Zoster Paresis Research Articles

Zoster-associated Limb Paralysis: Clinical and Electrophysiological Data of 15 Cases with Segmental Zoster Paresis with the Literature Review

ABSTRACT Background: Herpes zoster (HZ) is a viral disease characterized by skin eruptions and pain in specific dermatomes. Focal motor weakness that appears in the segment of skin eruptions is a rare complication of this infection. Because of the difficulty in clinically diagnosing thoracic or upper cervical motor weakness and due to the pain that causes overlooking of weakness, the true incidence of this complication is not known. In this study, we want to review the clinical presentation of segmental zoster paresis and also discuss electrophysiological findings with the involvement of nerve, plexus parts, or spinal roots. Methods: Electromyography records were examined retrospectively from 2010 to 2023 for patients who had HZ-associated limb paresis. Clinical data were reviewed and abstracted, and patients whose clinical limb weakness and sensory deficits conformed to the distribution of peripheral nerve (s) or spinal root and whose electrodiagnostic evaluation corroborated the localization, were included in the series. Results: Fifteen patients were included in our study. Ten of them were men and five of them were women. Paresis and neuropathic pain are the main complaints. In all patients, the distribution of paresis was consistent with the area of skin eruptions. C8–T1 in the upper extremity and L5–S1 in the lower extremity are the most commonly involved segments. Electrophysiological findings showed radicular involvement in three cases, brachial plexus in six cases, ulnar nerve in one case, sciatic nerve in two cases, and fibular nerve in three cases. Axonopathy is the main detected pathology in all cases. Conclusion: Segmental zoster paresis is a rare complication of cutaneous zona zoster and it affects different nerve segments. Clinicians should be aware of clinical and electrophysiological findings of this disease for the appropriate management of the patients.

Clinical investigation of segmental zoster paresis: A case of rare motor complications of herpes zoster

Introduction: Motor involvement is a rare complication of herpes zoster (HZ) infection, which is referred to as segmental zoster paresis (SZP). Case Report: We evaluated the clinical course of a rare case of motor complications of HZ. A 77-year-old man showed limb paresis, considered as SZP of the limb, of which one also had hemidiaphragmatic paralysis. The time between onset and start of antiviral drug administration was 29 days. An almost complete recovery from motor complications was achieved nine months after onset. Conclusion: Segmental zoster paresis was found in an old patient aged ≥75 years. In addition to age, it was suggested that a delay in antiviral drug initiation may have caused SZP. However, further large prospective cohort studies are required. The patient has recovered from motor paralysis slowly over half a year, which is consistent with the prognosis of conventional SZP.

THE IMPORTANT OF NEUROPHYSIOLOGY EXAMINATION IN DIAGNOSING SEGMENTAL ZOSTER PARESIS: CASE REPORT

Background: Segmental zoster paresis (SZP) is a very uncommon complication characterized by localized weakening of the upper or lower limbs. Case report: A 69-year-old man came with complaints of weakness in the right leg two months ago. He had weakness in his right leg after two days of having herpes on his right leg. There was paresthesia and hypesthesia on neurological examination according to the L1-L3 dermatome. Neurophysiology examination revealed a neuropathy in the right femoral nerve. Discussion: Varicella-zoster virus, being a neurotrophic virus, primarily invades and incubates in the dorsal root or cerebral ganglion nerve cells. Etiological investigations in SZP patients have revealed that the anterior root is the most prevalent location of inflammation and degeneration. Conclusion: SZP is a rare complication following VZV infection that can lead to misdiagnosis and overtreatment in clinical practice. The neurophysiological examination is very important in diagnosing segmental zoster paresis.

