Herpes zoster involving the abducens and vagus nerves without typical skin rash

Abstract

Rationale: Herpes zoster is characterized by unilateral vesicular eruption and it most often affects the trigeminal nerve. We would like to report a rare case of abducens and vagus nerves palsy caused by varicella zoster virus (VZV) without the typical vesicular rash. Patient concerns: A 71-year-old woman presented with diplopia. Three days previously, she had experienced sore throat and hoarseness. Diagnosis: At presentation, the prism cover test revealed esotropia of 10 prism diopters at primary gaze, and abduction was restricted in the right eye. No vesicular rash was observed on the patient's face, and magnetic resonance imaging of the brain showed no pathology. Flexible fiberoptic laryngoscopy revealed multiple ulcerations on the right side of the larynx—from the epiglottis to the arytenoid. After 1 day of hospitalization, a diffuse skin rash occurred on the patient's trunk, and polymerase chain reaction for VZV DNA was positive at the skin lesion. The patient was diagnosed as having herpes zoster associated with vagus and sixth nerve palsy. Intervention and outcomes: She received famciclovir at a dose of 500 mg 3 times daily for 7 days and coadministered methylprednisolone. At the 4-month follow-up, her diplopia and eye movement had resolved completely. Lessons: In patients with abducens nerve palsy without typical vesicular lesion, herpes zoster may not be detected early. In that case, systemic examination is very important for diagnosing herpes zoster.

A Case Report of Acute Laryngitis with Auricular Lesion: Herpes Zoster Infection with Isolated Vagus Nerve Involvement and Vocal Fold Paresis

“…3) Since the main manifestation of herpes zoster (HZ) infection is a skin or mucosal lesion appearing in an area that is innervated by an infected nerve, the location of vesicles indicates which nerve is affected by VZV infection. 5,6) Thus, VHZ was suspected in this patient because of the observation of vesicular lesions in the ipsilateral auricle and larynx. In addition, accompanying ipsilateral vocal fold paresis made VHZ more likely based on the function of the vagus nerve.…”

A Case Report of Acute Laryngitis with Auricular Lesion: Herpes Zoster Infection with Isolated Vagus Nerve Involvement and Vocal Fold Paresis

“…3) Since the main manifestation of herpes zoster (HZ) infection is a skin or mucosal lesion appearing in an area that is innervated by an infected nerve, the location of vesicles indicates which nerve is affected by VZV infection. 5,6) Thus, VHZ was suspected in this patient because of the observation of vesicular lesions in the ipsilateral auricle and larynx. In addition, accompanying ipsilateral vocal fold paresis made VHZ more likely based on the function of the vagus nerve.…”

Abducens Nerve Palsy as a Complication of Herpes Zoster Ophthalmicus: A Case Report

“…From this, we may conclude that the pathophysiology of ophthalmoplegia may be attributable to one of the following: direct cytopathic impact of the virus on the brain tissue it infects, central nervous system's immunological reaction to the infection, or attributes it to a virus-induced occlusive vasculitis [1].…”

“…Edgerton and Godtfredsen et al [14,8] hypothesized that the second, third, fourth, and sixth nerves were involved as a result of continuous intracavernous radiculomeningitis. Kreibig et al [1] proposed that perivasculitis-myositis rather than a neurological cause caused extraocular palsies.…”

Bilateral Cranial Nerve VI Palsies in Cryptococcal Meningitis, HIV, and Syphilis: A Case Report

“…A biopsy of the skin lesions showed VZV and the mechanism by which CN VI was involved remain poorly understood. 7 Another case report involving unilateral CN VI palsy was discussed by Lundin et al (2020) in a 70-year-old man with right eye pain and double vision who later developed erythema migrans. This patient was found to have optic neuritis with CN VI palsy secondary to Lyme disease.…”

“…Nevertheless, these cases are often unilateral and involve additional cranial nerves, such as oculomotor, facial and vagus nerves. 7,8,9 Joo, Lee and Kim (2019) reported a 71-year-old female who presented with vocal cord paralysis and diplopia who later developed a skin rash. A biopsy of the skin lesions showed VZV and the mechanism by which CN VI was involved remain poorly understood.…”

