Herpes zoster ophthalmicus and delayed contralateral hemiparesis

Herpes-zoster-Update – was gibt es Neues?

Shingles are triggered by the reactivation of an infection with the varicella zoster virus (VZV) and are characterized by specific vesicular skin lesions. Mostly, elderly patients are affected. Depending on the affected dermatome, some serious complications can be observed. The introduction of a vaccine against shingles in Germany offers a great potential for reducing the frequency and severity of this disease. There are both a live vaccine, which is no longer recommended, and an inactivated vaccine, which, however, is still not sufficiently recommended to the authorized patient groups and is also only available to a limited extent due to delivery bottlenecks. HZ neuralgia is a serious complication of the disease that requires rapid and effective therapy and should be handed over to experienced pain therapists rather too early than too late. Unfortunately, in everyday clinical practice only a few people are familiar with VZV vasculopathy, which is associated with a significantly increased risk of cerebral insults.

[A long-term follow up of right ophthalmoplegia and severe right middle cerebral artery stenosis with right herpes zoster ophthalmics: a case report]

Here we report a case of a 68-year-old man with severe stenosis of the right middle cerebral artery (MCA) following herpes zoster ophthalmicus. He presented with right-sided ptosis and ophthalmoplegia 2 months after herpes zoster ophthalmicus. Cerebrospinal fluid (CSF) analysis revealed monocytosis, increased protein levels, and positivity for herpes zoster virus immunoglobulin M (IgM). Brain magnetic resonance imaging (MRI) revealed a small asymptomatic infarct in the right basal ganglia and severe stenosis of the right MCA (M1 segment). One month later, he presented with muscle weakness of the fingers of the left hand. Repeat CSF analysis revealed similar abnormalities to the previous analysis, and MRI showed a new small infarct in the right-sided motor area corresponding to the left fingers. He was treated with acyclovir (750 mg/day), prednisolone (1 mg/kg/day), and aspirin (100 mg/day). O2-gas positron emission tomography (PET) revealed decreased cerebral blood flow (CBF) after acetazolamide injection and normal cerebral vascular reactivity (CVR). He was on continuous treatment with prednisolone and aspirin for 1 year. The muscle weakness of the fingers of the left hand and right-sided ophthalmoplegia improved, and magnetic resonance angiography revealed considerable decrease in the stenosis of the right middle cerebral artery. CBF before and after acetazolamide injection and CVR on O2-gas PET also normalized. These results suggested that long-term treatment may prevent subsequent infarcts following herpes zoster ophthalmics.