HERPES ZOSTER ENCEPHALITIS in association with the Ramsay Hunt
Report of a
syndrome
case
BY
R. D. G. CREERY, M.D., M.R.C.P., D.C.H.
Principal
Paediatric Registrar, Royal Belfast late Medical Registrar, Southmead
Hospital for Sick Hospital, Bristol.
Children*
Encephalitis is one of the rarer complications of herpes zoster. I he c picture of the encephalitis may be fulminating with a fatal outcome, or it ^ here be of a much milder nature with ultimate recovery, as in the case The present case is reported as an example of its association with occasional manifestation, the Ramsay Hunt syndrome, or so-called " herpes (Hunt, 1907). This syndrome in its most severe form, peripheral facial palsy, herpetic eruption on the ear, face or neck, and in ment of the auditory nerve.
recor^
comp^,
CASE REPORT
J
A carpenter, aged forty years, was admitted to hospital on 25th May, 195 I# ^ " weeks before, he had been in contact with a case of shingles ". One week before 31 Two he ear. in the of sion, days later "he had difficulty wit complained right pain ^ and noticed right-sided facial weakness. Later he became dizzy and comp a1 J e severe headache and photophobia. On the day before admission his right ear and he felt drowsy. Examination showed an apprehensive man, fully ^ co-operative and apyrexial. The relevant findings were as follows: complete rig ^ thet of paralysis (lower motor neurone in type), with loss of taste on the anterior part ^ right-sided deafness (middle-ear in type, as judged by tuning-fork tests). Co w tests were normal. The right ear showed an external otitis with herpetic external auditory meatus and on the pinna. The tympanic membrane was invo v of M was not bulging, nor was there any perforation. When standing, with eyes open ^ dar Jf he tended to fall to the Two other clinical no There was abnormality. right. admission he suddenly became rigid, and lost consciousness for several j, rapidly recovered, but remained drowsy for some hours. A transient
discharge,
vesicles^
^
right
minute^(| weakness^,
external rectus muscle was noted.
The plantar reflexes were equivocal,^ c' performed. The pressure was 260 mm. of The cerebrospinal fluid contai^^! was faintly cloudy. maj?"ty being polymorphonuclears; protein 130 mgm. Pef J
^umbar puncture
exor.
corning
3nC^
was
lei]03 fU1 C'mm'' chlnrvf m?n1, Per CS
cent- 5 sugar 54 mgm. per cent. There were organis111 fl1 -^S ?^? ?n Culture- He was seen the following day by Dr. A. M. G. Who71; r Stuen herpes zoster encephalitis, presenting as the Rams^ aV VNfS n Case Patient's ^ condition gradually improved, the facial on,.t^le rum derrpiQP^ 'esi?ns healed, and he was discharged on 19th June, I951' 1S
C
last
wen
a
no
3
erPetlf
an
out"Patlent three months after admission, he a minor degree of deafness.
facial wmI weakness and
was
well and had only
3
DISCUSSION .
?
j
J
.