A Case Report of Acute Laryngitis with Auricular Lesion: Herpes Zoster Infection with Isolated Vagus Nerve Involvement and Vocal Fold Paresis

“…3) Since the main manifestation of herpes zoster (HZ) infection is a skin or mucosal lesion appearing in an area that is innervated by an infected nerve, the location of vesicles indicates which nerve is affected by VZV infection. 5,6) Thus, VHZ was suspected in this patient because of the observation of vesicular lesions in the ipsilateral auricle and larynx. In addition, accompanying ipsilateral vocal fold paresis made VHZ more likely based on the function of the vagus nerve.…”

Abducens Nerve Palsy as a Complication of Herpes Zoster Ophthalmicus: A Case Report

“…From this, we may conclude that the pathophysiology of ophthalmoplegia may be attributable to one of the following: direct cytopathic impact of the virus on the brain tissue it infects, central nervous system's immunological reaction to the infection, or attributes it to a virus-induced occlusive vasculitis [1].…”

“…Edgerton and Godtfredsen et al [14,8] hypothesized that the second, third, fourth, and sixth nerves were involved as a result of continuous intracavernous radiculomeningitis. Kreibig et al [1] proposed that perivasculitis-myositis rather than a neurological cause caused extraocular palsies.…”

Bilateral Cranial Nerve VI Palsies in Cryptococcal Meningitis, HIV, and Syphilis: A Case Report

“…A biopsy of the skin lesions showed VZV and the mechanism by which CN VI was involved remain poorly understood. 7 Another case report involving unilateral CN VI palsy was discussed by Lundin et al (2020) in a 70-year-old man with right eye pain and double vision who later developed erythema migrans. This patient was found to have optic neuritis with CN VI palsy secondary to Lyme disease.…”

“…Nevertheless, these cases are often unilateral and involve additional cranial nerves, such as oculomotor, facial and vagus nerves. 7,8,9 Joo, Lee and Kim (2019) reported a 71-year-old female who presented with vocal cord paralysis and diplopia who later developed a skin rash. A biopsy of the skin lesions showed VZV and the mechanism by which CN VI was involved remain poorly understood.…”

A Case Report of Acute Laryngitis with Auricular Lesion: Herpes Zoster Infection with Isolated Vagus Nerve Involvement and Vocal Fold Paresis

“…3) Since the main manifestation of herpes zoster (HZ) infection is a skin or mucosal lesion appearing in an area that is innervated by an infected nerve, the location of vesicles indicates which nerve is affected by VZV infection. 5,6) Thus, VHZ was suspected in this patient because of the observation of vesicular lesions in the ipsilateral auricle and larynx. In addition, accompanying ipsilateral vocal fold paresis made VHZ more likely based on the function of the vagus nerve.…”

Abducens Nerve Palsy as a Complication of Herpes Zoster Ophthalmicus: A Case Report

“…From this, we may conclude that the pathophysiology of ophthalmoplegia may be attributable to one of the following: direct cytopathic impact of the virus on the brain tissue it infects, central nervous system's immunological reaction to the infection, or attributes it to a virus-induced occlusive vasculitis [1].…”

“…Edgerton and Godtfredsen et al [14,8] hypothesized that the second, third, fourth, and sixth nerves were involved as a result of continuous intracavernous radiculomeningitis. Kreibig et al [1] proposed that perivasculitis-myositis rather than a neurological cause caused extraocular palsies.…”

Bilateral Cranial Nerve VI Palsies in Cryptococcal Meningitis, HIV, and Syphilis: A Case Report

“…A biopsy of the skin lesions showed VZV and the mechanism by which CN VI was involved remain poorly understood. 7 Another case report involving unilateral CN VI palsy was discussed by Lundin et al (2020) in a 70-year-old man with right eye pain and double vision who later developed erythema migrans. This patient was found to have optic neuritis with CN VI palsy secondary to Lyme disease.…”

“…Nevertheless, these cases are often unilateral and involve additional cranial nerves, such as oculomotor, facial and vagus nerves. 7,8,9 Joo, Lee and Kim (2019) reported a 71-year-old female who presented with vocal cord paralysis and diplopia who later developed a skin rash. A biopsy of the skin lesions showed VZV and the mechanism by which CN VI was involved remain poorly understood.…”