Images in Clinical Medicine

Herpes Zoster Ophthalmicus Followed by Contralateral Hemiparesis

Raul G. Nogueira, M.D., and Volney L. Sheen, M.D., Ph.D.

N Engl J Med 2002; 346:1127April 11, 2002

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Figure 1 A 71-year-old man with a history of multiple myeloma and subsequent autologous bone marrow transplantation was evaluated for a facial rash in the distribution of the ophthalmic branch of the right trigeminal nerve (Panel A). The findings were consistent with the presence of herpes zoster ophthalmicus, and he was treated with intravenous acyclovir, leading to nearly complete resolution of his skin lesions after three weeks. Two months later, skin lesions recurred in the same distribution, with progressive worsening of his mental status and the acute onset of left hemiparesis. Examination revealed partial palsy of the right third cranial nerve and complete palsy of the left seventh cranial nerve, with an upper motor neuron distribution. Magnetic resonance imaging of the brain revealed an area of restricted diffusion in the right posterior basal ganglia (Panel B) that extended laterally to the external capsule and superiorly to the right corona radiata (Panel C). The patient received a second course of acyclovir, which was complicated by renal failure, and then completed a short course of prednisone, with partial improvement of his symptoms.

Herpes zoster ophthalmicus followed by contralateral hemiparesis is a well-recognized syndrome in which reemergence of zoster infection, usually in the setting of immunosuppression, leads to a granulomatous arteritis and cerebral infarction.

Raul G. Nogueira, M.D.
Brigham and Women's Hospital, Boston, MA 02115

Volney L. Sheen, M.D., Ph.D.
Beth Israel Deaconess Medical Center, Boston, MA 02115

Citing Articles (2)

Citing Articles

1. 1

   Saranya Srinivasan, Grace Ahn, Andy Anderson. (2009) Meningoencephalitis-complicating herpes zoster ophthalmicus infection. Journal of Hospital Medicine 4:6, E19-E22
   CrossRef

2. 2

   Hendrikus G.J Krouwer, Eelco F.M Wijdicks. (2003) Neurologic complications of bone marrow transplantation. Neurologic Clinics 21:1, 319-352
   CrossRef