t>Crain ^ss?ciat^n (193?),
of encephalitis with zoster infection was discussed by who reviewed the literature, and recorded a further fa*a 54
J j
HERPES ZOSTER ENCEPHALITIS
They
concluded that, although
55
the zoster was a complication of the zoster infection had extension ProH In their case this latter conclusion was supencePhahtic picture. Ported ^ resu^ts ?f cerebrospinal fluid complement-fixation tests. Biggart and P" r in their report of a fatal case of meningo-encephalitis complicati u erpes zoster, gave a very full account of the clinical and pathological Pat*ent became drowsy five weeks after the onset of herpes zoster in lstnbution of the right ilio-inguinal nerve, and later became comatose and de|-. US' fluid contained 20 cells per cmm. Pathologically, cerebrospinal there Were ^0rsal ganglionitis, mononuclear infiltration of the subarachnoid SpaCe pyelitis, and encephalitic changes such as peri-vascular roundCeH ratlon" They concluded that these findings supported the possibility that the was due t0 zoster infection, as the lesions in the medulla mid to be merely an upward extension of the same lesions appeared f?Und cord. The encephalitic picture in the present case comprised SS headache, followed by a seizure with transient coma and sixthnerve cerebrospinal fluid pressure was high, as in SchifF and 'CaSe" feature was the high proportion of polymorphonuinteresting c^ars which probably indicated an early stage of the reaction; Unmore commonly found (Brain, 1951). ^?rtUnat n?CC^S are state three local in the features of the syndrome could be eccentricities K the re postulating a varying attack on the nerves and their ganglia supply" the head and neck. It is suggested that the term geniculate as it does not satisfactorily explain the variations in an^ has little, if any, pathological foundation. Recent adVai*ces in ^ght he antibiotics have produced hopes that some of these drugs ^ ^ ^ t^le treatment of herpes zoster. Binder and Stubbs (1949), reported good results with aureomycin. It is to be that n Ser*es was controlled. More recent work, in which controls e.re Used K e arter (1951), and Kass et al. (1952), suggests that there is little ?Ur a 0r sPec^c effect against the zoster virus by either aureotio* chlor ^arter ^as suggest, however, that secondary infec6 ^Ut ^ass et ?L' were unable to find any significant difference
0?
ln^ePenc^ent encephalitis,
in
some
in others
patients an
th^r
?'i^0ste>r^or '
drotyS-ln
?rain's^areS^S"
(1944)
i6ar
of^L '
They
,
'
gangly11 'p^.arkinson syndrorn'e
'
"
CoAvenieritj
"
^
probablC ksion, hmC
ni^p0r
^pla^ed
"
^rPes m-??
wCl^ca&dr?PPfd. hpf ^Se.?f
^nlar^
^oted
^^*949)> pGr
^ence ^ ^0ri avoided1^^611^00^ '
(ii)
^?'
254
h
^6
HERPES ZOSTER ENCEPHALITIS
between treated and untreated cases. That the treatment of zoster in^ect, with antibiotics is not satisfactory is suggested by the experience of Foster Jackson (1951) who reported the occurrence of herpes zoster encephalitis 1 patient treated with aureomycin for the original infection. At present as op * such in severe to use antibiotics these cases, probably justifiable only mic zoster, or where a potentially fatal complication such as meningo-encep a has occurred.
J
SUMMARY
of herpes zoster presenting with auricular eruption, facial paralysis ^ encephalitis is reported. The pleomorphism of the disease is noted. encephalitis and the Ramsay Hunt syndrome are discussed. The use 0 " term geniculate herpes is deprecated. It is suggested that treatment antibiotics might be reserved for severe cases and for those with serious co#1 cations. A
case
"
,
thank Dr. A. M. G. Campbell for his opinion, Dr. F. J. W. Lewis f? pathological report and Dr. J. A. Birrell for permission to publish. I wish
to
^
REFERENCES
Biggart, J. H., and Fisher, J. A. (1938). Lancet, 2, 944. Binder, M. L., and Stubbs, L. E. (1949). J. Amer. med. Ass., 141, 1050. Brain, W. R. (1951). Diseases of the Nervous System, 4th ed., 491. London. Carter, A. B. (1951). Brit. med. J., i, 987. Critchley, M. (1947), in The Medical Annual, 281. Bristol. .y Denny-Brown, D., Adams, R. D., and Fitzgerald, P. J., (1944). Arch. NeUt? Psychiat., 51, 2x6. Finland, M., Finnarty, E. F., Jr., Collins, H. S., Baird, J. W., Gocke, T. M., an E. H., (1949). New. Engl. J J. Med., 241,1037. Foster, J. H., and Jackson, A. H. (1951). Conn. med. J., 15, 199, quoted in & Medica (Internal Medicine), (1951), 5, 1482. Amsterdam. Hunt, J. Ramsay (1907). J. nerv. ment. Dis., 34,73. Kass, E. H., Aycock, R. R., and Finland, M. (1952). New Engl. J. Med., 24?> Parkinson, T. (1948). Brit. med. J., 1, 8. Schiff, C. I., and Brain, W. R. (1930). Lancet, 2, 70. ,
Report of a
syndrome
case
BY
R. D. G. CREERY, M.D., M.R.C.P., D.C.H.
Principal
Paediatric Registrar, Royal Belfast late Medical Registrar, Southmead
Hospital for Sick Hospital, Bristol.
