A Rare Complication of Herpes Zoster: Segmental Zoster Paresis

Abstract

Herpes zoster is a common presentation in both the community and emergency department; however segmental zoster paresis is a rare complication that can lead to misdiagnosis. We present a case of a 74-year-old Indian gentleman with a background of well controlled diabetes mellitus, hypertension, and ischaemic heart disease who presented with sudden right lower limb weakness. This was preceded by a 5-day history of paraesthesia starting in the right foot and ascending up the right lower limb. On examination, there was a characteristic vesicular rash in the L2/3 region with MRC grading 3/5 in the right hip flexors. The rest of the neurological examination was unremarkable. MRI of the spine did not show any evidence of spinal disease. The patient was initiated on IV acyclovir with improvement of the lower limb weakness to MRC grading 5/5 as the vesicles improved. This is an interesting case as it highlights a rare presentation of zoster: segmental motor paresis that recovered fully with resolution of the rash. It shows the importance of recognizing motor neuropathy as a complication of shingles as it has a very good prognosis with most patients regaining full motor function of the affected limb with treatment.

Ultrasound-guided peri-brachial plexus polydeoxyribonucleotide injection for a patient with postherpetic brachial plexopathy

“…Motor recovery varied from full recovery within a few days to partial recovery after 2 years. [1,3,14–16] Our patient did not gain full recovery, even after 6 months. This is thought to be due to the degree of motor nerve involvement.…”

Clinical Presentations and Outcome Studies of Cranial Nerve Involvement in Herpes Zoster Infection: A Retrospective Single-Center Analysis

“…We raise a hypothesis to explain the occurrence of cranial motor neuropathy in herpes zoster infection. The reactivation of latent VZV in the cranial sensory ganglia (geniculate ganglion and/or trigeminal ganglion) may activate cellular immune responses and induce collateral damage to nearby single or multiple cranial motor nerves due to a close proximity of the cranial motor nerves and sensory ganglia [21].…”

Segmental Zoster Paresis: A Literature Review

“…The involvement of C3-C5 motor nerves could lead to diaphragmatic paresis and induce the clinical manifestations, including dyspnea and pulmonary dysfunction (42,43). The affected ganglion segments and possible clinical manifestation are summarized in Table 1 (3,7,28,34,(44)(45)(46)(47)(48)(49)(50)(51)(52)(53)(54)(55)(56)(57)(58)(59)(60)(61)(62)(63).…”

“…Previous studies have reported that the infection of VZV accounts for 0.5% -5% of all the motor impairments (3). Nevertheless, the exact odds related to this complication still remain unclear, which is mainly due to the following 2 factors: 1) the difficulties in clinical diagnosis (the differentiation from myasthenia induced by other causes, or the limb weakness masked by drastic pain); and 2) atypical clinical symptoms of segmental intercostal paresis and abdominal muscle paresis.…”