MRI negative Varicella zoster virus (VZV) plexopathy in a young man with history of malignancy (P2-4.001)

<h3>Objective:</h3> To emphasize the importance of including VZV plexopathy in differential diagnosis in young individuals and to prevent the delay in diagnosis and treatment <h3>Background:</h3> VZV-associated plexopathy in mainly patients over 60 years old. Post herpetic neuralgia is a well-known complication of Herpes Zoster (HZ), however segmental zoster paresis secondary to HZ was reported in 1–20% of the cases in literature. MRI findings may be positive in up to 70% of the patients. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> 43 years-old man with history of grade 2 left frontal oligodendroglioma which was treated with 2 partial resections, radiation and adjuvant procarbazine/lomustine presented with left upper extremity pain and developed a blistering rash in dermatomal pattern in left proximal upper extremity 2 weeks after the initial symptoms. He was diagnosed with shingles and treated with steroids and acyclovir with minimal improvement. 6 weeks after presentation, physical exam revealed left deltoid, supraspinatus and infraspinatus weakness with normal muscle stretch reflexes and decreased sensation on C5 dermatome. EMG revealed absent left lateral antebrachial cutaneous sensory nerve action potentials (SNAP) amplitude, and a small left radial SNAP amplitude compared to the right side. Evidence of ongoing denervation with reinnervation was seen in the left upper trunk supplied muscles. MRI of the brachial plexus was negative for any abnormalities. Patient was diagnosed with VZV-associated plexopathy, improved with pregabalin and physical therapy. <h3>Conclusions:</h3> Our patient was significantly younger than expected in HZ group. MRI usually shows T2 hyperintensities and thickening of the nerve roots in patients with VZV-associated plexopathy. However, the presentation, onset of symptoms, characteristics of the rash and clinical course was diagnostic of HZ, and the weakness pattern, supported by the EMG findings were diagnostic for VZV-associated plexopathy. <b>Disclosure:</b> Dr. Gul has nothing to disclose. Ms. Ahmed has nothing to disclose. Dr. McGraw has nothing to disclose. Dr. Alshiekh Nasany has nothing to disclose.

Segmental Zoster Paresis with Late-Onset Skin Rash Mimicking a Herniated Cervical Disc: A Case Report

Segmental zoster paresis (SZP) of the limbs, characterized by focal weakness of the extremity, is recognized as a rare complication of herpes zoster that can lead to a misdiagnosis of other radiculopathies or musculoskeletal problems. Here, we present a rare case where the patient experienced severe pain and weakness of the right upper extremity caused by SZP. A 58-year-old man came to the hospital with severe right upper extremity radicular pain. Cervical magnetic resonance imaging of the spinal cord showed disc protrusion at the C5-6 level with a high signal change. Anterior cervical discectomy and fusion was performed. On the first and second postoperative days, the patient’s symptoms showed slight improvements. However, on the fourth postoperative day, the patient experienced a right shoulder drop along with exacerbated radicular pain and presented a herpetic rash on the right extremity. The patient showed a dramatic improvement in pain and weakness after taking antiviral medication and undergoing a fluoroscopic-guided right C6 selective nerve root block. He fully recovered from his symptoms after 12 weeks of rehabilitation and physical therapy. This rare case involved SZP which was misunderstood as a herniated cervical disc. If a patient complains of severe pain with motor weakness inconsistent with radiologic findings, SZP should be discriminated from other possible diagnosis.

Post-herpetic abdominal pseudohernia – An uncommon/under-recognized complication of a common disease, herpes zoster – A case report

Acute zoster pain and post-herpetic neuralgia are the most common and nagging complications after herpes zoster. Sometimes, temporary paresis of the segmental nerves follows herpes zoster resulting in zoster paresis or muscle zoster. Here, we report a case of zoster paresis manifesting as post-herpetic abdominal pseudohernia. A 55-year-old male presented to the dermatology outpatient department with the complaints of intense pain, burning sensation, and paresthesia over the left side of his abdomen. He had a history of herpes zoster over the same site 2 weeks back. Then, he noticed a swelling over the left side of his abdomen, associated with bloating, decreased appetite, and easy satiety. Examination revealed hyperpigmented scars of herpes zoster in the T9-T11 dermatome along with an ipsilateral bulge of size 20 × 15 cm over the same site. The skin overlying the bulge was lax. The swelling increased in size following coughing and Valsalva maneuver. An ultrasonogram of the abdomen ruled out a ventral hernia. One should be aware of this entity, when examining patients with abdominal bulge along with herpes zoster scars, to avoid unnecessary surgeries.

