Tracing the Rash: Diaphragmatic Paralysis Following Cervical Herpes Zoster

Abstract

An 80-year-old man presented with a two-day history of anorexia and decreased daily activity. A physical examination revealed an erythematous, crusted, vesicular eruption distributed along the C3-C5 dermatome. Chest x-ray and computed tomography during inspiration and expiration demonstrated an elevation of the left hemidiaphragm with almost no movement of the left diaphragm during respiration. These findings were consistent with left diaphragmatic paralysis due to cervical herpes zoster. As a rare type of segmental motor paresis, cervical herpes zoster can cause phrenic nerve paralysis because the phrenic nerve originates in the anterior horn of the C3 to C5 roots. Diaphragmatic paralysis results in diminished vital capacity and can lead to a decline in exercise tolerance or daily activity, especially in elderly patients.

Case Presentation

An 80-year-old man presented with a 2-day history of anorexia and decreased daily activity. On presentation, his oxygen saturation was 90% on ambient air at rest. A physical examination revealed diminished breath sounds in the left lung and an erythematous, crusted, vesicular eruption distributed along the C3-C5 dermatome (Figure 1A and B). Chest X-ray and computed tomography during inspiration and expiration demonstrated an elevation of the left hemidiaphragm with almost no movement of the left diaphragm during respiration (Figure 2A-D), which had not been observed on a chest X-ray 1 year ago. Pulmonary function tests demonstrated that his vital capacity (% of predicted value) had declined to 61.7%.

Figure 1.

Photograph showing a mostly crusted, erythematous, vesicular eruption along the left C3-C5 dermatome (A, B).

Figure 2.

Chest radiographs taken during inspiration (A) and expiration (B) and chest computed tomography taken during inspiration (C) and expiration (D), demonstrating an elevated left hemidiaphragm with almost no movement of the left diaphragm during respiration.

Questions: What is the most likely cause of the abnormality on the chest X-ray?

Answers: Diaphragmatic paralysis due to cervical herpes zoster.

Discussion

Approximately 3% of herpes zoster cases are complicated by segmental motor paresis.¹ As a rare type of segmental motor paresis, cervical herpes zoster can cause phrenic nerve paralysis because the phrenic nerve originates in the anterior horn of the C3-C5 roots. While unilateral diaphragmatic paralysis often remains asymptomatic, some patients may experience dyspnea, particularly during exertion or in the supine position.

Even in a case with no respiratory symptoms, diaphragmatic paralysis results in diminished vital capacity.² This can lead to a decline in exercise tolerance or daily activity, especially in elderly patients. Although there is no specific treatment for diaphragmatic paralysis due to cervical herpes zoster, some patients recover over the course of months to years while the majority (72.8%) show no improvement.² In this case, his symptoms improved with supportive therapy and rehabilitation, but the left diaphragmatic paralysis on X-ray had not improved by the 12-month follow-up. Long-term rehabilitation and follow-up may be desirable for such patients.

Patient Consent

Consent to publish the details of the present case was obtained from the patient.

CRediT authorship contribution statement

Yasuhiro Kano: Writing – original draft, Visualization, Investigation, Conceptualization.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.