PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of bmjcrInstructions for authorsCurrent ToCBMJ Case Reports
 
BMJ Case Rep. 2010; 2010: bcr11.2009.2440.
Published online May 4, 2010. doi:  10.1136/bcr.11.2009.2440
PMCID: PMC3047490
Unusual association of diseases/symptoms
Horner’s syndrome with an ipsilateral X nerve palsy following presumed shingles
Saam Sedehizadeh1 and John Bowen2
1Queens Medical Centre, Neurology, Derby Road, Nottingham, Nottingham NG7 2UH, UK
2Lincoln County Hospital, Neurology, Greetwell Road, Lincoln, LN2 5QY, UK
Correspondence to Saam Sedehizadeh, SSedehizadeh/at/doctors.org.uk
Abstract
Herpes zoster is a common clinical problem but its complications, apart from post-herpetic neuralgia, are comparatively rare. We describe a case of Horner’s syndrome and ipsilateral vagal paresis following likely herpes zoster of the third and fourth cervical roots. This unusual combination has not, to our knowledge, been previously described.
Background
Herpes zoster may cause protean neurological complications including cranial neuropathies, radiculitis. myelitis, and encephalitis.14 We describe a case of Horner’s syndrome and ipsilateral vagal paresis following likely herpes zoster of the third and fourth cervical roots.
A previously healthy 64-year-old right handed lorry driver presented in July 2007 with a 2 day history of sudden onset dysphagia and dysarthria, 3 weeks after developing a prickling vesicular rash over the right posterior aspect of his neck with subsequent right facial pain.
The dysphagia was unassociated with odynophagia or difficulty chewing. There was no dysgeusia, visual disturbance, nor problems with limb, autonomic or sphincter function.
A longstanding unchanging asymmetrical hearing loss attributed to otosclerosis was noted. Examination revealed healing lesions characteristic of herpetic vesicles over the right C3 and C4 dermatomes. A nasal, non-fatigable dysarthria was apparent. A right Horner’s was present (fig 1) with associated palatal weakness (fig 2) and bovine cough.
Figure 1
Figure 1
Right Horner’s syndrome.
Figure 2
Figure 2
Palatal paralysis.
Cranial nerves IX, XI, and XII were intact. Fibreoptic nasendoscopy revealed reduced excursion of the right vocal cord with pooling of saliva. The general medical examination was otherwise non-contributory.
A clinical diagnosis of herpes zoster associated cranial polyradiculoneuritis was made and antiviral therapy with corticosteroids were commenced. Feeding continued via a nasogastric tube.
Recovery followed and the patient was discharged home 8 days later tube-free, asymptomatic, and taking a normal diet.
Investigations
A lymphopenia (0.9×109/l (normal range 1.5–4.0)) was found but haematology and biochemistry, chest and cervical spine plain radiography were unremarkable.
Computed tomography and subsequent magnetic resonance imaging of the brain with gadolinium demonstrated appearances consistent with mild non-specific ischaemia with no evidence of carotid dissection or pathological enhancement.
Cerebrospinal fluid (CSF) analysis was unremarkable with negative varicella zoster (VZ), herpes simplex virus (HSV) and enterovirus PCR and cytology.
Treatment
  • Dexamethasone and intravenous aciclovir.
Horner’s syndrome is described in association with ophthalmic5,6 or thoracic zoster79 causing both peripheral and central disruption of oculosympathetic function, respectively. In addition vagal mononeuritis of viral aetiology, including herpetic, has been reported.1015
Pupillary reactions to hydroxyamphetamine can differentiate between a peripheral (post-superior cervical ganglionic) from central (pre- (superior cervical) ganglionic) lesion with pupillary dilatation in the latter but not the former. Although this was not undertaken in our case, the occurrence of facial pain may implicate the sympathetic fibres in the carotid sheath producing a painful Horner’s syndrome also seen in carotid artery dissection.
Furthermore, the coexistence of an isolated ipsilateral X palsy without other cranial nerve involvement or long tract signs is consistent with a multifocal peripherally sited inflammatory process rather than a central disturbance.
