Reactivation of type 1 herpes simplex virus and varicella zoster virus in an immunosuppressed patient with acute peripheral facial weakness

Abstract

We describe a 26-year-old man treated with azathioprine for myasthenia gravis who developed acute left-sided peripheral facial weakness. Brain magnetic resonance imaging (MRI) revealed enhancement in the left geniculate ganglion and in the intracanalicular and tympanic segments of the facial nerve. Analysis of cerebrospinal fluid (CSF) and serum revealed intrathecal synthesis of anti-varicella zoster virus (VZV) IgG antibody. Although previous analyses of saliva, blood mononuclear cells, serum antibodies, middle ear fluid, and auricular and geniculate zone skin scrapings have shown that a small but definite proportion of patients with idiopathic peripheral facial palsy (“Bell's palsy”) have the Ramsay Hunt syndrome zoster sine herpete (RHS ZSH), this is the first confirmation of RHS ZSH by intrathecal synthesis of anti-VZV IgG antibody. In addition, herpes simplex virus (HSV)-1 DNA was found in saliva of the patient on 3 consecutive days. Simultaneous reactivation of two alphaherpesviruses (HSV-1 and VZV) in our immunosuppressed patient underscores the need to consider opportunistic infection as a cause of facial weakness.

Azathioprine therapy induces selective NK cell depletion and IFN-γ deficiency predisposing to herpesvirus reactivation

“…Accordingly, a survey among patients with MG reported that susceptibility to infections ranked among the most severe constraints during their daily life. 3 Several reports describe patients with MG and rheumatoid arthritis who are taking AZP Abbreviations used AZP: Azathioprine MCV: Mean corpuscular volume MG: Myasthenia gravis NK: Natural killer VZV: Varicella-zoster virus and have experienced development of aggressive varicella-zoster virus complications 4,5 or reactivation of chronic viral hepatitis. 6 Furthermore, the risk of development of malignancies, including squamous cell carcinomas of the skin, non-Hodgkin lymphoma, Kaposi sarcoma, and in situ carcinoma of the uterine cervix, seems to be particularly high in transplant recipients during AZP therapy.…”

Assessment of Oral Shedding of Herpes Simplex Virus Before and After Endodontic and Fixed Partial Prosthodontics Treatment in Patients with Recurrent Herpes Simplex

“…Asymptomatic shedding promotes the risk of crossinfection not only to other patients but also to dental staff (20,21). This is especially important in immunocompro-mised patients and pregnant women (22,23). Therefore, the evaluation of asymptomatic HSV-1 shedding induced by dental treatment is important.…”

Successful response of non-recovering Ramsay Hunt syndrome to intravenous high dose methylprednisolone

“…It is characterized by inflammation and edema of the VIIth cranial nerve as a consequence of an active infection of the genicolate ganglion by herpes zoster virus, leading to the definition of herpes zoster oticus, or, less frequently, by herpes simplex virus [4]. Symptoms include acute peripheral facial weakness associated with pain in the ear as well as herpetic vesicular rash in the auricle, ear canal and that may extend to face and neck as well as tongue, hard palate, larynx and buccal mucosa.…”