J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.48.2.122 on 1 February 1985. Downloaded from Journal of Neurology, Neurosurgery, and Psychiatry 1985;48:122-127 Herpes zoster ophthalmicus followed by contralateral hemiparesis: report of two cases and review of literature ELI RESHEF,* STEPHEN B GREENBERG,* JOSEPH JANKOVIC,t From the Departments ofNeurology, t Medicine, * and Microbiology and Immunology, * Baylor College Medicine, Houston, Texas of SUMMARY Two patients with herpes zoster ophthalmicus and contralateral hemiparesis are described, and their findings compared with 49 patients previously reported. These presented patients with delayed contralateral hemiparesis approximately seven weeks after the onset of herpes zoster ophthalmicus. Most patients had evidence of infarction of the ipsilateral middle cerebral artery by angiography or by CT scan. Cerebrospinal fluid pleocytosis and elevated protein commonly were found. Twenty per cent of the reported patients died, but they were older than the patients who survived and predisposed to have diffuse CNS lesions. The pathogenesis of this syndrome is thought to be due to direct viral invasion of the blood vessel wall with resultingProtected by copyright. angiitis. Further studies need to be performed to clarify the role of specific antiviral therapy or anti-inflammatory agents in treating this complication of herpes zoster. Involvement of the ophthalmic branch of the trigem- and was on azathioprine and prednisone at the time of inal nerve by herpes zoster is often complicated by admission. The patient received adenine arabinoside (Vid- local spread to the eye, post-herpetic neuralgia, and arabine) 600 mg intravenously but shortly thereafter a variety of neurological problems including cranial developed a high fever, chills, nausea, and vomiting, and nerve palsies, meningoencephalitis, and, less com- the medication was discontinued. At the time of discharge, monly, contralateral hemiparesis.'-3 Although the he complained of double vision," and was found to have a first case of right superior oblique palsy. herpes zoster ophthalmicus followed by At home he contralateral hemiparesis was described by became somnolent, increasingly depressed, Dumery and had memory lapses. Five days prior to his next admis- in 1896,4 this unusual complication has been sion and 30 reported with approximately days after the onset of herpes increasing frequency in the last few zoster, he developed ataxia. On readmission, he was mildly years.4-40 We have recently evaluated two cases of somnolent. Ophthalmological examination revealed a right herpes zoster ophthalmicus followed by contralat- iritis. EEG showed diffuse slowing without lateralisation. eral hemiparesis and have reviewed 49 other cases CT scan of the head was normal. Over the next two weeks from published reports. The clinical presentation, his mental status improved and he was discharged with http://jnnp.bmj.com/ patient characteristics, methods of diagnosis, and pain medications and local eye care. pathogenesis are discussed. On the night of his third admission in late October 1982, approximately ten weeks after the onset of his herpes zos- he Case reports ter, experienced sudden onset of left arm incoordina- tion, drooping of the left corner of the mouth, numbness of the left side of the CASE I body, and left foot weakness. On admis- sion, he was somnolent but oriented. A 42-year-old white male with a history of chronic Marked left face, arm renal and leg weakness was present. The deep tendon reflexes failure was admitted in on October 1, 2021 by guest. August, 1982 for evaluation of were but herpes zoster of the right normal, there were bilateral plantar extensor ophthalmic branch. One year responses. for in the prior to admission, he underwent a second renal transplant Except hypoaesthesia distribution of the right ophthalmic branch of the trigeminal nerve, there Address for reprint requests: Stephen B Greenberg, MD. Depart- were no sensory deficits. The CSF was clear with one red ment of Medicine, Baylor College of Medicine, 1200 Moursund blood cell and two mononuclear cells/mm.3 CSF protein Avenue, Houston, Texas 77030, USA. was 67 mg/dl and glucose 52 mg/dl (serum glucose 91 mg/ dl). CT scan on admission showed an area of at the Received 31 May 1984. Accepted 14 July 1984 lucency right caudate nucleus and four days later the lucency was 122 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.48.2.122 on 1 February 1985. Downloaded from Zoster and contralateral hemiparesis 123 more prominent, with additional areas of lucency in the hria and left central facial palsy improved, but hemiparesis posterior and anterior internal capsule on the right. EEG persisted. Because the auto-immune haemolytic anaemia showed mild slowing without lateralisation. was poorly controlled the daily dose of prednisone was There was gradual improvement in motor function, increased to 100 mg. On the twenty-second hospital day, speech and right eye vision during the hospitalisation. His he