Facial nerve palsy associated with Rickettsia conorii infection

West Nile Virus: A Neglected Cause of Bell's Palsy?

The West Nile virus (WNV) is the leading cause of mosquito-borne disease in the United States. Bell's palsy (BP) is a clinical syndrome associated with viral infections, but an association with West Nile virus (WNV) is not well-described, with only two cases reported in the literature. We present a case of a 68-year-old woman presenting with fevers and encephalopathy. Cerebrospinal fluid was positive for WNV. Following improvement, she developed facial weakness and was diagnosed with BP secondary to the WNV infection. Identifying BP associated with WNV infection may have significant clinical implications, but further studies are needed to fully characterize a causative relationship.

Retrospective serological study of Rickettsia spp. and Borrelia spp. antibodies in patients with peripheral facial nerve palsy

In a retrospective study, 36 patients with peripheral facial palsy were serologically evaluated for the presence of Rickettsia spp. and Borrelia spp. antibodies. All sera underwent immunofluorescence and Western blot analysis for IgG and IgM antibodies using Rickettsia helvetica and R. felis as antigens. Anti-Borrelia antibodies were detected using a commercial ELISA detecting Borrelia burgdorferi, B. afzelii and B. garinii. Three patients (8.3%) were seropositive for Rickettsia spp. with IgG titres equal to 1:128, and six patients (16.7%) had IgM titres equal to or above 1:128. All samples with IgG/IgM titres equal to or above 1:128 were confirmed by Western Blot. Four patients (11.1%) had IgG antibodies against Borrelia at a titre level normally judged to be indicative of current infection. Two of these patients had significant IgG or IgM titres for both Rickettsia spp. and Borrelia spp., indicating co-infection. In conclusion, the findings indicate current rickettsial infection or early response at about the same degree as for Lyme borreliosis in patients with facial palsy, but they need to be further examined with a larger number of patients and paired serum analyses.

When to Think of Rickettsia

Rickettsiae are globally encountered pathogens with foci of endemicity and epidemic exacerbations under circumstances of crowding and decline of sanitation. Diagnosis is often missed due to misconceptions about epidemiology, confusing terminology and nonspecific clinical presentation. Rickettsioses should be considered in children with febrile illnesses exceeding the usual duration of a viral infection, in particular in children with rash, lymphadenopathy and nearly normal first-line laboratory tests, who reside in or return from endemic areas, recall a compatible contact history, have a constellation of symptoms starting after an arthropod bite, live under troubled social circumstances, or are part of a cluster of similar cases.

The neurologist's dilemma: a comprehensive clinical review of Bell's palsy, with emphasis on current management trends

Background

Recent advances in Bell’s palsy (BP) were reviewed to assess the current trends in its management and prognosis.

Material/Methods

We retrieved the literature on BP using the Cochrane Database of Systematic Reviews, PubMed, and Google Scholar. Key words and phrases used during the search included ‘Bell’s palsy’, ‘Bell’s phenomenon’, ‘facial palsy’, and ‘idiopathic facial paralysis’. Emphasis was placed on articles and randomized controlled trails (RCTs) published within the last 5 years.

Results

BP is currently considered the leading disorder affecting the facial nerve. The literature is replete with theories of its etiology, but the reactivation of herpes simplex virus isoform 1 (HSV-1) and/or herpes zoster virus (HZV) from the geniculate ganglia is now the most strongly suspected cause. Despite the advancements in neuroimaging techniques, the diagnosis of BP remains one of exclusion. In addition, most patients with BP recover spontaneously within 3 weeks.

Conclusions

Corticosteroids are currently the drug of choice when medical therapy is needed. Antivirals, in contrast, are not superior to placebo according to most reliable studies. At the time of publication, there is no consensus as to the benefit of acupuncture or surgical decompression of the facial nerve. Long-term therapeutic agents and adjuvant medications for BP are necessary due to recurrence and intractable cases. In the future, large RCTs will be required to determine whether BP is associated with an increased risk of stroke.

Bell's palsy and sudden deafness associated with Rickettsia spp. infection in Sweden. A retrospective and prospective serological survey including PCR findings

BACKGROUND AND PURPOSE

Sixty patients with facial palsy and 67 with sudden deafness were retrospectively or prospectively examined for serological evidence of rickettsial infection; in six cases where cerebrospinal fluid was available, patients were also examined for presence of rickettsial DNA.

METHODS

Rickettsial antibodies were detected in single or paired serum samples using immunofluorescence with Rickettsia helvetica as the antigen and in four cases also using western blot. Using PCR and subsequent direct cycle sequencing, the nucleotide sequences of the amplicons (17 kDa protein gene) in cerebrospinal fluid were analysed.