Children*
Encephalitis is one of the rarer complications of herpes zoster. I he c picture of the encephalitis may be fulminating with a fatal outcome, or it ^ here be of a much milder nature with ultimate recovery, as in the case The present case is reported as an example of its association with occasional manifestation, the Ramsay Hunt syndrome, or so-called " herpes (Hunt, 1907). This syndrome in its most severe form, peripheral facial palsy, herpetic eruption on the ear, face or neck, and in ment of the auditory nerve.
recor^
comp^,
CASE REPORT
J
A carpenter, aged forty years, was admitted to hospital on 25th May, 195 I# ^ " weeks before, he had been in contact with a case of shingles ". One week before 31 Two he ear. in the of sion, days later "he had difficulty wit complained right pain ^ and noticed right-sided facial weakness. Later he became dizzy and comp a1 J e severe headache and photophobia. On the day before admission his right ear and he felt drowsy. Examination showed an apprehensive man, fully ^ co-operative and apyrexial. The relevant findings were as follows: complete rig ^ thet of paralysis (lower motor neurone in type), with loss of taste on the anterior part ^ right-sided deafness (middle-ear in type, as judged by tuning-fork tests). Co w tests were normal. The right ear showed an external otitis with herpetic external auditory meatus and on the pinna. The tympanic membrane was invo v of M was not bulging, nor was there any perforation. When standing, with eyes open ^ dar Jf he tended to fall to the Two other clinical no There was abnormality. right. admission he suddenly became rigid, and lost consciousness for several j, rapidly recovered, but remained drowsy for some hours. A transient
discharge,
vesicles^
^
right
minute^(| weakness^,
external rectus muscle was noted.
The plantar reflexes were equivocal,^ c' performed. The pressure was 260 mm. of The cerebrospinal fluid contai^^! was faintly cloudy. maj?"ty being polymorphonuclears; protein 130 mgm. Pef J
^umbar puncture
exor.
corning
3nC^
was
lei]03 fU1 C'mm'' chlnrvf m?n1, Per CS
cent- 5 sugar 54 mgm. per cent. There were organis111 fl1 -^S ?^? ?n Culture- He was seen the following day by Dr. A. M. G. Who71; r Stuen herpes zoster encephalitis, presenting as the Rams^ aV VNfS n Case Patient's ^ condition gradually improved, the facial on,.t^le rum derrpiQP^ 'esi?ns healed, and he was discharged on 19th June, I951' 1S
C
last
wen
a
no
3
erPetlf
an
out"Patlent three months after admission, he a minor degree of deafness.
facial wmI weakness and
was
well and had only
3
DISCUSSION .
?
j
J
.
