herpes zoster which is typically characterized by peripheral facial palsy and unilateral herpetic vesicles on the ear. These symptoms are often accompanied by vestibulocochlear dysfunction and other neurological and ophthalmological symptoms. The diagnosis and therapy requires a multidisciplinary approach. The authors present a typical case where the early administration of combined antiviral and systemic corticosteroid therapy led to complete recovery. The authors emphasize the importance of early diagnosis and adequate combination therapy, which improves the prognosis of this disease. Orv. Hetil., 2012, 153, 1281–1283.

Herpes zoster oticus (Ramsay Hunt syndrome) in children: case report and literature review

INTRODUCTION

Approximately 10% of patients with peripheral facial nerve palsy are children. Facial nerve palsy is usually idiopathic. An uncommon cause is herpes zoster oticus (Ramsay Hunt syndrome). This syndrome usually affects adults and is rare in children.

METHODS

We reviewed the literature and describe the cause, clinical manifestations, and treatment of Ramsay Hunt syndrome. We also report a case of the syndrome in a 12-year-old boy.

CONCLUSION

Ramsay Hunt syndrome is characterized by peripheral facial paralysis associated with herpetic eruption on the auricula and external ear, and by vestibulocochlear dysfunction. It occurs by reactivation of latent varicella-zoster virus (VZV) in the geniculate ganglion, affecting the seventh and eighth cranial nerves. The diagnosis is based on history and physical findings. Treatment of Ramsay Hunt syndrome uses a combination of high-dose corticosteroids and acyclovir. Although the prognosis is better in children than in adults, it is not good enough.

Unilateral facial paralysis caused by Ramsay Hunt syndrome

The Ramsay Hunt syndrome is a rare disease caused by an infection of the geniculate ganglion by the varicella-zoster virus. The main clinical features of the syndrome are as follows: Bell palsy unilateral or bilateral, vesicular eruptions on the ears, ear pain, dizziness, preauricular swelling, tingling, tearing, loss of taste sensation, and nystagmus. We describe a 23-year-old white woman, who presented with facial paralysis on the left side of the face, pain, fever, ear pain, and swelling in the neck and auricular region on the left side. She received appropriate treatment with acyclovir, vitamin B complex, and CMP nucleus. After 30 days after presentation, the patient did not show any signs or symptoms of the syndrome. At follow-up at 1 year, she showed no relapse of the syndrome.

Surgical management of facial nerve paralysis in the pediatric population

BACKGROUND

In the pediatric patient population, both the pathology and the surgical managements of seventh cranial nerve palsy are complicated by the small size of the patients. Adding to the technical difficulty is the relative infrequency of the diagnosis, thus making it harder to become proficient in the management of the condition. The magnitude of the functional and aesthetic deficits these children manifest is significantly troubling to both the patient and the parents, which makes immediate attention, treatment, and functional restoration essential.

METHODS

A literature search using PubMed (http://www.pubmed.org) was undertaken to identify the current state of surgical management of pediatric facial paralysis.

RESULTS

Although a multitude of techniques have been used, the ideal reconstructive procedure that addresses all of the functional and cosmetic needs of these children has yet to be described. Certainly, future research and innovative thinking will yield progressively better techniques that may, one day, emulate the native facial musculature with remarkable precision.

CONCLUSION

The necessity for surgical intervention in children with facial nerve paralysis differs depending on many factors including the acute/chronic nature of the defect as well as the extent of functional and cosmetic damage. In this article, we review the surgical procedures that have been used to treat pediatric facial nerve paralysis and provide therapeutic facial reanimation.

Risk factors of herpes zoster among children immunized with varicella vaccine: results from a nested case-control study

BACKGROUND

Previous studies of varicella-zoster virus reactivation in children have provided little information on potential risk factors. The aim of this study was to investigate the effects of race, chronic medical conditions and treatments, and recent vaccination, on the risk of herpes zoster (HZ) in children vaccinated with one dose of varicella vaccine.

