A retrospective case series of segmental zoster paresis of limbs: clinical, electrophysiological and imaging characteristics

Case Report of Herpes Zoster Infection of the Cervical Dermatome - A Rare Cause of Acute Shoulder Pain

Introduction

Acute shoulder pain is among the most common presenting complaints in the clinic. Clinicians may find it challenging with the myriad of potential etiologies to explain for the presenting complaint. We present a unique case, where a herpes zoster infection in the C6 dermatome mimicked the presentation of rotator cuff pathology and was admitted to the care of orthopedics. We have also included a detailed literature review on the topic in our study.

Case Report

The patient was a 38-year-old Chinese female who presented with acute atraumatic right-sided shoulder pain and weakness which was potentially confounded by an attempt of traditional Chinese medicine. Clinical examination revealed that the range of motion was globally reduced and painful in all directions with equivocal impingement testing. Examination of the skin revealed the presence of polymorphous eruption of erythematous papules and vesicles in the right shoulder and C6 region. In this paper, we discuss a possible algorithm to aid clinicians in an acute shoulder pain history with accompanying red flags to look out for. This is accompanied by a detailed literature review on the topic which demonstrates the rarity of this presentation which eventually confounded the initial management of the patient.

Conclusion

A thorough history and physical examination must remain the cornerstone of a clinician's diagnostic algorithm. Zoster neuropathy at the level of the cervical spine is a rare entity. This case report also emphasizes the need for cognizance of local traditional remedies practiced and their interactions with clinical diagnosis and treatment.

Herpes zoster peripheral nerve complications: Their pathophysiology in spinal ganglia and nerve roots

Varicella zoster virus (VZV) causes chickenpox at the primary infection and then becomes latent in the spinal dorsal root ganglia; VZV can reactivate with aging, immunosuppression, stress, and other factors, occurring as herpes zoster (HZ) at 1-2 skin segments. HZ peripheral nerve complications caused by VZV reactivation include Hunt syndrome, segmental HZ paresis, post-herpetic neuralgia, and Guillain-Barré syndrome (GBS). We have encountered the rare HZ complications of upper-limb paresis, myeloradiculitis, and polyradiculoneuritis: an adult woman with upper-limb paresis consistent with the nerve root on segments above the thoracic HZ dermatome; another woman exhibiting ascending myeloradiculitis originating at the Th11-12 roots; an elderly woman with ascending VZV polyradiculoneuritis resembling GBS; an adult with VZV quadriplegia with disseminated HZ; and an elderly patient with VZV-associated polyradiculoneuritis. The three polyradiculoneuritis cases may be a new subtype of HZ peripheral neuropathy, but the pathophysiology for these HZ peripheral nerve complications unrelated to HZ dermatomes is unclear. We analyzed host factors, skin lesions, neurological and virological findings, and MRI results including 3D NerveVIEW in 15 Japanese patients treated at our facility for HZ peripheral neuropathy, including six differing from the HZ dermatome. Based on the clinical findings including MRI results of spinal ganglia and roots, we identified four possible routes for the patterns of VZV spread: (i) ascending spinal roots, (ii) ascending spinal cord, (iii) polyradiculopathy, and (iv) intrathecal spread. The incidence of HZ is increasing with the aging of many populations, and clinicians should be aware of these HZ neuropathies.

A Report of a Case of Segmental Zoster Paresis Demonstrated by Limb Paralysis and a Review of the Literature

Varicella zoster virus (VZV) lies dormant in our spinal dorsal root ganglia until reactivation occurs and causes herpes zoster. VZV can spread from the dorsal root to the neighboring ventral root and cause subsequent segmental paresis. In this case report, we present the case of a 78-year-old female who was hospitalized after she developed right upper extremity paresis and altered mental status four days after the eruption of a vesicular rash involving the same dermatome. The patient received intravenous acyclovir, gabapentin, and inpatient rehabilitation. She was found to have made a full recovery one year later. Pain and a vesicular rash is the most common presentation of VZV infection in the elderly. However, segmental zoster paresis should be suspected in any patient with paralysis and a recent diagnosis of herpes zoster.