t>Crain ^ss?ciat^n (193?),
of encephalitis with zoster infection was discussed by who reviewed the literature, and recorded a further fa*a 54
J j
HERPES ZOSTER ENCEPHALITIS
They
concluded that, although
55
the zoster was a complication of the zoster infection had extension ProH In their case this latter conclusion was supencePhahtic picture. Ported ^ resu^ts ?f cerebrospinal fluid complement-fixation tests. Biggart and P" r in their report of a fatal case of meningo-encephalitis complicati u erpes zoster, gave a very full account of the clinical and pathological Pat*ent became drowsy five weeks after the onset of herpes zoster in lstnbution of the right ilio-inguinal nerve, and later became comatose and de|-. US' fluid contained 20 cells per cmm. Pathologically, cerebrospinal there Were ^0rsal ganglionitis, mononuclear infiltration of the subarachnoid SpaCe pyelitis, and encephalitic changes such as peri-vascular roundCeH ratlon" They concluded that these findings supported the possibility that the was due t0 zoster infection, as the lesions in the medulla mid to be merely an upward extension of the same lesions appeared f?Und cord. The encephalitic picture in the present case comprised SS headache, followed by a seizure with transient coma and sixthnerve cerebrospinal fluid pressure was high, as in SchifF and 'CaSe" feature was the high proportion of polymorphonuinteresting c^ars which probably indicated an early stage of the reaction; Unmore commonly found (Brain, 1951). ^?rtUnat n?CC^S are state three local in the features of the syndrome could be eccentricities K the re postulating a varying attack on the nerves and their ganglia supply" the head and neck. It is suggested that the term geniculate as it does not satisfactorily explain the variations in an^ has little, if any, pathological foundation. Recent adVai*ces in ^ght he antibiotics have produced hopes that some of these drugs ^ ^ ^ t^le treatment of herpes zoster. Binder and Stubbs (1949), reported good results with aureomycin. It is to be that n Ser*es was controlled. More recent work, in which controls e.re Used K e arter (1951), and Kass et al. (1952), suggests that there is little ?Ur a 0r sPec^c effect against the zoster virus by either aureotio* chlor ^arter ^as suggest, however, that secondary infec6 ^Ut ^ass et ?L' were unable to find any significant difference
0?
ln^ePenc^ent encephalitis,
in
some
in others
patients an
th^r
?'i^0ste>r^or '
drotyS-ln
?rain's^areS^S"
(1944)
i6ar
of^L '
They
,
'
gangly11 'p^.arkinson syndrorn'e
'
"
CoAvenieritj
"
^
probablC ksion, hmC
ni^p0r
^pla^ed
"
^rPes m-??
wCl^ca&dr?PPfd. hpf ^Se.?f
^nlar^
^oted
^^*949)> pGr
^ence ^ ^0ri avoided1^^611^00^ '
(ii)
^?'
254
h
^6
HERPES ZOSTER ENCEPHALITIS
between treated and untreated cases. That the treatment of zoster in^ect, with antibiotics is not satisfactory is suggested by the experience of Foster Jackson (1951) who reported the occurrence of herpes zoster encephalitis 1 patient treated with aureomycin for the original infection. At present as op * such in severe to use antibiotics these cases, probably justifiable only mic zoster, or where a potentially fatal complication such as meningo-encep a has occurred.
J
SUMMARY
of herpes zoster presenting with auricular eruption, facial paralysis ^ encephalitis is reported. The pleomorphism of the disease is noted. encephalitis and the Ramsay Hunt syndrome are discussed. The use 0 " term geniculate herpes is deprecated. It is suggested that treatment antibiotics might be reserved for severe cases and for those with serious co#1 cations. A
case
"
,
thank Dr. A. M. G. Campbell for his opinion, Dr. F. J. W. Lewis f? pathological report and Dr. J. A. Birrell for permission to publish. I wish
to
^
REFERENCES
Biggart, J. H., and Fisher, J. A. (1938). Lancet, 2, 944. Binder, M. L., and Stubbs, L. E. (1949). J. Amer. med. Ass., 141, 1050. Brain, W. R. (1951). Diseases of the Nervous System, 4th ed., 491. London. Carter, A. B. (1951). Brit. med. J., i, 987. Critchley, M. (1947), in The Medical Annual, 281. Bristol. .y Denny-Brown, D., Adams, R. D., and Fitzgerald, P. J., (1944). Arch. NeUt? Psychiat., 51, 2x6. Finland, M., Finnarty, E. F., Jr., Collins, H. S., Baird, J. W., Gocke, T. M., an E. H., (1949). New. Engl. J J. Med., 241,1037. Foster, J. H., and Jackson, A. H. (1951). Conn. med. J., 15, 199, quoted in & Medica (Internal Medicine), (1951), 5, 1482. Amsterdam. Hunt, J. Ramsay (1907). J. nerv. ment. Dis., 34,73. Kass, E. H., Aycock, R. R., and Finland, M. (1952). New Engl. J. Med., 24?> Parkinson, T. (1948). Brit. med. J., 1, 8. Schiff, C. I., and Brain, W. R. (1930). Lancet, 2, 70. ,