MONOPARESIS INFERIOR POST HERPES ZOSTER

Background: Herpes zoster (HZ) is caused by reactivation of Varicella Zoster Virus (VZV). Segmental zoster paresis (SZP) is a rare neurological complication of HZ. Case: A 58-year-old woman came to our clinic with a complaint of a post HZ lesion accompanied by weakness, burning sensation, and paresthesia of the left lower limb. These complaints were felt suddenly about 2 weeks after the vesicles appeared. The patient had a history of diabetes mellitus (DM) and hypertension. From physical examination, there was a lesions on the L2-L3 dermatome which had dried out with hyperpigmentation and crusted. Motoric examination of the left lower limb showed weakness of the hip flexors (MRC grade 3/5). While the power of the other muscles in right lower limb and in all muscles groups was MRC 5/5. Tonus and trophic was normal. There was hyperaesthesia noted in the left thigh in the L2-L3 dermatome. Discussion: Neurological complications in HZ can occur in the central nervous system or peripheral nervous system. In this case the patient had SZP as a complication of HZ that involving the motor system. This complication was characterized by paresis of the left lower limb after developing HZ infection. The pathogenesis of SZP remains unclear. Having a history of DM increases the incidence of neurological complications in HZ. This is because the effectiveness of cellular immunity against VZV in DM patients decreases. Conclusion: Segmental zoster paresis (SZP) is a rare neurological complication of HZ. SZP involves the motor nervous system. There are several risk factors that increase the incidence of neurological complications in HZ infection. Key words: Herpes Zoster, Segmental Zoster Paresis

Successful management of segmental zoster paresis on the upper arm with temporally burst spinal cord stimulation

Segmental zoster paresis (SZP) of the limbs is characterized by a focal, asymmetric neurogenic weakness that may occur in an extremity affected by herpes zoster (HZ). In this case report, we describe the case of a patient with SZP who presented with these problems and responded well to temporary spinal cord stimulation (SCS) and systematic rehabilitation. A 62-year-old female patient was referred for right upper limb pain, weakness, and insomnia due to pain. After completing the 14-day trial stimulation, the pain numerical rating scale of the patient in the right upper extremity decreased from 8/10 to 2/10. The Athens insomnia scale score decreased from 15/24 to 10/24. Furthermore, the grip strength of the right hands increased from 6.7 to 16.8kg at discharge. We induced temporal SCS and rehabilitation of the right upper limb SZP and successfully reduced the pain. An in-depth understanding of the neurological complications secondary to HZ should be emphasized, with temporal SCS and rehabilitation expected to play a crucial role in the motor recovery of patients with SZP.

Dramatic improvement of segmental Zoster Paresis by late-onset antiviral therapy

Focal paresis secondary to Herpes zoster (HZ) is a rare neurological complication and should be kept in mind in the differential diagnosis of acute weakness with corresponding dermatomal rashes. In this case report, we illustrate an 84-year-old male patient, who presented with focal upper extremity weakness following HZ on right C4-8 dermatome. After clinical and electrophysiological evaluations, segmental zoster paresis was diagnosed. Although antiviral medication(oral brivudine) had been administered previously, oral valacyclovir and low dosage methylprednisolone were initiated. In the following 2 months interval, a progressive and dramatic recovery in extremity weakness and neuropathic pain were achieved. The clinical course of this patient may give substantial perspectives regarding the clinical evaluation of similar cases.

