Abducens Palsy & Superinfected Zoster

As a future Neurologist, there were two cases that I found particularly interesting over the past month. Pictures were taken of these patients with their permission. Their names, gender, clinic locations and other details will not be mentioned in order to protect their privacy.

The first case is of a young child who came to the hospital with overt meningeal signs and fever that had progressively gotten worse over 2-3 weeks, according to the family. The patient presented with a stiff neck and positive Brudzinski's sign (hips flexed when chin was tilted toward chest). The child was treated empirically for meningitis with the available antibiotics, an antiviral (acyclovir) and anti-tubercular treatment (rifampin, isoniazid, pyrazinamide plus pyridoxine). No ethambutol was given as the child is less than 5 years old and resistant TB was not suspected. The child was also given a dose of steroids. The presumptive diagnosis was TB meningitis given the indolent course, low-grade fever and rapid response to treatment. However, a viral meningitis is also a possibility. The patient recovered within a few days and the only sequela was a cranial nerve 6 (abducens nerve) palsy of her left eye. As a result of the CN VI palsy she was unable to abduct her left eye. This apparently is a fairly common sequela of meningitis as CN VI has the longest subarachnoid tract of any of the cranial nerves. Inflammation from the meningitis presumably damages or alters the function of CN VI itself. Most cases resolved spontaneously within 6 months, although alternate side patching may be an option if the palsy does not resolve on its own. Since the child cannot move her left eye out laterally it appears positioned toward the midline when the right eye is moved laterally to the left.

The second case was of an adult who presented with a very painful, burning sensation of the left side of the face and lateral/posterior scalp. The patient had pustules in that region that had recently burst and had left open sores. The patient had been treated by another physician with acyclovir for varicella zoster virus (shingles). The patient was still having intense pain and it appeared that there may have been a superimposed bacterial infection. The photos below clearly demonstrate the dermatomal distribution of zoster and how it does not cross the midline. The patient was treated with oral chloramphenicol for bacterial infection (it was the only antibiotic available) and amitriptyline for pain.