Cerebral vasculitis associated with shingles.

A 77-year-old lady initially presented to her family doctor in January 1987. She complained of a painful left ear with associated hearing loss and dizziness. There were vesicles on the left pinna, and she had a left lower motor neurone facial palsy. She was treated for five days with oral acyclovir and topical idoxuridine, but her symptoms did not resolve. Two weeks after the onset she became ataxic, with double vision and nausea. She was admitted to an ear, nose and throat ward, and a neurological opinion was sought. She was fully alert and orientated. There were vesicles on the left pinna. She had gaze -evoked nystagmus on horizontal and vertical gaze, maximum on left lateral gaze. There was a complete left lower motor neurone facial palsy. There was a right carotid artery bruit. There were no other cranial nerve lesions. Power and sensation were fully intact, tendon reflexes were symmetrical but the left plantar response was extensor. She had marked truncal ataxia and left sided inco ordination. Computerised tomography scan of the head showed evidence of cerebral atrophy but no focal lesion. Treatment with heparin and acyclovir was started intravenously. Her ataxia showed a steady improvement but left tarsorrhaphy was required due to the absent corneal reflex. At review five months later she was walking unaided though her balance was poor. The left lower motor neurone lesion persisted.