Successful oral treatment of third cranial nerve palsy and optic neuritis from neglected herpes zoster in an immunocompetent patient

Abstract

Purpose Herpes zoster (HZ) is an acute viral eruption caused by the reactivation of varicella zoster virus (VZV), a herpes virus causing chicken pox in children. We aimed to report a 3-month neglected case of acute herpes zoster-induced third nerve palsy and optic neuritis, followed by a late-onset keratouveitis in an immunocompetent young adult. Observations A 36-year old immunocompetent Egyptian male patient presented with 3-month complaints of blurred vision and drooping of his left upper eyelid that appeared 4 days after a herpetic rash. He had been diagnosed with herpes zoster ophthalmicus (HZO) of the left eye. However, he had not received any systemic antiviral treatment. The patient had an abnormal head posture with post-eruptive scars on the left forehead and the nose tip. Examination revealed weakness of elevation and adduction, partial ptosis, and mid-dilated non-reactive pupil in the left eye. A relative afferent pupillary defect (RAPD) was present in the affected eye. His blood sugar and blood pressure were within normal limits. Contrast magnetic resonance imaging (MRI) showed no space-occupying lesion. However, there were enhancement and enlargement of the left optic nerve on T1-weighted images, denoting optic neuritis. A diagnosis of acute left third nerve palsy with pupil involvement and optic neuritis secondary to HZO was made. Despite late treatment with oral acyclovir and prednisolone, the patient recovered. One and a half months later, he developed a late-onset keratouveitis about 8 months after the rash onset. After the resolution of the episode, oral acyclovir was continued at a prophylactic dose (400 mg BID). Conclusions and importance HZ is a rare cause of third nerve palsy with pupil involvement and optic neuritis. Oral acyclovir and steroids were effective in the delayed treatment in this case. Abnormal optic nerve enhancement on MRI 3 months after the appearance of vesicular rash may suggest chronic HZ activity. Concurrent optic neuritis and third cranial nerve palsy in the absence of other signs of orbital apex syndrome can be seen in cases of HZO. Regular follow-up of patients with HZ is important for detecting recurrence and initiating prompt treatment.

Severe Bilateral Photophobia and Unilateral Abducens Nerve Palsy: An Unusual Presentation of Herpes Zoster Ophthalmicus

“…In a recent retrospective study, 9 of 12 patients with HZO-related optic neuropathy experienced improved visual outcomes after receiving adjuvant corticosteroid therapy [12]. Furthermore, there are multiple reports of delayed onset ophthalmoplegia after antiviral treatment, indicating that antiviral therapy alone may not be sufficient to prevent the neurologic complications of HZO [13].…”

Unilateral Pupil Sparing: Viral Oculomotor Neuritis With Concomitant Vestibular Neuritis

“…This case also represents a rarely attributed cause of oculomotor neuritis - a viral infection. Notably, there has been a reported case of simultaneous oculomotor and facial nerve neuritis in a patient with systemic lupus erythematosus and Sjogren syndrome, and a reported case of oculomotor and optic nerve neuritis in a patient with herpes zoster ophthalmicus [ 3 - 4 ].…”

“…A few cases have been reported in patients with infectious mononucleosis and dengue fever [ 6 - 7 ]. Additionally, viral herpes zoster-induced CN III palsy has been reported in a patient who presented with herpes zoster ophthalmicus [ 4 ]. In one of the previously reported cases of viral oculomotor neuritis, MRI revealed abnormal enhancement and a lesion on CN III, clinically correlated to the patient’s symptoms [ 6 ].…”

“…However, prednisone during the first 10 to 20 days of the attack may shorten the illness [ 12 ]. Acyclovir has also been suggested for use in patients with herpes caused oculomotor neuritis [ 4 ]. Clinically, our patient’s symptoms improved after starting steroids.…”

Bioinformatic analyses suggest augmented interleukin-17 signaling as the mechanism of COVID-19-associated herpes zoster

“…VZV is also the causative agent of varicella (commonly known as chickenpox) that predominantly affects children under the age of 12 (Bérar et al 2021 , Shiraki et al 2021 ). Following the initial infection, this virus remains latent in the ganglion cells of dorsal root or cranial nerve (Fukuyasu et al 2021 , Osman 2020 , Zhu et al 2020 ). Increasing age and immunosuppression are two major risk factors for VZV reactivation (Amaral et al 2021 ).…”