Multicranial neuropathy in reactivated varicella zoster virus infection - a case report

Abstract

Introduction: Herpes zoster typically presents with dermatomal rash and radicular pain. Although rare, but it can cause various neurological complications such as meningitis, encephalitis, myelitis, cerebral angiitis, subacute amyotrophy and cranial nerve palsy. A diagnostic dilemma arises in cases of zoster sine herpete, where the absence of the characteristic vesicular rash may delay recognition of varicella zoster virus infection.

Case: We report a case of a 63-year-old male who presented with otalgia, facial asymmetry, hearing loss, and subsequently developed dysphagia and hoarseness. Clinical examination revealed involvement of multiple cranial nerves (VII, VIII, IX, and X), consistent with polyneuritis cranialis. Notably, there were no characteristic vesicular eruptions. Cerebrospinal fluid analysis demonstrated lymphocytic pleocytosis with elevated protein, and polymerase chain reaction confirmed VZV DNA. A diagnosis of herpes zoster meningitis with cranial polyneuropathy was established. The patient was treated with intravenous acyclovir and corticosteroids, resulting in complete recovery of neurological deficits on follow-up.

Conclusion: Varicella zoster virus (VZV) is an often overlooked etiology of polyneuritis cranialis. This case highlights that, in addition to more common causes such as vascular disorders, neoplasms, chemotherapy-related neuropathy, diabetes mellitus, and vasculitis, rare infectious etiologies like VZV should be considered in appropriate clinical contexts. Early recognition is crucial to facilitate prompt diagnosis and timely initiation of therapy, thereby reducing the risk of long-term neurological sequelae.