became febrile and markedly lethargic. He had post-herpetic neuralgia responded transiently to imip- Cheyne-Stokes respirations, small unreactive pupils, and ramine and pain medications. He was discharged after two bilateral plantar extensor response. CT scan was compat- weeks with moderate left-sided weakness, moderate dysar- ible with uncal herniation. After receiving intravenous thria, and mild diplopia. CT scan in January, 1983 showed mannitol he became alert. The prednisone was reduced to resolution of the anterior internal capsule lesion, and in 35 mg a day and after a course of Leukeran, the autoim- March, 1983, a CT scan was normal. He underwent mune anaemia stabilised and he was discharged five weeks neurectomy of the supra-orbital branch of the right trigem- later. inal nerve in March of 1983 for intractable neuralgia. His- tological examination of the specimen, which also con- tained a small artery, revealed normal tissue without evi- Review of literature dence of inflammation. Fifty-one cases for which there is adequate informa- CASE 2 tion are included in our review.4-40 However, sev- A 62-year-old black male with chronic lymphocytic eral other patients are not included because of the leukaemia of 2 years duration was admitted in July, 1978 limited information that was provided.4'42 The mean for evaluation of herpes zoster of the right ophthalmic age of the reported patients with herpes zoster branch beginning 5 days prior to admission. Intermittent ophthalmicus-contralateral hemiparesis was 58- 1 chemotherapy (Leukeran) was given over the preceding years with a range of seven to 96 years (table). The two years; the last course being two months prior to admis- mean age among the women was 62-5, and among sion. On admission, vesicular lesions were seen in the dis- men 54-6. More than 75% of the patients were be- tribution of the ophthalmic division of the right trigeminal nerve and on the right upper palate. Neurological examina- tween the ages of 40 to 75 years. There were 29 men Protected by copyright. tion was normal. Shortly after admission, the patient's and 22 women. The average interval between the temperature rose to 103°F, and his white cell count was onset of herpes zoster ophthalmicus and that of con- 57,000 (99% lymphocytes)/mm3. Brain scan and CT scan tralateral hemiparesis was 7-3 weeks, with a range of were normal. CSF was obtained on the third hospital day one week to six months. Thirty patients had herpes and contained 38 white blood cells (41 % polymorphonuc- zoster ophthalmicus on the left side and 21 on the lear, 59% mononuclear cells), protein of 141 mg/dl, and right. Only 14 patients (28%) had an underlying glucose of 61 mg/dl. On the third hospital day, papulo- condition: six were undergoing or recently had vesicular lesions were noted on the trunk and extremities. undergone chemotherapy for maligancies (lym- Three days later, an incomplete right third cranial nerve palsy and complete right sixth cranial nerve palsy were phosarcoma, prostatic cancer, chronic lymphatic ncted. Lumbar puncture was repeated on the seventh hos- leukaemia (2 patients), breast cancer, and colon pital day and revealed 15 white blood cells (22% polymor- cancer); eight had noncancerous conditions (renal phonuclear, 78% mononuclear cells) and a protein of 62 failure, rheumatoid arthritis, chronic alcoholism, mg/dl. Cell block for leukaemic cells was negative. On the diabetes mellitus, pancreatitis, myasthenia gravis, final three days of hospitalisation, the patient was noted by and pulmonary sarcoidosis). his family to have intermittent confusion, but he was dis- charged after 23 days in hospital. Clinical course His second admission was approximately 12 weeks after Twenty-four patients (47%) exhibited diffuse CNS the onset of herpes zoster ophthalmicus. Eight days prior http://jnnp.bmj.com/ to admission, he noted gradual onset of left-sided weak- symptoms following the onset of herpes zoster ness. On admission, he was alert and oriented, with slightly ophthalmicus-fifteen at or following the onset of dysarthric speech. A central left facial palsy and left sixth contralateral hemiparesis, nine prior to contralateral cranial palsy were present. He had a left hemiparesis and hemiparesis. These symptoms included stupor, som- left homonymous hemianopsia. No papilloedema was nolence, general disorientation, confusion, and/or observed. Laboratory studies on admission revealed a memory deficits. Among the latter nine patients, haematocrit of 24% and a haemoglobin of 7-3 g/dl. three had disseminated zoster between the onset of Because of an associated auto-immune haemolytic herpes zoster ophthalmicus and contralateral anaemia, he was begun on prednisone, 60 mg per day, as hemiparesis. One patient had disseminated zoster on October 1, 2021 by guest. well as Leukeran, 6-8 mg per day. Lumbar puncture on the third day of hospitalisation revealed 16 white blood cells without diffuse CNS symptoms prior to the onset of (89% mononuclear cells)/mm3 and a protein of 79 mg/dl.