Risk factors and nomogram-based prediction of the risk of limb weakness in herpes zoster

Background

Limb weakness is a less common complication of herpes zoster (HZ). There has been comparatively little study of limb weakness. The aim of this study is to develop a risk nomogram for limb weakness in HZ patients.

Methods

Limb weakness was diagnosed using the Medical Research Council (MRC) muscle power scale. The entire cohort was assigned to a training set (from January 1, 2018 to December 30, 2019, n = 169) and a validation set (from October 1, 2020 to December 30, 2021, n = 145). The least absolute shrinkage and selection operator (LASSO) regression analysis method and multivariable logistic regression analysis were used to identify the risk factors of limb weakness. A nomogram was established based on the training set. The discriminative ability and calibration of the nomogram to predict limb weakness were tested using the receiver operating characteristic (ROC) curve, calibration plots, and decision curve analysis (DCA). A validation set was used to further assess the model by external validation.

Results

Three hundred and fourteen patients with HZ of the extremities were included in the study. Three significant risk factors: age (OR = 1.058, 95% CI: 1.021–1.100, P = 0.003), VAS (OR = 2.013, 95% CI: 1.101–3.790, P = 0.024), involving C6 or C7 nerve roots (OR = 3.218, 95% CI: 1.180–9.450, P = 0.027) were selected by the LASSO regression analysis and the multivariable logistic regression analysis. The nomogram to predict limb weakness was constructed based on the three predictors. The area under the ROC was 0.751 (95% CI: 0.673–0.829) in the training set and 0.705 (95% CI: 0.619–0.791) in the validation set. The DCA indicated that using the nomogram to predict the risk of limb weakness would be more accurate when the risk threshold probability was 10–68% in the training set and 15–57% in the validation set.

Conclusion

Age, VAS, and involving C6 or C7 nerve roots are potential risk factors for limb weakness in patients with HZ. Based on these three indicators, our model predicted the probability of limb weakness in patients with HZ with good accuracy.

Segmental Zoster Paresis of the Unilateral Lower Extremity With Neuritis MRI Findings: A Case Report and Literature Review

Herpes zoster (HZ) is a common clinical condition caused by the reactivation of the latent varicella-zoster virus (VZV). Neurological complications after HZ have been described, including a rare condition of segmental zoster paresis (SZP), which results in unilateral motor impairment in the extremities. Only two cases of HZ patients with radiculopathy and MRI findings of neuritis have been reported. We present a 62-year-old male with a HZ rash in the right calf and low back pain radiating to the right leg accompanied by a right leg great toe weakness for one week. Neurological examination revealed 4/5 dorsiflexion of the right great toe. Also, the patient’s rash was distributed on the L5 dermatome. The lumbar MRI showed a contrast enhancement of the right L5 nerve root with enlargement diagnosed as neuritis. The patient was treated with valacyclovir. The neuromotor deficit and the cutaneous rash started to improve on the third day of treatment. This case emphasizes the necessity of considering SZP in the differential diagnosis of elderly patients presenting with muscle weakness in the lower extremity with or without a rash. MRI evaluations of HZ patients with radiculopathy may include contrast-enhanced sequences.

Cervical Root Enlargement in Segmental Zoster Paresis: A Study with Magnetic Resonance Imaging and Nerve Ultrasound

A 72-year-old woman presented with acute-progressive muscle weakness after a rash in the left upper limb. Muscle weakness was restricted to the left C5 innervated muscles. Short inversion time inversion recovery magnetic resonance imaging (MRI) showed a high-intensity signal in the left C5 nerve root, and nerve ultrasound showed its enlargement. She was diagnosed with segmental zoster paralysis (SZP) and treated with acyclovir and methylprednisolone. Her muscle strength gradually recovered, and the abnormal signal and enlargement in the left C5 nerve root improved. This is the first SZP case of confirmed improvement of abnormal findings on MRI and nerve ultrasound in association with muscle power recovery.

