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Peduncular Hallucinosis and Right Hemi- Parkinsonism Caused by Left 870 Letters to the Editor after admission, a week before the appear- ism. An MRI showed a unilateral infarction nosis due to unilateral lesion. Although the ance of the cutaneous eruption. involving the left cerebral peduncle. precise anatomical basis for peduncular hal- J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.57.7.870 on 1 July 1994. Downloaded from The pathogenesis of HSV-2 myelitis in A previously healthy 70 year old right lucinosis remains unclear, it seems that the this case remains ill defined. Although IgM handed woman presented with visual hallu- substantia nigra pars reticulata (SNpr) is antibodies were detected in the first serum cinations. Two months previously, she directly implicated.3 Little is known about sample we are not sure that the patient's began, one night, to see objects (motor- the pathogenesis of peduncular hallucinosis. myeloradiculitis reflected true HSV-2 pri- bikes), animals (dogs, horses), and people A relation with the rapid eye movement mary infection because reappearance of (Japanese) entering and driving silently (REM) phase of sleep has been proposed. IgM antibodies can be detected in herpes round her room, across the entire visual In this sense, it is known that the SNpr may virus reactivation. All but one preriously field. Although the images were of normal play an important part in the regulation of reported case of HSV-2 myelitis were fatal colours and sizes, she was aware that they the different phases of sleep through its and occurred in immunocompromised were not real, and never described "deja connections with centromedian/parafascicu- hosts. This patient was neither diabetic nor vu" or "jamais vu" phenomena, tactile, or lar nuclei of the thalamus, superior collicu- HIV-infected, but despite normal CT auditory hallucinosis. The hallucinatory lus, and reticular formation.4 examinations of the thorax and abdomen, a events became progressively longer and Finally, although we cannot rule out the hidden malignancy cannot be excluded. more frequent, lasting from minutes to presence of brainstem Lewy bodies, it is Reactivation of a latent infection within hours, during both day and night. Her probable that the right hemiparkinsonism dorsal root ganglia neurons with a contigu- medical history included mild hypertension, found in our patient was related to ous spread via sacral ganglia to the spinal normofunctional multinodular goitre, and ischaemic damage of the left substantia cord has already been proposed in HSV-2 surgery for left breast carcinoma six years nigra pars compacta.5 ascending myelitis.' It is of note that despite earlier, without subsequent evidence of RAUL DE LA FUENTE FERNANDEZ antiviral treatment, our patient died within recurrence. There were no other remarkable JOSE MAREY LOPEZ six weeks. Thus an immunologically personal or familial antecedents. On exami- PABLO REY DEL CORRAL mediated injury triggered by the herpes nation, she was alert, oriented, and cooper- Service ofNeurology infection could also be involved here, as in ative. She remembered four of five words FERNANDO DE LA IGLESIA MARTINEZ Department ofInternal Medicine, another patient with HSV-1 myelitis whose after five minutes, and the mini mental state HospitalYuan Canalejo, necropsy examination showed patchy test was 32/35. She remained in a left tilted La Coruna, Spain demyelination of the spinal cord.7 posture, and showed severe impairment of EMMANUEL ELLIE postural reflexes, mild bradykinesia, cog- Correspondence to: Dr Rail de la Fuente Service de Neurologie, Fernandez, Servicio de Neurologia, Hospital Juan Hopital du Haut-Livique, wheel rigidity, and intermittent resting Canalejo, Xubias de Arriba, 84, 15006 La CHU Bordeaux, France tremor in the right extremities (mainly in Coruina, Spain. FLORE ROZENBERG the lower limb). Tendon reflexes were brisk Service de Bactiriologie-Virologie, 1 Lhermitte J. Syndrome de la calotte du pedon- H6pital Saint-Vincent de Paul, and increased on the right side, but there cule cerebral. Les troubles psycho-sensoriels Paris, France was no clonus and the plantar responses dans les lesions du mesocephale. Rev Neurol VINCENT DOUSSET were flexor. There were no other remark- (Paris) 1922;38: 1359-65. Service de Neuroradiologie, able findings on general or neurological 2 Geller TI, Bellur SN. Peduncular hallucinosis: CHU Bordeaux, France magnetic resonance imaging confirmation of MARIE BEYLOT-BARRY examination. Laboratory investigations, mesencephalic infarction during life. Ann Service de Dermatologie, including ESR, routine haematological, bio- Neurol 1987;21:602-4. CHU Bordeaux, France chemical, and immunological studies, thy- 3 McKee AC, Levine DN, Kowall NW, Richardson EP Jr. Peduncular hallucinosis roid function tests, serological tests for associated with isolated infarction of the Correspondence to: Dr Emmanuel Ellie, fluid INSERM U394, rue Camille Saint-Saens, 33077 syphilis, cerebrospinal examination, substantia nigra pars reticulata. Ann Neurol EEG, and cranial CT were normal or nega- 1990;27:500-4. Bordeaux Cedex, France. 