Varicella-zoster virus reactivation from multiple ganglia: a case report

Efficacy of 1064 nm Photobiomodulation Dosimetry Delivered with a Collimated Flat-Top Handpiece in the Management of Peripheral Facial Paralysis in Patients Unresponsive to Standard Treatment Care: A Case Series

Peripheral facial paralysis (PFP) is a common condition where oxidative stress (OS) is involved in the pathophysiology of facial paralysis, inhibiting peripheral nerve regeneration, which can be featured in Bell's palsy, Ramsay Hunt syndrome and Lyme disease. The current standard care treatments lack consensus and clear guidelines. Hence, the utilization of the antioxidant immunomodulator photobiomodulation (PBM) can optimize clinical outcomes in patients who are unresponsive to standard care treatments. Our study describes three unique cases of chronic PFP of various origins that were unresponsive to standard care treatments, but achieved a significant and complete recovery of facial paralysis following PBM therapy. Case presentations: Case #1: a 30-year-old male who presented with a history of 12 years of left-side facial paralysis and tingling as a result of Bell's palsy, where all the standard care treatments failed to restore the facial muscles' paralysis. Eleven trigger and affected points were irradiated with 1064 nm with an irradiance of ~0.5 W/cm2 delivered with a collimated prototype flat-top (6 cm2) in a pulsed mode, with a 100 µs pulse duration at a frequency of 10 Hz for 60 s (s) per point. Each point received a fluence of 30 J/cm2 according to the following treatment protocol: three times a week for the first three months, then twice a week for another three weeks, and finally once a week for the following three months. The results showed an improvement in facial muscles' functionality (FMF) by week two, whereas significant improvement was observed after 11 weeks of PBM, after which the House-Brackmann grading scale (HBGS) of facial nerve palsy dropped to 8 from 13 prior to the treatment. Six months after PBM commencement, electromyography (EMG) showed sustainability of the FMF. Case #2: A five-year-old female who presented with a 6-month history of severe facial paralysis due to Lyme disease. The same PBM parameters were utilized, but the treatment protocol was as follows: three times a week for one month (12 consecutive treatment sessions), then the patient received seven more sessions twice a week. During the same time period, the physiotherapy of the face muscles was also delivered intensively twice a week (10 consecutive treatments in five weeks). Significant improvements in FMF and sustainability over a 6-month follow-up were observed. Case #3: A 52-year-old male who presented with severe facial palsy (Grade 6 on HBGS) and was diagnosed with Ramsay Hunt syndrome. The same laser parameters were employed, but the treatment protocol was as follows: three times a week for three weeks, then reduced to twice a week for another three weeks, then weekly for the next three months. By week 12, the patient showed a significant FMF improvement, and by week 20, complete FMF had been restored. Our results, for the first time, showed pulsed 1064 nm PBM delivered with a flat-top handpiece protocol is a valid and its treatment protocol modified, depending on the origin and severity of the condition, which is fundamental in optimizing facial paralysis recovery and alleviating neurological symptoms. Further extensive studies with large data are warranted to validate our PBM dosimetry and treatment protocols.

[A 73-year-old man with polyradiculopathy and multiple cranial neuropathies emerging separate from the originating dermatome of a varicella zoster skin lesion]

A 73-year-old man developed delayed-onset multiple cranial neuropathies of cranial nerves V, VII and VIII, and segmental paresis in the ipsilateral upper extremity related to the C4 to Th1 segment, after all skin lesions with varicella zoster (VZV) on the left neck of the C3-4 dermatome had dried and crusted over. On admission, cerebrospinal fluid (CSF) revealed pleocytosis (all mononuclear cells, 12/μl). Treatment was started with intravenous acyclovir (10 mg/kg, every 8 h for 14 days) and methylprednisolone (1,000 mg/day for 3 days). Four days after starting treatment, left segmental paresis was improved, but the multiple cranial neuropathies persisted. Oral prednisolone (0.5 mg/kg/day) was administered for 5 days, then tapered off. All neurological symptoms had disappeared by hospital day 23. Of particular interest was the discrepancy between skin regions affected by VZV (C3-4) and the regions of cranial neuropathy (cranial nerves V, VII, and VIII) and muscle weakness innervated by C4-Th1. Although CSF was negative for VZV DNA according to PCR testing, the antibody index for VZV was elevated. This suggests intrathecal synthesis of VZV antibodies and supports the diagnosis of VZV meningitis. Also, all cranial nerves involved in this case were reported to have the cranial nerve ganglia where VZV could have established latency and been reactivated. This suggests concurrent reactivation on each cranial nerve ganglia without cutaneous lesions, as zoster sine herpete. In addition, anastomoses among the upper cervical nerves, which are found in some patients, may have contributed to this condition. These mechanisms underlie various neurological symptoms associated with VZV infection.