A Rare Complication of Herpes Zoster: Segmental Zoster Paresis

Segmental zoster paresis (SZP) is a rare complication of herpes zoster (HZ) that results in focal weakness of the extremity in the myotome that corresponds to dermatomal involvement.We present a case of an 80-year-old female with a resolving HZ rash on her left leg and buttocks that presented with left leg weakness for two weeks. The patient’s rash preceded the left leg weakness by two weeks. The exam revealed erythematous macular and crusting lesions in the left L3/L4 distribution. The left thigh was flaccid with 1/5 knee extension strength with an absent patellar reflex. Lumbar spine magnetic resonance imaging (MRI) revealed enhancement of the left L4 roots, suggestive of inflammation or neuropathy. The patient was discharged on gabapentin, amitriptyline, and a two-week prednisone taper. In this case study, we present SZP, a rare complication that occurs in approximately 3% of HZ patients. The majority of SZP cases occur on the face or upper extremity, whereas our patient had SZP of the lower extremity. This case emphasizes the importance of maintaining a comprehensive differential diagnosis and highlights that SZP should be considered in patients who present with acute weakness in an extremity.

Successful management of segmental zoster paresis on the upper arm with temporally burst spinal cord stimulation

Segmental zoster paresis (SZP) of the limbs is characterized by a focal, asymmetric neurogenic weakness that may occur in an extremity affected by herpes zoster (HZ). In this case report, we describe the case of a patient with SZP who presented with these problems and responded well to temporary spinal cord stimulation (SCS) and systematic rehabilitation. A 62-year-old female patient was referred for right upper limb pain, weakness, and insomnia due to pain. After completing the 14-day trial stimulation, the pain numerical rating scale of the patient in the right upper extremity decreased from 8/10 to 2/10. The Athens insomnia scale score decreased from 15/24 to 10/24. Furthermore, the grip strength of the right hands increased from 6.7 to 16.8 kg at discharge. We induced temporal SCS and rehabilitation of the right upper limb SZP and successfully reduced the pain. An in-depth understanding of the neurological complications secondary to HZ should be emphasized, with temporal SCS and rehabilitation expected to play a crucial role in the motor recovery of patients with SZP.

ACR Appropriateness Criteria® Plexopathy: 2021 Update

Plexopathy may be caused by diverse pathologies, including trauma, nerve entrapment, neoplasm, inflammation, infection, autoimmune disease, hereditary disease, and idiopathic etiologies. For patients presenting with brachial or lumbosacral plexopathy, dedicated plexus MRI is the most appropriate initial imaging modality for all clinical scenarios and can identify processes both intrinsic and extrinsic to the nerves. Other imaging tests may be appropriate for initial imaging depending on the clinical scenario. This document addresses initial imaging strategies for brachial and lumbosacral plexopathy in the following clinical situations: nontraumatic plexopathy with no known malignancy, traumatic plexopathy (not perinatal), and plexopathy occurring in the context of a known malignancy or posttreatment syndrome. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Segmental zoster paresis as a cause for persistent fever in an immunocompromised patient

Herpes zoster reactivation is a frequently encountered condition that can result in several uncommon complications. This case report highlights one such frequently overlooked complication, segmental zoster paresis. We discuss a case of prolonged fever and lower limb weakness in an immunocompromised patient with breast cancer on active chemotherapy after resolution of a herpetiform rash in the L2, L3 and L4 dermatomes. Early investigation with lumbar puncture, looking for cerebrospinal fluid pleocytosis, varicella zoster virus detection by PCR or molecular testing and immunoglobulins against varicella zoster virus, should be undertaken to support the diagnosis. Nerve conduction studies, electromyography and MRI of the spine can sometimes help with neurolocalisation. Intravenous acyclovir and a tapering course of steroids can help with resolution of symptoms. The variegate presentation can make diagnosis challenging. Awareness and a high index of suspicion can prevent delays in diagnosis and treatment and improve patient outcomes.

