Ramsay Hunt syndrome in a patient with metastatic lung cancer to brain

Abstract

A 65-year-old right-handed woman with history of nonsmall-cell-lung cancer (NSCLC) metastatic to the brain presented to the emergency room with right facial weakness. She was diagnosed with lung cancer 3 months prior after a workup for persistent cough and dyspnea. Biopsy revealed poorly differentiated NSCLC. Staging brain magnetic resonance imaging (MRI) showed multiple enhancing lesions consistent with metastatic disease to the CNS. She received a cycle of Carboplatin and paclitaxel and whole brain irradiation. Two days prior to admission, she underwent stereotactic radiosurgery (SRS) for residual metastatic disease following administration of intravenous steroids. These lesions were cortically based and not in the typical location of the gray–white junction (Fig. 1). Significantly, none of these metastatic lesions (left medial parietal region, left parietal region, right frontal cystic lesion and right superior frontal region) was close to the brain stem or the right 7th cranial nerve. On admission, spinal fluid evaluation showed glucose of 80 mg/dl, protein of 108 mg/dl, 80 white blood cells (85% lymphocytes), and 15 red blood cells. Cytology (14 cc) evaluation was negative for malignant cells. The patient was treated empirically with Valacyclovir and two additional spinal fluid evaluations were obtained to rule out carcinomatous meningitis (12 and 10 cc, respectively). On the forth hospital day a vesicular rash was noted over the patient’s right ear (Fig. 2). Cerebrospinal Varicella Zoster virus (VZV) PCR returned positive. The patient was diagnosed with Ramsay Hunt syndrome and anti-viral treatment was continued for 2 weeks. This case emphasizes the importance of meticulous evaluation in a patient presenting with cranial neuropathy and metastatic cancer. If no other diagnosis was found, the patient would have met the criteria for presumed carcinomatous meningitis [1] and may have received chemotherapy. Unfortunately, not all patients with Ramsay Hunt syndrome develop a rash [2] and even though VZV PCR is highly specific, it is positive in only about 44% of the cases [3].