Herpes zoster ophthalmicus with stroke

Case 373: MRI Brain, 1/15/96 & Cerebral Angiogram 1/19/96: Herpes Zoster Ophthalmicus.

CC: Left sided weakness.

 

Hx: 46y/o RHM suffered an episode of herpes zoster in the right ophthalmic division of the Trigeminal nerve in 10/95. He recovered well and was back in his usual state of health until 12/27/95, when while driving his car he experienced sudden onset left sided hemiparesis. He was hospitalized locally, and his symptoms resolved within one hour. A HCT without contrast at that time was normal, and a Carotid Doppler scan was unremarkable. He was discharged 3 days later on daily aspirin. Upon returning home, he began experiencing intermittent episodes of LLE weakness, and at 2:00PM, on 1/14/96, while walking in a ditch, he experienced sudden onset LLE weakness. Several hours later the weakness began to involve his LUE and left lower face as well. He was evaluated locally and treated with IV heparin but did not subsequently improve. His symptoms continued to worsen and he was transferred to UIHC.

Upon arrival at UIHC, he complained of left hemiparesis, slurred speech, and mild left lower extremity numbness. He denied any recently associated headache, CP, SOB, diplopia, blurred vision, dysphagia, fever, chill, or recent weight loss.

 

MEDS: ECASA 325gm qd, Cardizem CD 240mg qd, Synthroid 0.05mg, Chlorpropamide 25mg qd, Gemfibrozil, Zestril 10mg qd.

PMH: 1)Non-insulin dependent diabetes mellitus for 6 years, 2) HTN since age 25, 3) Hypothyroidism, 4) Multiple work related lower back injuries, 5) Right CNV1 distribution herpes zoster of the face, 10/95.

FHx: Father died age 56 of MI and had h/o DM. Mother is alive and healthy. Sister has HTN. His 3 children are healthy.

SHx: Currently chews tobacco, but denied smoking. No ETOH for 18 years.

EXAM: BP121/53, HR84, RR20, 37.0C

MS: A&O to person, place and time. Speech was fluent, monotone, and mildly to moderately dysarthric. Verbal responses were appropriate and thought process was lucid. Repetition, reading and naming were intact.

CN: Left lower facial weakness with no loss of facial sensation. The rest of the CN exam was unremarkable.

MOTOR: Dense left hemiparesis. He had full strength in the RUE and RLE.

SENSORY: Intact PP/VIB/LT/TEMP/PROP throughout except for slightly decreased PP sensation over the anterior aspect of the left side. There was no graphesthesia or astereognosis elicited.

COORD: Normal on right side, but very slow FNF/HKS/RAM movements on left.

REFLEXES: Trace/O in the UE. Trace/O in LE. Plantar responses were flexor on the right and extensor on the left.

GEN EXAM: unremarkable.

 

COURSE: Glucose 253, otherwise the Gen Screen was unremarkable. INR 1.1, PTT 6.9, Hgb 13.5, Hct 39%, Plt 179k, WBC 6.6 with normal differential, ESR 20 and CRP 0.5. HCT without contrast on 1/14/95 revealed an older right frontal hypodensity and a subacute right frontal( ACA-MCA) watershed hypodensity which was not present on his 12/27/95 HCT. There was no evidence of acute hemorrhage or mass effect. A CXR revealed an elevated right hemidiaphragm but was otherwise unremarkable.

MRI brain on 1/15/96, revealed a large area of increased signal on T2- weighted images and decreased signal on T1-weighted images in the right hemisphere white matter predominately in the centrum semiovale and adjacent to the right frontal horn. There was no significant gadolinium enhancement. There was sparing of the overlying gray matter. There was mild decreased flow void in the RICA compared to the LICA. The findings were most consistent with an ischemic lesion, though a low grade glioma could not be excluded.

Cerebral Angiogram, 1/17/96, revealed a high grade distal(supraclinoid) RICA stenosis and segmental stenoses of the RPCA and RACA. These findings were suspicious of a vasculitis, and given his history of recent herpes zoster, it was felt that this represented Herpes Zoster Angiitis(HZA). HZA may occur several weeks to months following and episode of herpes zoster. The patient underwent more cerebral angiography on 1/19/96 to better evaluate the possibility of a right external carotid artery(RecA) to right internal carotid artery(RICA) bypass. This revealed normal RecA circulation.

He was placed on Famvir 500mg tid on 1/20/96 and on heparin. He was also place on a burst(80mg qid) and taper of prednisone.

On 2/5/96, he underwent RecA to RICA anastomoses via the right superficial temporal artery(right STA) to the right MCA. The procedure went well with no subsequent neurologic events.

He completed a 14 day course of Famvir 500mg tid. He had severe left face and LUE weakness and moderate LLE weakness and mild dysarthria at time of discharge,2/15/96.

He was last seen, 2/13/97, in the Neurology Clinic, and had moderate grade 4 strength in LLE and zero to grade 2 strength in the LUE(worse distally). His speech has improved in melody and spontaneity. He continued to have a left lower facial paresis. He had a palpable bypass shunt in the right temporal bone. He continues to take ASA 325mg qd.

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