Rinsho Shinkeigaku (Clinical Neurology)

Case Report

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

Saya Motohashi1), Junichiro Takahashi, M.D.2), Tadashi Umehara, M.D., Ph.D.2), Teppei Komatsu, M.D., Ph.D.2), Hidetomo Murakami, M.D., Ph.D.2) and Yasuyuki Iguchi, M.D., Ph.D.2)

1) The Jikei University School of Medicine
2) Department of Neurology, The Jikei University School of Medicine

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.
Full Text of this Article in Japanese PDF (1659K)

(CLINICA NEUROL, 62: 380−385, 2022)
key words: varicella-zoster virus, multiple cranial neuropathies, polyradiculopathy, anatomical interconnections among neurons, meningitis, zoster sine herpete

(Received: 11-Sep-21)