METHODS

Case subjects were identified from a cohort of subjects who were members of the Southern California Kaiser Permanente Health Plan and received primary immunization with a single-antigen live varicella vaccine at age < or = 12 years from 2002 to 2008. Control subjects free of HZ during the study period were matched at a 5:1 ratio to each case subject on date of birth and sex. Race information was obtained from membership files, health records, and phone interview. Immunization history, medical history, and health care utilization were identified from Southern California Kaiser Permanente Health Plan electronic records.

RESULTS

During this time, 122 children were diagnosed with HZ. With adjustment for the number of hospitalizations, outpatient visits, and length of time between vaccination with varicella vaccine and the onset of HZ, Black children were at lower risk of developing HZ than were White (OR=0.41, 95% CI=0.17-0.98) and Asian children (OR=0.30, 95% CI=0.11-0.84).

CONCLUSIONS

These data suggest that the racial differences in the risk of developing HZ seen in adults are manifest in children as well. As children are not subject to the majority of factors hypothesized to underlie HZ in adults and as this study was conducted in a setting which affords equal access to health care, it is possible that genetic variation may explain some portion of varicella-zoster virus reactivation.

Incidence of herpes zoster among children vaccinated with varicella vaccine in a prepaid health care plan in the United States, 2002-2008

BACKGROUND

Herpes zoster (HZ), or shingles, is caused by reactivation of latent varicella-zoster virus after a primary infection with either wild-type or vaccine-type varicella-zoster virus, the latter having been introduced in 1995 for children. Since then, few population-based data about the incidence of childhood HZ are available.

METHODS

We identified children aged < or = 12 years who were vaccinated with 1 dose of varicella vaccine between 2002 and 2008 in a prepaid health plan and followed them through their electronic health records for a diagnosis of HZ. The medical records of these children were reviewed. Persistent and chronic conditions for these children before HZ were identified.

RESULTS

There were 172,163 children vaccinated, with overall follow-up of 446,027 person-years (Incidence rate = 27.4 per 100,000 person-years, 95% confidence interval: 22.7-32.7). Children vaccinated after age 5 years had a higher but not statistically significant different rate than children vaccinated between 12 and 18 months (34.3 vs. 28.5 per 100,000 person-years). Among children vaccinated between 12 and 18 months, incidence rates gradually increased each year in the first 4 years after vaccination (P < 0.001). Among the HZ cases, there were 1 (0.7%) case of lymphoid leukemia, 1 (0.7%) case of drug abuse, 16 (11.1%) cases of asthma with 3 or more acute exacerbations, 12 (8.3%) cases of developmental disorders, and 3 (2.1%) cases of psychological or mental disorders.

CONCLUSIONS

These data demonstrate that diagnosed HZ is rare among children following varicella vaccine. Despite the small numbers, the roles of delayed vaccination, severe asthma, and development disorders warrant further investigation. In the future, analyses of HZ isolates will be needed to identify the virus strains causing reactivation.

Varicella-zoster virus reactivation from multiple ganglia: a case report

Introduction

Simultaneous involvements of multiple cranial nerve ganglia (geniculate ganglion and peripheral ganglia of cranial nerves VIII, IX and X) by varicella-zoster virus and its subsequent activation may result in the characteristic eruptions of herpes zoster cephalicus. Coexistence of facial palsy and involvement of upper cervical dermatomes by varicella-zoster virus is quite rare.

Case presentation

Here, we report a 71-year-old Iranian man with involvement of multiple sensory ganglia (geniculate ganglion and upper dorsal root ganglia) by varicella-zoster virus. He presented with right-sided facial weakness along with vesicular eruptions on the right side of his neck, and second and third cervical dermatomes.

Conclusion

The present case is an example of herpes zoster cephalicus with cervical nerve involvement. Although resembling Ramsay Hunt syndrome with presence of facial nerve paralysis and accompanying vesicles, involvement of cervical dermatomes is not a feature of the classic Ramsay Hunt syndrome.

[Postvaricella cerebellar ataxia in children in Costa Rica]

INTRODUCTION

Postvaricella cerebellar ataxia (PVCA) and meningoencephalitis are the most common acute neurological complications of chickenpox. The objective of this study was to describe the clinical presentation, management, and outcome of children hospitalized with PVCA in the only pediatric hospital of this developing country, where routine varicella immunization is not yet available.

