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NEUROIMAGE
Year : 2021  |  Volume : 69  |  Issue : 6  |  Page : 1899-1900

Transaxonal Spread of Varicella-Zoster Virus in Trigeminal Zoster Followed by Ramsay Hunt Syndrome


1 Department of Neurology, Huashan Hospital, Fudan University, China
2 Department of Neurology, Shanghai General Hospital, Shanghai General Hospital (Originally Shanghai First People's Hospital), Shanghai Jiao Tong University School of Medicine, China

Date of Submission10-Aug-2018
Date of Decision08-Apr-2020
Date of Acceptance18-Aug-2020
Date of Web Publication23-Dec-2021

Correspondence Address:
Dr. Guo-Dong Wang
Department of Neurology, Shanghai General Hospital, Shanghai General Hospital (Originally Shanghai First People's Hospital), Shanghai Jiao Tong University School of Medicine
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.333511

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How to cite this article:
Yang SL, Han X, Wang GD. Transaxonal Spread of Varicella-Zoster Virus in Trigeminal Zoster Followed by Ramsay Hunt Syndrome. Neurol India 2021;69:1899-900

How to cite this URL:
Yang SL, Han X, Wang GD. Transaxonal Spread of Varicella-Zoster Virus in Trigeminal Zoster Followed by Ramsay Hunt Syndrome. Neurol India [serial online] 2021 [cited 2022 Jan 18];69:1899-900. Available from: https://www.neurologyindia.com/text.asp?2021/69/6/1899/333511




A 60-year-old immunocompetent man presented with severe stabbing right facial pain for five days and herpes on the right face for one day. He was diagnosed with trigeminal zoster and administered with intravenous acyclovir and steroids. He developed right otalgia, vesicular rash on the concha of the right earlobe and right peripheral facial palsy after two weeks, and the diagnosis of Ramsay Hunt syndrome (RHS) was made. Brain MRI demonstrated fluid-attenuated inversion recovery (FLAIR) hyperintensity involving the right lateral pons [Figure 1]a and [Figure 1]b, right lateral medulla [Figure 1]c and [Figure 1]d, and right trigeminal nerve [Figure 1]b. These lesions also showed increased diffusion-weighted imaging (DWI) signal [Figure 1]e,[Figure 1]f,[Figure 1]g,[Figure 1]h. Gadolinium enhancement was seen in the pontine lesion [Figure 1]i. The extent of the lesion in the level of the pons is illustrated in [Figure 1]j, indicating the involvement of the trigeminal nerve, the spinal trigeminal nucleus, and tract, along with the facial nucleus and nerve fibers. He had mild facial asymmetry as a sequel after the treatment of intravenous acyclovir and steroids for 2 weeks.
Figure 1: MRI findings of the patient. Brain MRI demonstrated FLAIR hyperintensity involving the right lateral pons (a and b), right lateral medulla (c and d), and right trigeminal nerve (b). (e-h) These lesions also showed an increased DWI signal. (i) Gadolinium enhancement was seen in the pontine lesion. (j) The extent of the lesion (dark triangle) indicates the involvement of the trigeminal nerve, the spinal trigeminal nucleus, and tract (yellow), along with the facial nucleus (blue) and nerve fibers

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T2 and FLAIR hyperintensities in the pons and/or medulla has been occasionally reported in trigeminal zoster or RHS.[1],[2], however, increased DWI signal is rare and easily misdiagnosed with acute infarction.[3] Varicella-Zoster Virus is a pathogen that can invade both central and peripheral nervous systems. The sequential development of trigeminal zoster and RHS and the well-defined lesion revealed by MRI in the presenting case might reflect transaxonal spreading of Varicella-Zoster Virus from Gasserian ganglion to spinal trigeminal nucleus and tract, facial nucleus and nerve fibers.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Aribandi M, Aribandi L. MRI of trigeminal zoster. Neurology 2005;65:1812.  Back to cited text no. 1
    
2.
Hung CW, Wang SJ, Chen SP, Lirng JF, Fuh JL. Trigeminal herpes zoster and Ramsay Hunt syndrome with a lesion in the spinal trigeminal nucleus and tract. J Neurol 2010;257:1045-6.  Back to cited text no. 2
    
3.
Himeno T, Takeshima S, Kubo S, Hara N, Tanaka A, Kuriyama M. Trigeminal herpes zoster presenting with high-intensity signals for the spinal trigeminal nucleus and tract on diffusion-weighted image: A case report of stroke mimic. Brain Nerve 2018;70:161-4.  Back to cited text no. 3
    


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