Segmental Zoster Paresis: A Literature Review

Herpes zoster is an acute infectious skin disease that is induced by the re-activation of the virus incubated in nerve ganglions following initial infection with varicella-zoster virus in childhood. Herpes zoster mainly affects sensory nerves, resulting in severe acute pain, which is also the most common reason for medical intervention in this patient group. The concurrent involvement of motor nerves could induce the symptoms of segmental zoster paresis, which is manifested by localized asymmetric myasthenia, whose range generally follows the distribution of myomere with skin rashes. Due to the low incidence and unspecific clinical manifestations, segmental zoster paresis has not been sufficiently recognized by clinicians, and can easily be misdiagnosed. To summarize the previous studies on segmental zoster paresis and analyze the pathogeneses, diagnosis, and treatment of this disease, as well as stress the challenges in current treatment, which could provide useful evidence for the clinical diagnosis and better the treatment of patients with segmental zoster paresis in the future. We conducted a narrative review. Hospitals, neurology departments, pain departments, and private practices. We searched PubMed and Chinese CNKI libraries using the terms "herpes zoster," "muscle paresis," "segmental zoster paresis," and "motor nerve." Clinical trials, reviews, and case reports were collected and reviewed. As a rare complication following varicella-zoster virus infection, segmental zoster paresis has not been sufficiently recognized by clinicians, and there are still no guidelines available to guide the clinical treatments. The exact mechanism of segmental zoster paresis is still unclear. Electromyographic and magnetic resonance imaging examinations could be used as auxiliary diagnostic methods for segmental zoster paresis. Early regular anti-viral therapy could substantially decrease the risk of herpes zoster related complications. Combined application of glucocorticoids and some other physical therapy may also be useful in certain patients. The general prognosis of segmental zoster paresis is relatively good, with 67% patients achieving complete or almost complete recovery of the muscle function. More clinical trials are needed to clarify the exact mechanisms and best treating methods. As the symptom in most segmental zoster paresis patients is self-limited, and the patients' prognosis is generally good, early diagnosis of the disease is especially important, due to the avoidance of unnecessary diagnostic procedures and incorrect treatments. Standard treatment guidelines regarding the functional rehabilitation are still needed for patients with refractory segmental zoster paresis.

Segmental Zoster Paresis of Lower Thoracic Segment Presenting as Pseudohernia-A Report of Three Cases.

Segmental zoster paresis is characterized by focal motor weakness affecting the myotome corresponding to the dermatomal distribution of the rash. Clinically, it presents as pseudohernia when it involves abdominal wall muscles. We report three cases of segmental zoster paresis presenting as pseudohernia of abdominal wall. All patients developed asymptomatic bulge in anterolateral side of abdomen between 10 and 15 days after appearance of vesicles. All patients developed post-herpetic neuralgia. One patient developed pseudo-obstruction of colon due to visceral involvement. Segmental zoster paresis of lower thoracic spinal segment often goes unnoticed due to its asymptomatic nature.

HERPES ZOSTER REACTIVATION ISOLATED TO THE ULNAR AND POSTERIOR ANTEBRACHIAL CUTANEOUS NERVES – CASE REPORT AND LITERATURE REVIEW

Varicella -zoster virus (VZV) is a neurotropic virus which causes two distinct syndromes: primary infection presenting as varicella, mainly occurring in children without previous exposure to VZV, and reactivation of the latent VZV in the dorsal root ganglia, causing herpes zoster in adults. Herpes zoster clinically presents as a unilateral, painful, vesicular eruption, usually distributed to one or two adjacent thoracic dermatomes. As it is rarely seen confined to the upper limbs, few reports of herpes zoster involving the ulnar nerve exist in the literature, the majority describing patients who present with segmental zoster paresis of the upper extremity. This paper reports the case of a 73-year-old woman with ulnar and posterior antebrachial cutaneous nerve zoster reactivation and no history of immunosuppressive disorders. Therefore, rare occurrences of herpes zoster, such as the involvement of cervical dermatomes, should also be considered when faced with the differential diagnosis of symptomatic skin rashes of the upper limb, especially in elderly or immunosuppressed patients. Key words - Herpes zoster; ulnar nerve; posterior antebrachial cutaneous nerve; chickenpox; female; exanthema.

A retrospective case series of segmental zoster paresis of limbs: clinical, electrophysiological and imaging characteristics

BackgroundSegmental zoster paresis (SZP) of limbs, characterized by focal weakness of extremity, is recognized as a rare complication of herpes zoster (HZ). The following study analyzes the clinical characteristics and data from electromyography and MRI scans in patients with motor weakness after zoster infection.MethodsOne thousand three hundred ninety-three patients from our database (Shandong Provincial Qianfoshan Hospital) suffering from HZ were retrospectively reviewed from June 2015 to July 2017. Patients who fulfilled the diagnostic criteria for SZP were included in the analysis. The clinical characteristics, as well as electromyography findings and MRI scans were analyzed.ResultsSZP was present in 0.57% of patients with HZ (8/1393). The average age of symptom onset in 8 SZP patients was 69 years old (SD: 13, range 47–87). The severity of muscle weakness ranged from mild to severe. The electrophysiological testing revealed the characteristics of axonopathy. Radiculopathy (2/8), plexopathy (2/8), radiculoplexopathy (3/8) and combined radiculopathy and mononeuropathy (1/8) were also identified. MRI revealed hyperintensity of the affected spinal dorsal horns, nerve roots or peripheral nerves.ConclusionsSZP is associated with obvious limb weakness, nerve axons lesions and localization to nerve roots, plexus or peripheral nerves.

