MULTIPLE CRANIAL NERVE INVOLVEMENT IN HERPES ZOSTER (A Case Report)

Introduction

Herpes zoster is a viral infection usually afflicting one or more adjacent spinal or cranial sensory nerves and the skin or mucous membrane supplied by them [1, 2]. The commonly involved dermatomes are thoracic, cervical, trigeminal and lumbosacral [3, 4]. Ramsay-Hunt syndrome is herpes zoster affecting the geniculate ganglion causing facial nerve palsy frequently. This syndrome occurs relatively commonly. However, association of zoster with other cranial nerve involvement is rare [5, 6]. One such case is reported here.

Case Report

A 20-year-old serving sailor reported with headache, right sided facial palsy and multiple painful grouped vesicular lesions on the right pinna, external auditory meatus and cheek. He gave history of fever, malaise and bodyache, one day prior to these symptoms. He also complained of severe earache and vesicular lesions inside mouth and tongue on the right side. He gave no history of drug intake. Clinical examination revealed multiple grouped vesicles on an erythematous base on right pinna, external auditory canal and cheek. Similar vesicles and superficial ulcers were present on the right side of buccal mucosa and anterior two third of tongue. He also had right sided facial palsy of the lower motor neurone type with Bell’s phenomenon. There was loss of taste sensation over the right half of the anterior two third of tongue. There was paresis of right vocal cord and soft palate also. There was no evidence of sensorineural deafness or canal paresis. General and systemic examination did not reveal any other abnormality. ELISA and HIV was negative. He was diagnosed as a case of herpes zoster of the facial nerve (Ramsay-Hunt Syndrome), trigeminal, glossopharyngeal and vagus nerves. He was treated with oral acyclovir, corticosteroids, NSAIDs and supportive therapy alongwith physiotherapy to which he responded well with residual minimal facial nerve palsy. Follow up at 6 months revealed complete recovery.

Discussion

Ramysay-Hunt Syndrome classically presents as herpes zoster involving the facial nerve with vesicular (spill over) lesions involving the external ear. The motor involvement may precede or follow the cutaneous lesions by a few days [7]. The interesting finding in this case is multiple cranial nerve involvement viz. trigeminal, facial, glossopharyngeal and vagus nerves. The facial nerve has communicating branches with the second and third cervical nerves and with other cranial nerves [1, 4].

Fig. 1.

Herpes zoster lesions on right side of tongue, face and ear.

Fig. 2.

Herpes zoster lesion on right side of face and seventh cranial nerve palsy.

Hence, in atypical cases there may be association of facial, palatal and vocal cord paralysis with vesicular skin lesions in the distribution of the sensory components of the above cranial nerves [5].