Contralateral stroke with rapid recovery in a patient of herpes zoster ophthalmicus

Herpes zoster ophthalmicus commonly presents with vesicular eruptions of skin along a dermatome and post herpetic neuralgia. Viral invasion into the intracranial vessel and resultant arteritis is rare complication, reported mainly in elderly, children and immunocompromised individuals. We report a young immunocompetent male who reported to us with acute right sided hemiparesis following an episode of left sided herpes zoster ophthalmicus three months prior to stroke. Patient had a near complete recovery of his weakness without any treatment with persistent mild dysarthria. Magnetic resonance imaging of brain showed subacute infarct in left middle cerebral artery territory. Magnetic resonance angiogram demonstrated marked narrowing of the proximal segment of left middle cerebral artery. This case highlights herpes zoster ophthalmicus as one of the causes of stroke in young with good prognosis. Neurology Asia 2011; 16(3) : 247 – 250 Address correspondence to: Professor Rajesh Verma DM (Neuro) DNB (Neuro), Neurology, Chhatrapati Sahuji Maharaj Medical University, Lucknow, UP, India. PHONE -09335915823, E-mail: [email protected] INTRODUCTION Herpes zoster ophthalmicus results from reactivation of the previously acquired varicella zoster virus (VZV) in childhood. The virus lies dormant in trigeminal ganglion and during reactivation it spreads along the ophthalmic division of trigeminal nerve to give rise to herpes zoster ophthalmicus. The incidence of herpes zoster (shingles) is around 1.3 to 1.6 per 1000 people per year. The most common presentation of herpes zoster is the characteristic vesicular eruptions in dermatomal distribution. The most common complications of Herpes Zoster ophthalmicus are local in nature in the form of post herpetic neuralgia, scar and ocular diseases. However, reactivation of varicella zoster can be associated with a variety of systemic complications such as granulomatous angiitis of central nervous system, cerebellitis, myelopathy, retinal necrosis and peripheral vascular disorders. Although VZV vasculopathy is a well documented cause of stroke after herpes zoster attack, it does not fully explain the unexpectedly high risk of stroke observed among these patients. A majority of previous reports show that contralateral hemiplegia is the most common manifestation of VZV vasculopathy resulting in stroke, particularly after herpes zoster ophthalmicus. The majority of reported patients of herpes zoster vasculopathy were depicted through case reports and guidelines about treatment, and outcome are not clearly mentioned in the literature. The association of HZO and stroke may be overlooked as this complication typically occurs a few months after the original episode. We report a young male who developed right sided hemiparesis with rapid recovery preceded by herpes zoster ophthalmicus on left side.