Complete recovery of herpes zoster radiculopathy based on electrodiagnostic study: A case report

BACKGROUND

Herpes zoster is a painful infectious disease caused by the varicella zoster virus. Herpes zoster radiculopathy, which is a type of segmental zoster paresis, can complicate the disease and cause motor weakness. This complication should be considered when a patient with a rash complains of acute-onset motor weakness, and the diagnosis can be verified via electrodiagnostic study.

CASE SUMMARY

A 64-year-old female with a history of asthma presented to the emergency department with stabbing pain, an itching sensation, and a rash on the right anterior shoulder that had begun 5 d prior. Physical examination revealed multiple erythematous grouped vesicles in the right C4-5 and T1 dermatome regions. Because herpes zoster was suspected, the patient immediately received intravenous acyclovir. On the third hospital day, she complained of motor weakness in the right upper extremity. Magnetic resonance imaging of the cervical spine revealed mild intervertebral disc herniation at C4-C5 without evidence of nerve root compression. On the 12^th hospital day, electrodiagnostic study revealed right cervical radiculopathy, mainly in the C5/6 roots. Six months later, monoparesis resolved, and follow-up electrodiagnostic study was normal.

CONCLUSION

This case emphasizes that clinicians should consider the possibility of post-herpetic paresis, such as herpes zoster radiculopathy, and that electrodiagnostic study is useful for diagnosis and follow-up.

Severe brachial plexopathy secondary to shingles (herpes zoster)

Varicella zoster reactivation ("shingles" or "herpes zoster") usually presents as a self-limiting, unilateral, dermatomal vesicular rash in older adults. We present the case of a 73 year-old woman with unilateral brachial plexopathy, an unusual but debilitating complication of shingles. Despite treatment with intravenous acyclovir and immunoglobulin she had a marked residual motor paresis that required an upper limb rehabilitation program after discharge.

Brachial plexopathy as a complication of COVID-19

COVID-19 affects a wide spectrum of organ systems. We report a 52-year-old man with hypertension and newly diagnosed diabetes mellitus who presented with hypoxic respiratory failure due to COVID-19 and developed severe brachial plexopathy. He was not treated with prone positioning respiratory therapy. Associated with the flaccid, painfully numb left upper extremity was a livedoid, purpuric rash on his left hand and forearm consistent with COVID-19-induced microangiopathy. Neuroimaging and electrophysiological data were consistent with near diffuse left brachial plexitis with selective sparing of axillary, suprascapular and pectoral fascicles. Given his microangiopathic rash, elevated D-dimers and paucifascicular plexopathy, we postulate a patchy microvascular thrombotic plexopathy. Providers should be aware of this significant and potentially under-recognised neurologic complication of COVID-19.

Varicella-Zoster Radiculitis Mimicking Sciatica: A Diagnostic Dilemma

Varicella-zoster virus (VZV) presenting as a radicular pain in the thoracic region is not uncommon, but the presentation in the lumbar and thigh region is not frequently seen. Characteristic segmental vesicular-bullous rash in a dermatomal distribution associated with pain and allodynia is a prominent feature. The pain appears before rash. It is not uncommon for clinicians to misdiagnose radicular pain caused by VZV due to prolapsed disc. We report two patients who presented to us with complaints of back pain with leg radiculopathy that were initially treated for discogenic radiculopathy and rash was wrongly attributed to hot fomentation. This case report emphasizes the importance of including varicella-zoster radiculitis in the differential diagnosis of radicular pain and clinical examination of every rash. Physical examination is must if the patient complains of rash. Appropriate and timely diagnosis can prevent unnecessary investigations.