4 Beckstead RM, Frankfurter A. The distribu- tive. An MRI showed an abnormal high tion and some morphological features of 1 Britton CB, Mesa-Tejada R, Fenoglio CM, intensity signal in the left cerebral peduncle substantia nigra that project to the thala- Hays AP, Garvey GJ, Miller JR. A new on T2-weighted images (figure). Multiple mus, superior colliculus and pedunculopon- complication of AIDS: thoracic myelitis foci of T2-weighted high signal intensity tine nucleus in the monkey. Neuroscience caused by herpes simplex virus. Neurology 1982;7:2377-88. 1985;35:1071-4. were also seen throughout the periventricu- 5 Jellinger K. The pathology of parkinsonism. 2 Tucker T, Dix RD, Katzen C, Davis RI, lar white matter. Such findings were consis- In: Marsden CD, Fahn S, eds. Movement Schmidley JW. Cytomegalovirus and herpes tent with ischaemic damage. Despite disorders. Vol 2. London: Butterworths, simplex virus ascending myelitis in a patient 1987:124-65. http://jnnp.bmj.com/ with acquired immune deficiency syndrome. treatment with haloperidol and phenytoin Ann Neurol 1985;18:74-9. the patient became more impaired within 3 Wiley CA, VanPatten PD, Carpenter PM, the next several weeks, showing continuous Powell HC, Thal U. Acute ascending visual hallucinations, with frequent episodes necrotizing myelopathy caused by herpes Intraneural ganglion of the sciatic simplex virus type 2. Neurolog 1987;37: of agitation and disorientation. 1791-4. Vascular lesion of the upper brainstem is nerve: detection by ultrasound 4 Iwamasa T, Yoshitake H, Sakuda H, et al. the most often cause of peduncular halluci- Acute ascending myelitis in Okinawa caused Intraneural ganglia are a rare cause of by herpes simplex virus type 2. Virchows nosis. A case of peduncular hallucinosis due bilateral infarction peripheral nerve lesions most often affecting Arch A Pathol Anat Histopathol 1991;418: to mesencephalic diag- on September 30, 2021 by guest. Protected copyright. 71-5. nosed by MRI has been recently reported.2 the peroneal nerve. Their origin is 5 Iwamasa T, Utsumi Y, Sakuda H, et al. Two The present one is the first report, however, unknown. Some 50 cases were reported up cases of necrotizing myelopathy associated to 1979.' Sciatic nerve ganglia are very rare. with malignancy caused by herpes simplex to our knowledge, of peduncular halluci- virus type 2. Acta Neuropathol (Bert) 1989; We report a sciatic nerve lesion caused by a 78:252-7. giant ganglion situated at the level of the 6 Ahmed I. Survival after herpes simplex type II distal thigh and damaging the tibial portion myelitis. Neurology 1988;38: 1500. 7 Klastersky J, Cappel R, Snoneck JM, Flament only. J, Thirty L. Ascending myelitis in associa- A 36 year old male right handed and tion with herpes simplex virus. N Engl J7 Med right footed state officer complained of pain 1972;287: 182-4. in his right calf for about six years especially when jogging and walking for more than 30 minutes. He was treated for a lumbar disc hernia, but a lumbar CT was unremarkable. Simultaneously he noted discomfort in his Peduncular hallucinosis and right hemi- right toes when wearing shoes; this was parkinsonism caused by left mesen- relieved by wearing orthopaedic sandals. cephalic infarction On first neurological examination he was found to have Lasegue's sign with his right Since the original description of Lhermittel leg at an angle of about 850. Reflexes and several causes of peduncular hallucinosis sensation in the lower extremities were nor- in mal. There was moderate paresis of the toe have been reported, but always relation Axial T2-weighted MR image obtained with a to a bilateral mesencephalic lesion. We 05-T unit shows an area of hyperintensity in flexors. Plain radiographs of the lower spine describe here a patient with prolonged vis- the left cerebral peduncle, consistent with showed six lumbar vertebrae and a fissured ual hallucinations and right hemiparkinson- infarction. vertebral arch of the first sacral segment..
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