RESULTS

Five out of 60 (8.3%) patients with facial palsy and eight of 67 (11.9%) with hearing loss showed confirmative serological evidence of infection with Rickettsia spp. An additional three and four patients in the facial palsy and hearing loss groups, respectively, showed evidence of having a recent or current infection or serological findings suggestive of infection. In four cases, the specificity of the reaction was confirmed by western blot. An additional 70 patients were seroreactive with IgG or IgM antibodies higher than or equal to the cut-off of 1:64, whereas 37 patients were seronegative. Only two of 127 patients had detectable antibodies to Borrelia spp. In three of six patients, rickettsial DNA was detected in the cerebrospinal fluid, where the obtained sequences (17 kDa) shared 100% similarity with the corresponding gene sequence of Rickettsia felis.

CONCLUSIONS

These results highlight the importance of considering Rickettsia spp. as a cause of neuritis, and perhaps as a primary cause of neuritis unrelated to neuroborreliosis.

Bilateral simultaneous facial palsy following scrub typhus meningitis: a case report and literature review

Scrub typhus is widely distributed across the Asia-Pacific region, Taiwan included. The clinical manifestations and complications of scrub typhus vary and the illness ranges in severity from mild to fatal. The etiology of facial nerve palsy varies and infectious agents have been associated with this condition. Rickettsiae species have, however, rarely been reported as the causative agents. We report the case of a 49-year-old man who had fever, malaise, headache, oligouria and tea-colored urine. Bilateral pneumonitis, acute renal failure, acalculous cholecystitis and aseptic meningitis were diagnosed after a series of examinations. The patient recovered after doxycycline treatment but he developed bilateral facial palsy during the convalescent phase, which improved after the administration of a steroid. The diagnosis of infection with Orientia tsutsugamushi was confirmed by the Taiwan Center of Disease Control and the tests for Leptospira, Rickettsia typhi and Coxiella burnetii were all negative. This case indicates that scrub typhus needs to be included in the differential diagnoses of cases of bilateral and simultaneous facial nerve palsy, particularly in areas where the disease is endemic.

Facial Paralysis and Meningitis Caused by Rickettsia typhi infection

Involvement of cranial nerves was rarely reported in various rickettsioses. We present here for the first time a case of peripheral facial paralysis associated with Rickettsia typhi infection.

A case of acute quadriplegia complicating Mediterranean spotted fever

Mediterranean spotted fever is a rickettsiosis caused by Rickettsia conorii. Mediterranean spotted fever is considered to be a benign disease, however, approximately 10% of patients present with a severe systemic manifestation in which neurologic involvement occurs. We present a case of an 80-year-old man with a R. conorii infection who developed an acute quadriplegia secondary to an axonal polyneuropathy. The characteristic tache noire was observed on the lateral region of the thigh and elevated IgM antibody titres against R. conorii were detected by an indirect immunofluorescence test.

Mediterranean spotted fever: A review of fifteen cases

We aimed to determine the following things: the frequency of patients with Mediterranean spotted fever (MSF) during the last 10 years among those patients admitted with fever and rash, their clinical features, and the factors predicting the diagnosis of MSF among patients admitted with fever and rash. Between 1993-2002, the files of all patients admitted to our hospital with fever and rash were collected. The clinical features and serologic results of the patients diagnosed with MSF were further investigated. The diagnosis of MSF was established by epidemiological and clinical features and also by the clinical response within 2 days after doxycycline treatment. During the previous 10 years, 140 patients were admitted with fever and rash, and 15 (10%; four females, 11 males; mean age: 41 years; range: 17-70) of them were diagnosed with MSF. Clinical features were as follows: fever (100%), rash (100%), myalgia and/or arthralgia (93%), headache (87%), petechiae (27%), tache noire (13%), leucocytosis (74%), thrombocytopenia (33%), and accelerated erythrocyte sedimentation rate (100%). In nine of these patients, the diagnosis of MSF was established by epidemiological and clinical features and was confirmed by serologic studies. As a complication, one patient developed facial paralysis. Six (40%) were given several antibiotics. In conclusion, MSF should be considered in the differential diagnosis when a patient is admitted with fever, maculopapular rash, headache, myalgia and/or arthralgia, especially in spring, summer, or autumn.

Rickettsial skin disease: uncommon presentations

Rickettsioses occurring worldwide show a significant morbidity and mortality when not properly treated. Early diagnosis is mandatory for better outcome. Clinical symptoms and patient's history are essential, but uncommon presentation of these arthropod-borne diseases may be a challenge.

Motor and sensory polyneuritis with distal conduction failure as uncommon complication of an acute Rickettsia conorii infection

Rickettsia conorii is endemic in the Mediterranean region. Infections are mostly benign and neurological involvement is unusual. We describe a case of a man who presented with acute facial nerve palsy followed by flaccid tetraparesis due to an electrophysiologically established polyneuritis with distal conduction failure. Elevated IgM antibody titres for R. conorii were documented by indirect immunofluorescent antibody test. After doxycycline therapy, the patient presented a rapid clinical improvement. Repeated electrophysiological examinations revealed significantly restored compound muscles, and sensory action potentials, corresponding to the clinical course after treatment and ex juvantibus, indicate the causative relation between R. conorii infection and the described clinical syndrome.