Herpes Zoster Radiculopathy in a Systemic Lupus Erythematosus Patient – A Case Report

Background:Motor neuropathy is an extremely rare herpes complication, with a mere prevalence of 0.5–5%. The case of segmental zoster paresis of limbs, resulting from motor radiculopathy, is especially limited, with cervical and thoracic segments being the least frequent.Setting:Neurology outpatient clinic. CaseDescription:We report a case of a 16-year-old female who presented sudden-onset right upper extremity weakness, a week after her herpes zoster lesions first appeared. As she was diagnosed with systemic lupus erythematosus (SLE) 4 months prior, she routinely consumed steroids and azathioprine. Initial examinations revealed multiple vesicles along right C5-C6 roots dermatome accompanied by upper right extremity weakness (manual muscle test [MMT] 3) corresponding to the myotome of C5-C6 roots. An electromyography assessment uncovered results relevant to motor root neuritis in C5-C6. Magnetic resonance imaging of the cervical radix with contrast showed no abnormality. Thus, she received acyclovir, gabapentin and physiotherapy.Results:A follow-up visit after 2 weeks revealed an improvement of the weakness along C5-C6 myotome (MMT 4). A month later, all motor functions were restored with hypoesthesia and hypoalgesia sensory sequelae along C5-C6 dermatome.Conclusion:Herpes zoster radiculopathy, though rare, can occur after the onset of characteristic rash. Since cellular-mediated immunity holds crucial roles in varicella zoster virus activation, SLE and immunosuppression therapy is pertinent to this rare motoric complication of herpes. The prognosis is good. Acyclovir, gabapentin and physiotherapy treatments resulted in satisfactory recovery.

Paraspinal muscle involvement in herpes zoster-induced abdominal wall pseudohernia revealed by electrophysiological and radiological studies

Segmental zoster paresis is an uncommon complication of herpes zoster, and abdominal wall pseudohernia is rare. Previous reports have emphasized the involvement of anterior rami of spinal nerves, while the involvement of posterior rami has been less frequently reported. We aimed to elucidate the involvement of posterior rami of spinal nerves in abdominal wall pseudohernia. Four patients with a diagnosis of abdominal wall pseudohernia underwent needle electromyography (nEMG) and magnetic resonance imaging (MRI). In three patients, nEMG of affected paraspinal muscles showed denervation potentials, and MRI showed hyperintensity of these muscles on short T1 inversion recovery imaging. These results suggested involvement of paraspinal muscles, and indicated that posterior rami of spinal nerves are also often affected in abdominal wall pseudohernia. MRI as well as nEMG could be useful for evaluating paraspinal muscle involvement and for the diagnosis.

Paraspinal muscles involvement in herpes zoster-induced abdominal wall pseudohernia revealed by electrophysiological and radiological studies

Background: Segmental zoster paresis is an uncommon complication of herpes zoster. In rare cases this paresis occurs in the abdominal wall and is called abdominal wall pseudohernia. Many previous reports have placed emphasis on the involvement of anterior rami of spinal nerves, but the involvement of posterior rami has been less frequently noted.

