Herpes zoster ophthalmicus and lateral rectus palsy in an elderly patient

Isolated Abducens Nerve Palsy After Herpes Zoster Ophthalmicus: A Case Report

Aim: The purpose of this study was to demonstrate a case of herpes zoster in the patient. Methods: Case report. Results: Herpes zoster ophthalmicus is a rare but well-known cause of CN VI palsy that affects an elderly patient due to a reduction in the immunity to the Varicella Zoster Virus (VZV). We reported a case of herpes zoster in our patient, a 67-year-old Javanese female who presented with a VI nerve palsy within 1 week after the vesicular rash. Our patient received Valacyclovir, Gabapentin, and steroid treatment, then responded quite well to the combination of these therapies without side effects as the goals were to diminish acute and chronic pain, fasten the healing of the skin and nerve, and reduce the chances of dissemination. Based on studies, systemic antivirals should be given in all cases of HZO to minimize complications and steroids should not be given without antiviral therapy so as not to increase viral replication. Conclusions: As a complication of HZO, ophthalmoplegia may have various origins. We reported a case of sixth nerve palsy in HZO. Abbreviations: HZO = herpes zoster ophthalmicus, VZV = varicella-zoster virus, CN = Cranial Nerve.

Herpes Zoster Burden of Disease and Clinical Management in Turkey: A Comprehensive Literature Review

INTRODUCTION

Herpes zoster (HZ), or shingles, is caused by the reactivation of varicella zoster virus (VZV) and typically presents as an acute, painful dermatomal rash, but can lead to long-term, distressing complications such as postherpetic neuralgia (PHN). Increasing trends in HZ cases are evident globally among the aging population; however, reviews investigating the epidemiology and clinical management of HZ in Turkey are lacking. Therefore, a literature review of local studies in Turkey was conducted to identify the data available and identify gaps in the literature.

METHODS

Literature searches were carried out in PubMed and local journals to retrieve published articles that reported surveillance data, seroepidemiology, patient outcomes, or clinical management related to HZ or VZV in Turkey until April 30, 2022. Studies included primary data reports, case studies, secondary data reviews, and epidemiological studies in healthy or at-risk populations; HZ was the primary focus of the review.

RESULTS

No studies reported VZV or HZ epidemiological data at a national level. One large retrospective study in Istanbul reported that HZ incidence rates significantly increased in adults 18-44 years of age between 2011 and 2019. Four single-center studies reported the proportion of dermatological patients with HZ at 0.43-1.56%. PHN was the most common reported complication, occurring in 8-58.9% of patients with HZ. However, out of 39 identified case reports, HZ ophthalmicus was the most frequently reported complication. Two studies highlighted poor disease awareness and risk perception of HZ among Turkish citizens.

CONCLUSION

Overall, there were limited comprehensive epidemiological data on HZ in Turkey. However, the abundance of case studies on HZ complications indicates a strong disease presence and diverse clinical management in Turkey. Further research will be important to understand the impact of HZ, increase disease awareness, and support the introduction of new preventative strategies.

The Neurotropic Varicella Zoster Virus: a Case of Isolated Abducens Nerve Palsy without Skin Rash in a Young Healthy Woman

INTRODUCTION

Varicella Zoster Virus (VZV) is a neurotropic virus whose reactivation can affect the central nervous system (CNS) and manifest as different neurological syndromes usually with dermatological involvement. Extraocular muscle palsies are not commonly described associated with VZV and their presence in the absence of a typical zoster rash is even rarer.

METHODS

Case report of a young immunocompetent patient with unilateral abducens nerve palsy, as an isolated manifestation of VZV infection.

RESULTS

A 25-year-old healthy female presented to the emergency department with a subacute onset of painless horizontal binocular diploplia, over a month. Ophthalmological and neurological examination revealed an isolated right abducens nerve palsy, and polymerase chain reaction of the cerebrospinal fluid identified a VZV infection. There was no skin rash involvement. Other infectious, inflammatory, and autoimmune diseases were excluded. Treatment with intravenous acyclovir and dexamethasone improved but not completely resolved the diplopia and strabismus. The patient was submitted to a medial rectus recession surgery.

DISCUSSION

VZV manifestations in the CNS can occur in healthy young individuals and can manifest in the absence of the typical skin rash. Isolated sixth nerve palsy is a very rare manifestation of VZV infection. Young patients with isolated ocular motor mononeuropathies, even with cardiovascular risk factors, benefit from a CNS-based approach and MRI and lumbar puncture should be considered. Reports show that extraocular muscle palsy associated with VZV is a transient condition and resolve partially or completely after few weeks.