Simultaneous herpes zoster rash in the upper extremity and interscapular region that resembles innervation zone of the dorsal ramus of the cervical nerve root: a case report

In daily medical practice, scapular pain associated with cervical radiculopathy is commonly seen prior to the onset of pain of the upper extremity; however, the cause of the scapular pain is uncertain. We report a case of herpes zoster with simultaneous skin rash in both the upper extremity and interscapular region, which corresponds to the painful scapular region in case of C8 cervical radiculopathy. A 71-year-old healthy woman complained of shoulder and scapular pain followed by a blistering skin rash on both the ulnar side of her upper extremity and intrascapular region on the right side. She was diagnosed with herpes zoster and was prescribed amenamevir as oral treatment with vidarabine ointment. After 1 year, she still had mild causalgia on her III-V fingers and needed oral treatment with pregabalin. To our knowledge, this is the first case report of a herpes zoster rash in the upper extremity and intrascapular region simultaneously. We speculate that the rash in the two regions is caused by the varicella zoster virus (VZV) traveling from the same ganglion, probably the C8 ganglion, considering the dermatome of the rash area in the upper extremity and the intrascapular region correspond to the innervation zone of the medial branches of the dorsal ramus of the cervical nerve root, which resembles the scapular region in case of cervical radiculopathy. This phenomenon implies the mechanism of scapular pain is related to cervical radiculopathy. Further case reports are needed to confirm this.

A New Skin Manifestation at the Site of a Previously Healed Dermatosis: A Case of Wolf's Isotopic Response

Wolf's isotopic response (WIR) is an uncommon phenomenon that refers to the occurrence of a new skin condition at the location of a previously healed dermatosis. We describe an unusual manifestation of bacterial furunculosis which arose as an isotopic response following a herpes zoster episode. The initial skin disease in most cases is herpes zoster and the isotopic response is a granulomatous reaction.  A 65-year-old female with a history of chronic lymphocytic leukemia (CLL) and currently on chemotherapy regimen presented with a pustular skin rash on the posterior scalp extending to the posterior right neck and shoulder. Prior to this presentation, the patient was treated for three weeks with valacyclovir for herpes zoster infection which improved her skin condition. During the current hospitalization, the patient's wound cultures from the pustule revealed the growth of methicillin-resistant Staphylococcus aureus (MRSA). Although the patient was on immunosuppressive therapy, her white blood cell (WBC) count increased to 9.9 x 10³/μL. After receiving vancomycin and valacyclovir, her cutaneous condition eventually improved. She was transitioned to oral clindamycin and discharged to a rehabilitation facility. This case describes an immunocompromised patient who was treated for herpes zoster, improved after treatment, and then developed MRSA furunculosis at the same site. It is of significance to report such manifestations, especially in immunocompromised patients, as it could be underdiagnosed. It is also important to inquire about the patients' herpes-related medical history because herpes is the most common initial dermatosis reported in the literature. In such cases of suspected WIR, it is vital to obtain a biopsy before starting treatment with antiviral medication to rule out the possibility of malignancy.

