Abstract
Herpes zoster ophthalmicus is a viral infection caused by the varicella-zoster virus, affecting the ophthalmic branch of the trigeminal nerve, called the ophthalmic nerve. Herpes zoster ophthalmicus is characterized by a painful rash and blisters on one side of the forehead and around the eye, along with symptoms such as eye redness, tearing, and sensitivity to light, and can also lead to serious complications, such as corneal ulcers, glaucoma, and vision loss, particularly if the eye is involved. Herpes zoster myositis and oculomotor nerve involvement are rare complications of herpes zoster infection. Early diagnosis and treatment, such as antiviral medications, corticosteroids, and pain management, are important to prevent complications and to alleviate symptoms. In our case report we demonstrate the case of an 81-year-old female patient with left sided herpes zoster ophthalmicus, associated with MRI proved orbital myositis and oculomotor nerve involvement. Symptoms were slowly reduced with antiviral therapy. People who develop symptoms of herpes zoster ophthalmicus should seek prompt medical attention to receive appropriate care and to avoid serious complications.
Introduction
Varicella zoster virus (VZV) reactivation can lead to vesicular rash eruption in the ophthalmic division of the trigeminal nerve, called herpes zoster ophthalmicus (HZO), a common ocular emergency [1]. In the literature, 7% of all cases of VZV infection present as HZO, of which 20–79% have orbital involvement [2]. VZV can affect almost all tissues located in the orbit, which includes the extra-ocular muscles, and can cause various forms of infection such as keratitis, scleritis, uveitis, ocular motor palsy, optic neuritis, or postherpetic neuralgia (PHN) [3]. Herpes zoster orbital myositis [4] and oculomotor nerve palsy [5] are rare conditions, occurring when the VZV reactivates in the nerves, controlling eye movement, leading to the inflammation of the extra-ocular muscles [4]. Symptoms typically include pain, double vision, and difficulty moving the eye. Diagnosis is typically made through a combination of physical exam, imaging studies, and laboratory tests [4, 6, 7]. Treatment options may include antiviral medications, corticosteroids, and supportive care [4]. Early recognition and timely medical management is important to prevent complications such as PHN and blindness [3].
Case presentation
An 81-year-old female patient suffering from left sided HZO for three weeks, progressively developed diplopia in all directions, with mydriasis and efferent pupillary defect. She had only hypertension and ischemic heart disease as chronic diseases.
Due to diplopia, contrast enhanced orbital MRI (Philips Ingenia 3 T, contrast material: Dotarem 10 ml) was requested, which revealed higher signal intensity on short tau inversion recovery (STIR) sequence in the left extraocular rectus muscles and of the intraorbital part of the left oculomotor nerve's lower division, corresponding to oedema. Mild contrast enhancement of the intraorbital part of the left oculomotor nerve's lower division was also observed on the fat suppressed (selective water excitation), contrast enhanced T1 weighted sequence (Figs 1 and 2). The radiological findings corresponded to both the left sided herpes zoster orbital myositis and oculomotor nerve involvement.