METHODS

We performed a retrospective chart review of children aged 1-12 years old admitted to the National Children's Hospital of Costa Rica from January 1997 to June 2004 with a diagnosis of PVCA.

RESULTS

Among the 441 immunocompetent patients admitted for varicella zoster virus-associated complications during this period, 37 (8.4%) had PVCA. Twenty-four of the 37 (64.9%) patients were boys. The mean (range) age was 5 (1-10) years. The median (range) interval from rash onset to admission was 2 (1-3) days. Cerebrospinal fluid analysis was available in 22 (59.5%) patients and was normal in all. Head computed tomography showed cerebral edema in six out of 18 patients (33.3%). Intravenous acyclovir was administered to 23 patients but no significant differences in clinical manifestations or outcomes were observed in treated versus untreated patients. The mean (range) length of ataxia was 4 (1-10) days, and seven (19%) patients were still ataxic on discharge. The mean (range) length of hospital stay was 4.4 (2-11) days. Minor sequelae were documented in 13 out of 24 (54.2%) patients during follow-up visits and telephone contacts.

CONCLUSIONS

PVCA is usually associated with a favorable prognosis; however, neurological sequelae can occur. The real utility of acyclovir treatment and brain imaging studies in these children remains controversial.

Varicella-zoster virus-specific immune responses in elderly recipients of a herpes zoster vaccine

BACKGROUND

A double-blind, placebo-controlled trial that involved 38,546 subjects > or =60 years old demonstrated efficacy of a high-potency live-attenuated Oka/Merck varicella-zoster virus (VZV) vaccine. The trial included an immunology substudy to determine the relationship of VZV-specific immune responses to vaccination and clinical outcome.

METHODS

The immunology substudy enrolled 1395 subjects at 2 sites where blood samples obtained prior to vaccination, at 6 weeks after vaccination, and at 1, 2, and 3 years thereafter were tested for VZV-specific cell-mediated immunity (VZV-CMI) by gamma-interferon ELISPOT and responder cell frequency assays and for VZV antibody by glycoprotein ELISA.

RESULTS

VZV-CMI and VZV antibodies were significantly increased in vaccine recipients at 6 weeks after vaccination. The vaccine-induced increases in VZV-CMI persisted during the 3 years of follow-up, although their magnitude decreased over time. The magnitude of these VZV-specific immune responses was greater in subjects 60-69 years old than in subjects > or =70 years old.

CONCLUSIONS

The zoster vaccine induced a significant increase in VZV-CMI and VZV antibody. The magnitude and duration of the boost in VZV-CMI in vaccine recipients and the relationship of this boost to age paralleled the clinical effects of the vaccine observed during the efficacy trial. These findings support the hypothesis that boosting VZV-CMI protects older adults against herpes zoster and postherpetic neuralgia.

Recommendations for the management of herpes zoster

The objective of this article is to provide evidence-based recommendations for the management of patients with herpes zoster (HZ) that take into account clinical efficacy, adverse effects, impact on quality of life, and costs of treatment. Systematic literature reviews, published randomized clinical trials, existing guidelines, and the authors' clinical and research experience relevant to the management of patients with HZ were reviewed at a consensus meeting. The results of controlled trials and the clinical experience of the authors support the use of acyclovir, brivudin (where available), famciclovir, and valacyclovir as first-line antiviral therapy for the treatment of patients with HZ. Specific recommendations for the use of these medications are provided. In addition, suggestions are made for treatments that, when used in combination with antiviral therapy, may further reduce pain and other complications of HZ.

Characteristics of facial nerve palsy during childhood in Japan: frequency of varicella-zoster virus association

BACKGROUND

The aim of this study was to clarify the clinical characteristics of facial nerve palsy and the frequency of varicella-zoster virus association in Japanese children, retrospectively.

METHODS

The subjects were 30 facial nerve palsy patients less than 15 years old, treated in the Department of Pediatrics, Kawasaki Medical School Hospital, Okayama, Japan, during the last 10 years.

