"Atypical" Ramsay Hunt syndrome

Typical or Atypical Ramsay-Hunt Syndrome in Delayed Facial Palsy After Stapedectomy?

OBJECTIVES

The aim of this study was to define the typical pattern for varicella zoster virus (VZV) reactivation in delayed facial palsy (DFP) after stapedectomy for otosclerosis.

MATERIALS AND METHODS

Review of the relevant literature, personal casistics, and case-report.

RESULTS

In total, 48 cases of DFP after stapes surgery have been described so far, including the reported case with exclusive manifestation of atypical Ramsay Hunt syndrome (RH); in the personal series of 1253 stapedectomies, DFP occurred in only one case (0.08%). Complete DFP (House-Brackmann grade VI) rapidly developed 12 days after surgery; RH appeared 2 days later, confirming the role of VZV. The DFP started improving after 8 weeks and completely recovered 6 months later.

CONCLUSION

Acute otalgia prior to DFP should raise the suspicion of VZV reactivation. Atypical RH is the most frequent pattern that occurs in DFP after stapedectomy.

Complications of varicella zoster virus reactivation

OPINION STATEMENT

Varicella zoster virus (VZV) is an exclusively human neurotropic alphaherpesvirus. Primary infection causes varicella (chickenpox), after which virus becomes latent in ganglionic neurons along the entire neuraxis. With advancing age or immunosuppression, cell-mediated immunity to VZV declines and virus reactivates to cause zoster (shingles), which can occur anywhere on the body. Skin lesions resolve within 1-2 weeks, while complete cessation of pain usually takes 4-6 weeks. Zoster can be followed by chronic pain (postherpetic neuralgia), cranial nerve palsies, zoster paresis, meningoencephalitis, cerebellitis, myelopathy, multiple ocular disorders and vasculopathy that can mimic giant cell arteritis. All of the neurological and ocular disorders listed above may also develop without rash. Diagnosis of VZV-induced neurological disease may require examination of cerebrospinal fluid (CSF), serum and/ or ocular fluids. In the absence of rash in a patient with neurological disease potentially due to VZV, CSF should be examined for VZV DNA by PCR and for anti-VZV IgG and IgM. Detection of VZV IgG antibody in CSF is superior to detection of VZV DNA in CSF to diagnose vasculopathy, recurrent myelopathy, and brainstem encephalitis. Oral antiviral drugs speed healing of rash and shorten acute pain. Immunocompromised patients require intravenous acyclovir. First-line treatments for post-herpetic neuralgia include tricyclic antidepressants, gabapentin, pregabalin, and topical lidocaine patches. VZV vasculopathy, meningoencephalitis, and myelitis are all treated with intravenous acyclovir.

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

Introduction

Simultaneous involvements of multiple cranial nerve ganglia (geniculate ganglion and peripheral ganglia of cranial nerves VIII, IX and X) by varicella-zoster virus and its subsequent activation may result in the characteristic eruptions of herpes zoster cephalicus. Coexistence of facial palsy and involvement of upper cervical dermatomes by varicella-zoster virus is quite rare.

Case presentation

Here, we report a 71-year-old Iranian man with involvement of multiple sensory ganglia (geniculate ganglion and upper dorsal root ganglia) by varicella-zoster virus. He presented with right-sided facial weakness along with vesicular eruptions on the right side of his neck, and second and third cervical dermatomes.

Conclusion

The present case is an example of herpes zoster cephalicus with cervical nerve involvement. Although resembling Ramsay Hunt syndrome with presence of facial nerve paralysis and accompanying vesicles, involvement of cervical dermatomes is not a feature of the classic Ramsay Hunt syndrome.

Varicella-zoster virus: a re-emerging infection

Varicella-zoster virus (VZV) causes chickenpox (varicella), becomes latent in cranial nerve and dorsal root ganglia, and can reactivate many years later to produce shingles (zoster) and postherpetic neuralgia (PHN). Elderly and immunocompromised individuals are also at risk for complications of VZV reactivation involving the central nervous system (CNS), including myelitis, large-vessel encephalitis/granulomatous arteritis, small-vessel encephalitis, meningoencephalitis, and ventriculitis. Peripheral nervous system (PNS) complications range from zoster and postherpetic neuralgia to postinfectious polyneuritis (Guillain-Barre syndrome, GBS). These complications can occur with or without cutaneous manifestations. An increase in elderly and immunocompromised individuals will likely result in a higher prevalence of these conditions; therefore, VZV can be seen as a "re-emerging" infection of the early twenty-first century. In this review, we summarize our experience and the existing literature on CNS and PNS complications of VZV reactivation. Special attention is paid to reports of complications without rash, as these entities are more difficult to diagnose.