Varicella zoster virus genotyping in chickenpox patient's clinical isolates from Iran

Aim: The varicella zoster virus (VZV) causes chickenpox and zoster infections. This study aimed to investigate the distribution of VZV genotypes among Iranian patients. Materials & methods: From 2010 to 2015, 244 patients were enrolled in this cross-sectional study, 45 of whom were positive for VZV DNA. Both direct sequencing and restriction fragment length polymorphism assay were performed for 19 positive specimens. SPSS v.20 was used for statistics. Results: The predominant VZV genotype was M1 (84.2%) followed by genotype E (10.5%) and genotype J (5.3%). Restriction fragment length polymorphism demonstrated that 17 strains were PstI+ BglI+ (M1 and/or J genotypes) and 2 were PstI+ BglI- (E genotype). Conclusion: This research is a prelim study on VZV genotyping. Further investigations will help to confirm the VZV genotype prevalence reported here.

Enzymatic Digestion Pattern of Varicella Zoster Virus ORF38 and ORF54 in Chickenpox Patients Using RFLP Technique

BACKGROUND

Varicella zoster virus (VZV) causes chickenpox in children and zoster (zona) in the elderly. Using RFLP-PCR method for detection of VZV specific SNPs ORF38, 54 and 62 could distinguish the profile of VZV isolates. The aim of this study was to investigate enzymatic digestion pattern of VZV ORF38 and ORF54 in chickenpox patients using RFLP technique.

METHODS

Thirty-eight chickenpox patients, who referred to the hospitals of Iran University of Medical Sciences in Tehran from May 2010 to June 2015 were enrolled in this cross sectional study. After the DNA extraction, PCR amplification of 38 VZV isolates performed by specific primers of ORFs 38 and 54, then RFLP assay and digestion carried out by PstI (for ORF38) and BglI (for ORF54) restriction enzymes.

RESULTS

Of 38 positive VZV DNA, the mean age (yr)±SD was 34.4±23.3 (range: 7-89). 22 (57.9%) were female and 16 (42.1%) were male. The predominant VZV profile of BglI(+) PstI(+) were 89.5% (34/38) followed by 10.5% (4/38) PstI(+) BglI‾. Statistical analysis showed that there was no significant relationship between genotype, age, sex, and year of infection variables (P value> 0.05). The common VZV genotype among Iranian patients with chickenpox and zona infection is genotype BglI(+) PstI(+) followed by PstI(+) BglI‾.

CONCLUSION

There are different VZV circulating genotypes that call for for more research on this field by widely population and other methods such as nucleotide sequencing to justify the accurate VZV genotype prevalence in Iran.

Vernet syndrome by varicella-zoster virus

Vernet syndrome involves the IX, X, and XI cranial nerves and is most often attributable to malignancy, aneurysm or skull base fracture. Although there have been several reports on Vernet's syndrome caused by fracture and inflammation, cases related to varicella-zoster virus are rare and have not yet been reported in South Korea. A 32-year-old man, who complained of left ear pain, hoarse voice and swallowing difficulty for 5 days, presented at the emergency room. He showed vesicular skin lesions on the left auricle. On neurologic examination, his uvula was deviated to the right side, and weakness was detected in his left shoulder. Left vocal cord palsy was noted on laryngoscopy. Antibody levels to varicella-zoster virus were elevated in the serum. Electrodiagnostic studies showed findings compatible with left spinal accessory neuropathy. Based on these findings, he was diagnosed with Vernet syndrome, involving left cranial nerves, attributable to varicella-zoster virus.

Disseminated herpes zoster in an immunocompetent elderly patient

Herpes zoster is a cutaneous infection that is characterized by an acute vesicobullous rash with ipsilateral one or two dermatomal distribution and painful allodynia, while predominantly being found in the elderly. Extensive cutaneous dissemination has been reported in immune-compromised patients, such as those who suffer from HIV infections, cancer, chemotherapy, and corticosteroid therapy patients. However, we report a case of disseminated herpes zoster infection in an immuno-competent elderly individual.

Where is reactivation after a long latency?

The authors present a 90-year-old woman with unilateral glossopharyngeal, vagal and spinal accessory cranial nerve palsy along with pharyngeal and laryngeal vesicular eruptions. She was diagnosed with herpes zoster based on PCR testing on vesicular fluid for varicella-zoster virus (VZV). Reactivation of VZV in the head and neck region can cause life-threatening neurologic sequelae. Clinicians should be alert to the possibility of herpes zoster in a case of unilateral multiple cranial neuropathies and rapid combination therapy with acyclovir and corticosteroid should be initiated.