Coronal short tau inversion recovery (STIR) images. Consecutive slices depicting the swollen lower branch of the left oculomotor nerve with higher signal intensity compared to the other side (A). Swollen rectus muscles with higher signal intensity, compared to the other side (B). Arrow with continuous line: lower branch of the left oculomotor nerve. Arrow with dashed line: lower branch of the right oculomotor nerve. Arrow with dotted line: extraocular rectus muscles
Citation: Imaging 15, 1; 10.1556/1647.2023.00110
Coronal short tau inversion recovery (STIR) images. Consecutive slices depicting the swollen lower branch of the left oculomotor nerve with higher signal intensity compared to the other side (A). Swollen rectus muscles with higher signal intensity, compared to the other side (B). Arrow with continuous line: lower branch of the left oculomotor nerve. Arrow with dashed line: lower branch of the right oculomotor nerve. Arrow with dotted line: extraocular rectus muscles
Citation: Imaging 15, 1; 10.1556/1647.2023.00110
Coronal short tau inversion recovery (STIR) images. Consecutive slices depicting the swollen lower branch of the left oculomotor nerve with higher signal intensity compared to the other side (A). Swollen rectus muscles with higher signal intensity, compared to the other side (B). Arrow with continuous line: lower branch of the left oculomotor nerve. Arrow with dashed line: lower branch of the right oculomotor nerve. Arrow with dotted line: extraocular rectus muscles
Citation: Imaging 15, 1; 10.1556/1647.2023.00110
Coronal, fat suppressed (selective water excitation), contrast enhanced T1 weighted image. Consecutive slices (A, B) depicting swollen and contrast enhancing lower branch of the left oculomotor nerve, and the normal lower branch of the right oculomotor nerve. Arrow with continuous line: lower branch of the left oculomotor nerve. Arrow with dashed line: lower branch of the right oculomotor nerve
Citation: Imaging 15, 1; 10.1556/1647.2023.00110
Coronal, fat suppressed (selective water excitation), contrast enhanced T1 weighted image. Consecutive slices (A, B) depicting swollen and contrast enhancing lower branch of the left oculomotor nerve, and the normal lower branch of the right oculomotor nerve. Arrow with continuous line: lower branch of the left oculomotor nerve. Arrow with dashed line: lower branch of the right oculomotor nerve
Citation: Imaging 15, 1; 10.1556/1647.2023.00110
Coronal, fat suppressed (selective water excitation), contrast enhanced T1 weighted image. Consecutive slices (A, B) depicting swollen and contrast enhancing lower branch of the left oculomotor nerve, and the normal lower branch of the right oculomotor nerve. Arrow with continuous line: lower branch of the left oculomotor nerve. Arrow with dashed line: lower branch of the right oculomotor nerve
Citation: Imaging 15, 1; 10.1556/1647.2023.00110
Moderate lymphocytic pleiocytosis was detected by cerebrospinal fluid (CSF) examination, as an indirect result of VZV infection, but VZV was not detected in the CSF by PCR (the multiplex-CSF PCR did not confirm any other pathogen either). Steroid administration was not necessary, while local-, and acyclovir treatment was completed under observation. The patient had particularly severe complaints of PHN, therefore, pregabalin treatment was started in a slowly building up dose.
After emission, following up on an outpatient basis, the patient's complaints and symptoms improved significantly.
Discussion
Herpes zoster orbital myositis [4] and oculomotor nerve palsy [5] are rare, but potentially serious complications of HZO. Symptoms of herpes zoster orbital myositis typically include pain and swelling around the eye, double visions, droopy eyelid, which can be very distressing and can have a significant impact on a person's quality of life [8, 9]. Additionally, if left untreated, herpes zoster infection can lead to permanent eye damage and vision loss [3]. Diagnosis can be challenging, requires a thorough evaluation by an ophthalmologist, neurologist and often imaging studies, such as an MRI [10]. Once, a diagnosis of herpes zoster ophthalmicus is confirmed, treatment typically involves a combination of antiviral medications to treat the underlying infection and corticosteroids to reduce inflammation and swelling [7]. In our case report, an 81-year-old female patient suffered from left sided HZO, which was complicated with a left sided orbital myositis, oculomotor nerve involvement (confirmed by MR imaging) and PHN. The patient's complaints and symptoms improved with complex therapy.
Conclusions
HZO is a common ocular emergency, which is rarely associated with herpes zoster orbital myositis and oculomotor nerve palsy. Early diagnosis and prompt treatment is crucial to prevent permanent eye damage and vision loss. MR imaging seems to be recommended in such ocular cases of HZO to be quite sure about the extension of the disease.
Authors’ contribution
All persons who meet authorship criteria are listed as authors, and all authors certify that they have participated sufficiently in the work to take public responsibility for the content, including participation in the development of concept, writing, or revision of the manuscript. Acquisition of images: MM, KK. Analysis and/or interpretation of literature: MM, KK. Drafting the manuscript: MM, KK. Revising the manuscript critically for important intellectual content: MM, KK. Approval of the version of the manuscript to be published: MM, KK. This manuscript has not been published previously and is not under consideration for publication elsewhere.
Ethical statement
The study submitted to IMAGING have been conducted in accordance with the Declaration of Helsinki and according to requirements of all applicable local and international standards.
Funding sources
No financial support was received for this case report.
Conflict of interests
The authors have no conflict of interest to disclose.
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