Guillain-Barré syndrome after varicella-zoster infection. Case report

Peripheral facial palsy after varicella. Report of two cases and review of the literature

BACKGROUND

There is little information regarding peripheral facial palsy (PFP) as a complication of varicella. We describe 2 adults who developed varicella-related PFP, in 1 case as a part of Guillain-Barré syndrome (GBS), and review all reported cases of this condition.

METHODS

MEDLINE search.

RESULTS

A total of 10 cases of isolated varicella-associated PFP have been reported. PFP was diagnosed 3 to 16 days after the onset of skin manifestations. Four (40%) patients developed bilateral PFP. Two patients had varicella meningitis; both were PCR-positive for varicella-zoster virus (VZV) in CSF. CSF IgG antibodies against VZV were demonstrated in 2 other patients. One patient had slight CSF albumino-cytological dissociation. Five patients were treated with acyclovir, and 3 of them also received corticosteroids. Most patients showed a favorable course, with partial or complete recovery of PFP. In addition, 17 patients with GBS after the onset of varicella were reviewed. Mean time to the development of GBS after varicella onset was 9.3 days, and 9 patients had PFP as a part of the neurologic picture. Seven patients (41%) developed respiratory failure requiring mechanical ventilation. Six patients received treatment with intravenous immunoglobulin, and all of them showed optimal evolution. One patient died.

CONCLUSIONS

Isolated PFP and GBS are rare peripheral nerve complications after varicella. Treatment should be individualized for each case, depending on the severity of the condition and the clinical evolution.

Severe Guillain-Barré syndrome following primary infection with varicella zoster virus in an adult

Varicella zoster virus (VZV) infection may trigger Guillain-Barré syndrome (GBS), but this is rare and almost always in the context of reactivation disease from latent VZV, 'shingles'. We report here a case of severe GBS following primary VZV infection in an adult. A 40-year-old man of Indian origin developed features of GBS including quadriplegia, bulbar paralysis, and bilateral facial nerve palsies 14 days after primary VZV infection contracted from a known case in a family member. Nerve conduction studies confirmed acute inflammatory demyelinating polyneuropathy. Anti-ganglioside antibodies were negative. The mechanism of Schwann cell attack following VZV infection is poorly understood but this case suggests that primary VZV infection may be a sufficient stimulus to drive antibody generation and precipitate severe clinical symptomatology. The morbidity associated with the complications of VZV infection in adulthood could be avoided if patients who are seronegative for VZV (frequently from the Asian subcontinent) are offered prophylaxis after an exposure in adulthood.