An extreme and unusual variant of Ramsay Hunt syndrome

Ramsay Hunt syndrome is characterized by facial nerve paralysis, herpetic vesicles in or around the ear and pain often associated with vestibulocochlear nerve involvement. It is thought to be a cranial polyneuropathy caused by the herpes zoster virus. We present an extreme and unusual variant of this disease with involvement of VIIth, VIIIth, Xth, XIth and XIIth cranial nerves as well as C2-4 sensory dermatomes and profound systemic upset which caused some diagnostic uncertainty.

Cranial polyneuropathy--Ramsay Hunt's syndrome: case report and discussion

Ramsay Hunt's syndrome is an infectious cranial polyneuropathy caused by varicella zoster, the herpetic virus that also causes chickenpox and shingles. Its symptoms include facial paralysis, ear pain, and an auricular rash. Oral lesions are also present in most cases. This syndrome can affect any cranial nerve and usually affects multiple nerves, causing central, cervical, and peripheral effects. This article reports the case of a 35-year-old white female who was treated by the oral surgery service of a large urban hospital, after first reporting to the emergency clinic. Her reported symptoms of unilateral left-side facial paralysis, auricular pain, and trigeminal hyperesthesia were confirmed by clinical examination. An initial short low-dose steroid regimen was unsuccessful. A second daily dosage of 50 mg of prednisone was successful in 21 days. No permanent sequelae were evident or reported after treatment.

Cephalic Zoster with Laryngeal Paralysis

Herpes zoster reactivaction in the head and neck region is often associated with multiple cranial neuropathies, the most common one being facial paralysis. Laryngeal paralysis has also been occasionally reported with zoster infection. We present two such cases, and discuss the relevant literature on the pathophysiology, evaluation and management of this disease. Recent advances in antiviral therapy have allowed for specific medical treatment, thus making it all the more imperative to suspect zoster, even in clinically atypical cases. We suggest aggressive treatment with intravenous acyclovir for cephalic zoster complicated by vocal cord paralysis.

Enhanced MRI in patients with Ramsay-Hunt's syndrome

Enhanced MRI was performed in 14 patients with Ramsay-Hunt's syndrome to investigate the pathogenesis of this syndrome. All MRI studies were performed on a 0.5T superconductivity MRI system using a head coil with Gd-DTPA. Enhancement was observed in the areas of the distal internal auditory canal and labyrinthine segment in many patients, and was especially prominent in patients suffering from vertigo, tinnitus, and hearing loss. In some patients it involved not only the facial nerve of the internal auditory canal but also the cochlear nerve and vestibular nerves. Since histological changes of the facial nerve in patients with Ramsay-Hunt's syndrome are assumed to occur in the distal internal auditory canal and labyrinthine segment, which is more proximal than the geniculate ganglion, and the possibility is suggested that inflammation may spread to the vestibular and cochlear nerve via the internal auditory canal.

Postherpes simplex type 1 neuralgia simulating postherpetic neuralgia

Patients with prodromal neuralgia associated with recurrent herpes simplex type 1 (HST1) infection and chronic facial pain following years of relapsing HST1 have been described. Chronic neuralgia following a single clinical HST1 infection and simulating postherpetic neuralgia has not been previously reported. Such a case is described: A 49-yr-old woman with a 2-mo history of oral-facial dyskinesia developed burning pain and hypersensitivity of the left side of the tongue, lower gum, and inner cheek, followed 1 day later by a vesicular rash in the same painful distribution. Viral cultures of the lesions identified HST1 but not herpes zoster. Cerebrospinal fluid analyses during the vesicular lesion stage and 1 mo later were normal with no viral growth. Oral and facial lesions resolved after 10 days; acyclovir was given for 3 wk. Brain and brainstem magnetic resonance imaging (MRI), electroencephalogram, and brainstem evoked potential studies were normal. Hyperesthesias, allodynia, and burning pain persisted despite nonsteroidal antiinflammatory agents, codeine and hydrocodone. Oral opioids were administered until sedation occurred, with no relief of pain. The burning pain and hyperesthesia resolved after the 16th day of amitriptyline use, 75 mg/day. A trial off amitriptyline 6 mo later resulted in recurrence of pain, and amitriptyline was restarted with good pain control. Post-HST1 neuralgia may simulate postherpetic neuralgia clinically, and painful symptoms may respond to amitriptyline.

Neurological complications of herpes zoster

We report 31 cases of herpes zoster (HZ) with neurological complications: 14 with cranial nerve deficits, 1 with cranial nerve deficit associated with segmental motor disorder, 3 with segmental motor deficits, 2 with meningoencephalitis, 2 with meningoencephalitis associated with cranial neuropathy or myelitis, 2 with meningitis, 2 with hemiplegia contralateral to the ophthalmic HZ. 1 with hemiplegia and motor deficit and finally 1 with hemiplegia and a cranial neuropathy. Smoking was the putative risk factor in 53% of our patients together with diabetes, which has already been mentioned in the literature. We frequently observed more than one complication in succession (19.3%) that could not easily be related to the cutaneous distribution. Acyclovir had no demonstrable positive effects on neurological complication in our patients.