Multiple cranial nerve involvement with herpes zoster

Unilateral associated laryngeal paralysis due to varicella-zoster virus: virus antibody testing and videofluoroscopic findings

The relationship between varicella-zoster virus and idiopathic associated laryngeal paralysis was examined in five patients, using complement fixation or enzyme immunoassay testing. In all cases, significant changes in serum levels of varicella-zoster virus antibody were observed. Videofluoroscopy was useful in assessing the severity of the dysphagia and in making an accurate diagnosis; both laryngeal elevation and weakness of pharyngeal wall contraction were also observed. In two cases in which antiviral therapy was delayed, the outcome was poor, with increased levels of varicella-zoster virus immunoglobulin M found on enzyme immunoassay. The outcome of the condition may thus depend both on the speed of antiviral therapy commencement following onset of symptoms, and on the levels of varicella-zoster virus immunoglobulin M antibody (measured by enzyme immunoassay). Our study suggests that varicella-zoster virus should be considered in the differential diagnosis of patients with idiopathic associated laryngeal paralysis, and rapid antiviral therapy should be initiated when necessary.

Cranial polyneuropathy--Ramsay Hunt's syndrome: case report and discussion

Ramsay Hunt's syndrome is an infectious cranial polyneuropathy caused by varicella zoster, the herpetic virus that also causes chickenpox and shingles. Its symptoms include facial paralysis, ear pain, and an auricular rash. Oral lesions are also present in most cases. This syndrome can affect any cranial nerve and usually affects multiple nerves, causing central, cervical, and peripheral effects. This article reports the case of a 35-year-old white female who was treated by the oral surgery service of a large urban hospital, after first reporting to the emergency clinic. Her reported symptoms of unilateral left-side facial paralysis, auricular pain, and trigeminal hyperesthesia were confirmed by clinical examination. An initial short low-dose steroid regimen was unsuccessful. A second daily dosage of 50 mg of prednisone was successful in 21 days. No permanent sequelae were evident or reported after treatment.

Cephalic Zoster with Laryngeal Paralysis

Herpes zoster reactivaction in the head and neck region is often associated with multiple cranial neuropathies, the most common one being facial paralysis. Laryngeal paralysis has also been occasionally reported with zoster infection. We present two such cases, and discuss the relevant literature on the pathophysiology, evaluation and management of this disease. Recent advances in antiviral therapy have allowed for specific medical treatment, thus making it all the more imperative to suspect zoster, even in clinically atypical cases. We suggest aggressive treatment with intravenous acyclovir for cephalic zoster complicated by vocal cord paralysis.

Enhanced MRI in patients with Ramsay-Hunt's syndrome

Enhanced MRI was performed in 14 patients with Ramsay-Hunt's syndrome to investigate the pathogenesis of this syndrome. All MRI studies were performed on a 0.5T superconductivity MRI system using a head coil with Gd-DTPA. Enhancement was observed in the areas of the distal internal auditory canal and labyrinthine segment in many patients, and was especially prominent in patients suffering from vertigo, tinnitus, and hearing loss. In some patients it involved not only the facial nerve of the internal auditory canal but also the cochlear nerve and vestibular nerves. Since histological changes of the facial nerve in patients with Ramsay-Hunt's syndrome are assumed to occur in the distal internal auditory canal and labyrinthine segment, which is more proximal than the geniculate ganglion, and the possibility is suggested that inflammation may spread to the vestibular and cochlear nerve via the internal auditory canal.

Herpes zoster ophthalmicus and delayed contralateral hemiparesis caused by cerebral angiitis: diagnosis and management approaches

Four patients with herpes zoster ophthalmicus and delayed contralateral hemiparesis are described, and their findings are compared with those in patients previously reported in the English language literature. The current patients evidenced multifocal ipsilateral cerebral angiitis by angiography and multifocal infarcts in the distribution of the ipsilateral middle cerebral artery by computed tomographic scanning. Cerebrospinal fluid showed mononuclear pleocytosis, positive oligoclonal bands, and an elevated immunoglobulin G index. Two patients were treated with corticosteroids and acyclovir, and 1 with corticosteroids alone, all without apparent response. Necrotizing angiitis ipsilateral to the herpes zoster ophthalmicus was demonstrated postmortem in 1 patient with multifocal cerebral infarction and progressive leukoencephalopathy. Neither herpes varicella zoster immunocytochemical reactivity nor viral inclusions were seen. The leukoencephalopathy associated with herpes varicella zoster either may be caused by cerebral angiitis or, as previously reported, may be a temporally remote manifestation of persistent herpes varicella zoster infection. The cerebral angiitis associated with herpes varicella zoster is histologically similar to granulomatous angiitis, and both may be related to herpes varicella zoster infection of the cerebral vasculature.

[Unilateral involvement of IX, X, Xi and XII in cervical zoster. Cranial nerve contribution to vascular pathology]

The authors report a case of a cervical zoster (C2 - C4) with unilateral involvement of the IXth, Xth, XIth and XIIth cranial nerves. Angiography failed to opacify the ascending pharyngeal artery on the same side, presumably because of a thrombosis secondary to the zoster infection. As the ascending pharyngeal artery is known to supply the last four cranial nerves, this study should be seen as a further example of the varied cranial nerve involvement which may arise on a vascular basis.