JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 90 July 1 997

Horner's syndrome due to herpes zoster in the T3-T4 dermatome

T R G Poole MB BSc1 J F Acheson MRCP FRCOphthl S E Smith FRCS FRCOphth2 M J Steiger MD MRCP3

J R Soc Med 1997;90:395-396

Chest disease is a well recognized cause of Homer's syndrome, when the lesion is at the second thoracic level (T2) or higher. A lesion below T3 affecting sympathetic outflow to the eye has not previously been documented. We report such a case.

Figure 1 Rash at 5 weeks CASE HISTORY A woman aged 57 developed a painful rash on her right Full blood count, electrolytes and VDRL were normal. upper chest. At the same time she noticed a drooping of her C-reactive protein was raised at 12 mg/L. Chest X-ray right eyelid. She had been previously well, apart from showed an enlarged heart consistent with hypertensive hypertension diagnosed a year before, treated with atenolol. disease but no focal lung disease, and in particular no apical Her general practitioner diagnosed herpes zoster and disease. Brain magnetic resonance imaging with axial T2 prescribed oral acyclovir, 200mg five times daily. Five weighted images and sagittal T1 weighted images showed no weeks later she presented to the eye casualty complaining of intracranial abnormality. a persistently drooping right eyelid. She also reported Pholedrine drops, a substitute for hydroxyamphetamine neuralgic chest pain, for which she had begun taking co- 1% produced mydriasis bilaterally, showing the lesion to be codamol and half a bottle of vodka a day. preganglionicl. Three years after the episode of infection, On examination there was no lymphadenopathy. The the Homer's syndrome showed no sign of recovery. remnants of her rash were visible in the fourth thoracic dermatome anteriorly (Figure 1), with a horizontal configuration indicating the cutaneous distribution of the COMMENT spinal nerve ventral rami. Of the three neurologists who A paretic lesion of the sympathetic pathway was described examined her, two placed the rash in the T4 dermatome and in detail by Claude Bernard (1852), but the Swiss the third in T3-4. There was anhidrosis of the right upper ophthalmologist Johann Friedrich Horner gave a detailed face. Acuities were 6/6 unaided bilaterally; there was a description of the clinical picture in 18692. right partial ptosis with frontalis overaction (Figure 2). Horner's syndrome is a rare complication of herpes Levator function was normal. The right pupil was miosed, zoster, either ophthalmic3 or thoracic4. A review of the diameter 3 mm, compared with its fellow, 5 mm. preganglionic sympathetic pathway reveals the unusual Pupillography revealed normal reflex responses to light on nature of the case reported here. both sides but marked redilatation lag on the right-a typical manifestation of a sympathetic deficit and character- istic of Horner's syndrome. Near responses were normal. Facial sensation and power were normal. Peripheral nervous system examination was normal except for reduced pin-prick sensation in the right T3-4 dermatome.

'Westem Eye Hospital, London NW1 5YE; 2National Hospital for Neurology and Neurosurgery, London WC1 N 3BG; 3Walton Centre for Neurology and Neurosurgery, Liverpool L9 1AE, England Correspondence to: Mr J E Acheson, Westem Eye Hospital, Marylebone Road, London NW1 5YE, England Figure 2 Eyes at 5 weeks 395 JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 90 July 1997

The descending oculosympathetic pathway from the damaging perineuritis and perivasculitis associated with its posterolateral hypothalamus is probably punctuated by one spread6, could then account for a preganglionic sympa- or more synapses in the pontine and mesencephalic thetic lesion. tegmentum, although some of the fibres descend directly, without synapse, to the ciliospinal centre of Budge5. This is REFERENCES found within the intermediolateral cell column of the spinal I Bates AT, Chamberlain S, Champion M, et a]. Pholedrine: a substitute cord at levels C8-T2, and contains the cell bodies of the for hydroxyamphetamine as a diagnostic evedrop test in Horner's preganglionic fibres. These leave the cord from the ventral syndrome. Neurol .Neurosurg Psychiatry 1995;58:215-17 root to form the paravertebral sympathetic chain, 2 Duke-Elder S. System of Ophthalmology, Vol XII. London, 1971:632 proceeding through the stellate ganglion to synapse in the 3 Smith EF, Santamarina L, Wolintz AH. Herpes zoster ophthalmicus as a superior cervical ganglion. Most of the pupillomotor fibres cause of Horner syndrome. J Clin Neuro-ophthalmol 1993;13:250 3 leave the cord by the first ventral thoracic route, but some 4 Wimalaratna HS, Capildeo R, Lee HY. Herpes zoster of second and third segments causing ipsilateral Horner's syndrome. BAIJ 1987; have been found to leave via the C8 or T2 roots5 294:1463 In this case, a more caudal excursion of sympathetic 5 FB Walsh, WF Hoyt. Clinical Neuroophthalmology, Vol II, 4th edn. fibres would have to be assumed. Reactivation of zoster Baltimore: Williams & Wilkins, 1985:424-5 virus in the T3 and T4 dorsal root ganglia, and the 6 Marsh RJ, Cooper M. Ophthalmic herpes zoster. Eye 1993;7:350-70

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