RESULTS

The male/female and right/left ratios were 16/14 and 16/13, respectively. The patients included 21 cases (70%) of Bell's palsy, four cases (13%) due to otitis media, three cases (10%) of Ramsay Hunt syndrome and two cases (7%) due to birth trauma. There were six cases of zoster sine herpete among the Bell's palsy cases.

CONCLUSION

Varicella-zoster virus-associated facial palsy was found in nine (36%) of the 25 patients examined. Zoster sine herpete was more frequently encountered in children than adults. Ramsay Hunt syndrome was found in school-age children and zoster sine herpete was often found in preschool children. The period of recovery was fast for facial nerve palsy due to acute otitis media, which occurred within 23 months of age, after myringotomy and administration of antibiotics.

Varicella-zoster virus reactivation is an important cause of acute peripheral facial paralysis in children

BACKGROUND

Reactivation of herpes simplex virus type 1 is thought to be a major cause of adult idiopathic peripheral facial paralysis or Bell's palsy. However, few studies have examined the pathogenesis of this condition in children. Serologic assays and polymerase chain reaction (PCR) analysis of paired sera and saliva samples were used here to investigate the causes of acute peripheral facial paralysis in pediatric patients.

METHODS

A total of 30 children with acute peripheral facial paralysis were recruited. Paired sera were assayed for evidence of herpesvirus, mumps virus or Borrelia infection. PCR was used to detect herpes simplex virus type 1 and varicella-zoster virus (VZV) DNA in saliva samples.

RESULTS

Ramsay Hunt syndrome with accompanying zoster lesions was diagnosed clinically in 2 patients, and VZV reactivation was confirmed serologically. VZV reactivation in the absence of zoster (zoster sine herpete) was diagnosed in 9 patients with either serologic assays or PCR. Thus VZV reactivation was demonstrated in 11 of 30 (37%) patients. The prevalence of VZV reactivation among patients between 6 and 15 years of age was significantly higher than in those younger than 5 years of age (53% versus 9%, P = 0.023).

CONCLUSIONS

Our data indicate that VZV reactivation is an important cause of acute peripheral facial paralysis in children, especially those between 6 and 15 years of age.

The role of viruses in idiopathic peripheral facial palsy and cellular immune response

PURPOSE

The purpose of this study is to investigate the role of viruses on the idiopathic peripheral facial palsy and show the interaction of immune system.

MATERIALS AND METHODS

The levels of immunoglobulin (Ig) G and IgM antibodies against to varicella-zoster virus (VZV), herpes simplex virus (HSV), cytomegalovirus (CMV), Ebstein-Barr virus (EBV), and mumps virus in venous blood taken from patients in the amount of 10 mL have been investigated by enzyme-linked immunosorbent assay method. Tumor necrosis factor-alpha (TNF-alpha), interferon-gamma (IFN-gamma), and transforming growth factor-beta (TGF-beta) were also examined. Of lymphocyte subpopulation, antibodies of CD3(+), CD4(+), CD8(+), CD19(+), and CD16(+) plus 56(+) were analyzed.

RESULTS

Ten of the patients had HSV-1 IgG; 1 of the patients IgM, 5 of the patients EBV IgG, 6 of the patients VZV IgG, 1 of the patients IgM, 9 of the patients mumps IgG, 1 of the patients IgM, and finally in 7 of the patients CMV IgG antibodies were obtained. It was found that CD4(+) cell and ratio of CD4(+)/CD8(+) lower and the percentage of the CD8(+) and CD16(+) plus 56(+) cells higher compared with the control group (P < .05). The levels of TNF-alpha were lower, whereas IFN-gamma and TGF-beta1 were higher.

CONCLUSION

It may be concluded from these results that VZV, HSV-1, CMV, EBV, and mumps virus play a significant role in the etiology of idiopathic peripheral facial palsy and activate the cellular immunity.

Facial nerve palsy after human herpesvirus 6 infection

Facial nerve palsy has long been considered to have an infectious etiology, either viruses, mainly herpesviruses, or bacteria, such as Borrelia burgdorferi. We report for the first time the association of human herpesvirus 6 and facial palsy in a previously healthy 1-year 9-month-old boy who developed left facial nerve palsy 7 days after exanthema subitum caused by human herpesvirus 6.