The transient nature of the Horner’s syndrome in this patient with resolution in 12 weeks has been described in a post-ganglionic lesion16 in contrast to its persistence (years) being reported in pre-ganglionic lesions.8
The lack of corroborative PCR studies in CSF is surprising and the herpetic aetiology of this illness cannot be confirmed with certainty. However, the diverse clinical complications of varicella zoster can be mediated by numerous pathological mechanisms including immunological and host inflammatory granulomatous reactions to infection,17 and in most clinical situations this diagnosis is established by the characteristic rash.
Learning points
  • Awareness of the diverse complications of herpes zoster including cranial neuropathies.
  • Complications can occur after the rash has disappeared, suggesting possible post-infectious/para-infectious mechanisms.
  • Early treatment with antivirals and corticosteroids may aid recovery.
Footnotes
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.
1. Kendall D. Motor complications of herpes zoster. BMJ 1957; ii: 616–8. [PMC free article] [PubMed]
2. Gardner-Thorpe C, Foster JB, Barwick DD. Unusual manifestations of herpes zoster. A clinical and electrophysiology study. J Neurol Sci 1976; 28: 427. [PubMed]
3. Reshef E, Greenberg SB, Jankovic J. Herpes zoster ophthalmicus followed by contralateral hemiparesis: a report of two cases and review of literature. J Neurol Neurosurg Psychiatry 1985; 48: 122–7. [PMC free article] [PubMed]
4. Cvjetkovic D, Jovanovic J. Reactivation of herpes zoster infection by varicella-zoster virus. Medicinski pregled 1999; 52: 125–8. [PubMed]
5. Smith EF, Santamarina L, Wolintz AH. Herpes zoster ophthalmicus as a cause of Horner syndrome. J Clin Neuro-ophthalmol 1993; 13: 250–3. [PubMed]
6. Tola-Arribas MA, Zarco-Tejada JM, Marco-Llorente J. Horner’s syndrome secondary to ophthalmic herpes zoster. Revista de Neurologia 1997; 25: 1922–4. [PubMed]
7. Wimalaratna HS, Santamarina L, Wolinz AH. Herpes zoster of second and third segments causing ipsilateral Horner’s syndrome. BMJ 1987; 294: 1463. [PMC free article] [PubMed]
8. Gabriel CM, Gale AN, Rossor MN. Zoster paresis with Horner’s syndrome. J Neurol 2003; 250: 1492–93. [PubMed]
9. Poole TRG, Acheson JF, Smith SE, et al. Horner’s syndrome due to herpes zoster in the T3-T4 dermatome. J R Soc Med 1997; 90: 395–6. [PMC free article] [PubMed]
10. Berry H, Blair RL. Isolated vagus nerve palsy and vagal mononeuritis. Arch Otolaryngol 1980; 106: 333–8. [PubMed]
11. Flowers RH, Kernodle DS. Vagal mononeuritis caused by herpes simplex virus: association with unilateral vocal cord paralysis. Am J Med 1990; 88: 686–8. [PubMed]
12. Blau JN, Kapadia R. Idiopathic palsy of the recurrent laryngeal nerve: a transient cranial mononeuropathy. BMJ 1972; 4: 259–61. [PMC free article] [PubMed]
13. Dabrowska A, Tarnowska C, Jalowinski R, et al. Paresis of the vagus and accessory nerve in the course of the herpes zoster. Otolaryngologia polska 2006; 60: 611–4. [PubMed]
14. Watelet JB, Evrard AS, Lawson G, et al. Herpes zoster laryngitis: case report and serological profile. Eur Arch Otorhinolaryngol 2007; 264: 505–7. [PubMed]
15. Wu CL, Linne OC, Chiang CW. Herpes zoster larynges with prelaryngeal skin erythema. Ann Otol Rhinol Laryngol 2004; 113: 113–4. [PubMed]
16. Kobayashi Y, Yamamoto T. Case of Horner’s syndrome associated with ophthalmic herpes zoster. Rinsho shinkeigaku = Clinical Neurology 2007; 47: 105–108. [PubMed]
17. Liesegang TJ. Varicella zoster viral disease. Mayo Clin Proc 1999; 74: 983–998. [PubMed]
Articles from BMJ Case Reports are provided here courtesy of
BMJ Group