Segmental zoster paresis

Herpes zoster is often associated with neurological manifestation but less frequently associated with motoric nerve involvement. The most common motoric involvement is paresis, seen only in 1-5% of all zoster cases. This case report a 39-year-old male, with recurrent abdominal liposarcoma under chemotherapy, presented with symptoms of fever, and painful and weak right leg for 2 weeks. Vesicles eruption was seen on his right leg nine days after these symptoms occurred. Physical examination revealed groups of haemorrhagic vesicles with erythematous base on the right lower leg. Lumbosacral spine x-ray showed spondylosis with radiculopathy. Electromyography (EMG) examination revealed lower motor neuron total denervation corresponding to right L5 radix. The patient was diagnosed as herpes zoster on right L5-S1 segment, herpetic neuralgia, and segmental zoster paresis with recurrent liposarcoma under chemotherapy. He was treated with oral acyclovir 800 mg five times a day and gabapentin 300 mg twice a day. Physical therapy and rehabilitation were started concurrently. Paresis is a rare complication of herpes zoster. Radicular pain and weakness preceded the skin lesion potentially lead to misdiagnoses. The most frequent diagnosis for patient suffering pain and weakness in the extremities is spinal disorder, such as stenosis and disc herniation. EMG can be helpful to recognise motoric involvement of herpes zoster, and preclude other diagnoses. Keywords: herpes zoster, paresis, radicular pain

Definition and management of varicella zoster virus-associated meningoradiculitis: a case report.

BackgroundThe varicella zoster virus affects the central or peripheral nervous systems upon reactivation, especially when cell-mediated immunity is impaired. Among varicella zoster virus-related neurological syndromes, meningoradiculitis is an ill-defined condition for which clear management guidelines are still lacking. Zoster paresis is usually considered to be a varicella zoster virus-peripheral nervous system complication and treated with oral antiviral therapy. Yet in the literature, the few reported cases of herpes zoster with mild cerebral spinal fluid inflammation were all considered meningoradiculitis and treated using intravenous antiviral drugs, despite absence of systemic signs of meningitis. Nevertheless, these two clinical pictures are very similar.Case presentationWe report the case of an alcohol-dependent elderly Caucasian man presenting with left lower limb zoster paresis and mild cerebral spinal fluid inflammation, with favorable outcome upon IV antiviral treatment. We discuss interpretation of liquor inflammation in the absence of clinical meningitis and implications for the antiviral treatment route.ConclusionFrom this case report we suggest that varicella zoster virus-associated meningoradiculitis should necessarily include meningitis symptoms with the peripheral neurological deficits and cerebral spinal fluid inflammation, requiring intravenous antiviral treatment. In the absence of (cell-mediated) immunosuppression, isolated zoster paresis does not necessitate spinal tap or intravenous antiviral therapy.

A Rare Complication of Herpes Zoster: Segmental Zoster Paresis.

Herpes zoster is a common presentation in both the community and emergency department; however segmental zoster paresis is a rare complication that can lead to misdiagnosis. We present a case of a 74-year-old Indian gentleman with a background of well controlled diabetes mellitus, hypertension, and ischaemic heart disease who presented with sudden right lower limb weakness. This was preceded by a 5-day history of paraesthesia starting in the right foot and ascending up the right lower limb. On examination, there was a characteristic vesicular rash in the L2/3 region with MRC grading 3/5 in the right hip flexors. The rest of the neurological examination was unremarkable. MRI of the spine did not show any evidence of spinal disease. The patient was initiated on IV acyclovir with improvement of the lower limb weakness to MRC grading 5/5 as the vesicles improved. This is an interesting case as it highlights a rare presentation of zoster: segmental motor paresis that recovered fully with resolution of the rash. It shows the importance of recognizing motor neuropathy as a complication of shingles as it has a very good prognosis with most patients regaining full motor function of the affected limb with treatment.

Herpes zoster segmental paresis in an immunocompromised breast cancer woman

Herpes zoster is an infectious disease with neurological complications caused by reactivation of varicella zoster virus in dorsal root ganglia of spinal cord which is also known as “Shingles.” Suppression of immune system is the major predisposing factor for reactivation of latent virus. Disease is mainly characterized by rash, vesicles and pain along one or more dermatomes which are innervated from one or more spinal nerve roots. Complications may be present after a while despite of patient treatment. Motor involvement is included. Some previous studies showed segmental zoster paresis as a rare complication, a few weeks after first presentation, among immunocompetent individuals. We present post herpetic motor involvement of C5 and C6 in a 59-year-old woman who underwent chemotherapy and radiotherapy due to breast cancer, manifesting left upper limb weakness and paresis, 6 months after left partial mastectomy. Segmental paresis of zoster virus should be considered as a cause of motor impairment in an immunocompromised person suffering from shingles.