Post-Herpetic Brachial Plexopathy: A Rare Case Report With a Side Note on Localizing Brachial Plexopathies and a Literature Review of Post-Herpetic Segmental Paresis

We present the case of a 77-year-old man who developed shingles over the cervical C8 dermatome followed by post-herpetic medial cord brachial plexopathy, with hand weakness and difficulty performing the pinch " O " sign. This is the very first case, to our knowledge, of a detailed presentation of a medial cord plexopathy following shingles. We review the literature of post-herpetic brachial plexopathies and discuss the magnetic resonance imaging (MRI) findings of the brachial plexus in this group of patients. We also speculate on the intriguing finding that despite frequent abnormalities on MRI such as T2 signal hyperintensity and nerve hypertrophy, contrast enhancement of nerves is exceedingly rare. Furthermore, we adumbrate on the localization of brachial plexus lesions by proposing a user-friendly diagram and table, which simplifies the diagnostic algorithm.

Segmental zoster paresis of unilateral upper extremity: A case report and literature review

RATIONALE

Segmental zoster paresis (SZP) is a relatively rare neurologic complication of herpes zoster (HZ), and is characterized by focal asymmetric motor weakness in the myotome that corresponds to skin lesions of the dermatome. The upper extremities are the second most commonly involved regions after the face, and predominantly involve proximal muscles. The pathogenesis of SZP remains unclear; however, most of the reports indicate that it is the inflammation because of the spread of the herpes virus.

PATIENT CONCERNS

A 72-year-old man without trauma history of the left shoulder joint developed weakness of the left proximal upper extremity 10 days after vesicular eruption of HZ.

DIAGNOSES

His left shoulder girdle paresis was diagnosed with the upper truncus of the brachial plexus as a HZ complication according to a series of tests, including cervical magnetic resonance imaging (MRI), cerebral fluid analysis, sonography, and electrophysiological studies.

INTERVENTIONS

Acyclovir and prednisolone were administered during hospitalization to treat SZP. Meanwhile, analgesics and gabapentin were administered to control the patient's neuralgic pain. He also received inpatient (daily) and outpatient (3 times per week) physical therapy along with range of motion and strengthening exercises.

OUTCOMES

Partial improvement of the strength of the left shoulder girdle, and no improvement of the left deltoid muscle was observed 2 months after the interventions.

LESSONS

This case emphasizes that HZ infections may be complicated by segmental paresis and they should be considered in the differential diagnosis of acute paresis in the upper limb. Awareness of this disorder is important because it avoids unnecessary invasive investigations and interventions, leading to suitable treatments with favorable prognosis.

Avoiding a lumbar puncture may be a rash decision: a case report of varicella-zoster virus-associated radiculopathy in advanced HIV infection

A 34-year-old man recently diagnosed with advanced human immunodeficiency virus infection (CD4 cell count of 139 cells/mm3), not yet started on antiretroviral medications, presented to hospital with a ten-day history of left leg weakness and difficulty walking. He described a childhood history of chickenpox with previous shingles over his buttock over three years ago. Examination revealed reduced power in the left hip and knee flexors and absent knee and adductor reflexes. Lumbar punctures were performed and polymerase chain reaction (PCR) detected varicella-zoster virus (VZV) DNA. Concurrent serum samples for VZV PCR were negative. The patient was diagnosed with VZV radiculopathy and treated with high-dose intravenous acyclovir. Within two days, neurological signs improved. Previous case reports define VZV radiculopathy by a temporal and geographical relationship with a zoster rash. Our diagnosis was based on a clinical picture of radiculopathy with virological evidence in CSF and confirmed by a dramatic clinical response to treatment. We propose that lumbar puncture and detection of VZV DNA by PCR in the cerebrospinal fluid (CSF) is an invaluable investigation that should be considered in the workup of immunosuppressed patients presenting with a radiculopathy.