Segmental Zoster Paresis Accompanied by Horner's Syndrome

We herein report a 90-year-old immunocompromised woman who developed right upper limb weakness and right ptosis with a miotic pupil 1 week after oral therapy for zoster on the right T2 dermatome. The right pupil was dilated with instillation of 1% apraclonidine, indicating Horner's syndrome. The patient was treated with intravenous acyclovir and methylprednisolone. Focal weakness related to zoster, generally known as segmental zoster paresis, improved over five months, but Horner's syndrome remained. We suggest that aggressive intravenous treatment should be considered for rare cases of zoster that occur with a combination of these two neurological conditions.

 

Comments:

The case you are describing involves a 90-year-old immunocompromised woman who developed several neurological symptoms following oral therapy for zoster on the right T2 dermatome. Here's a breakdown of the key points from this case:

1. **Patient Profile:**
   - The patient is a 90-year-old woman.
   - She is immunocompromised, meaning her immune system is weakened, making her more susceptible to infections and other medical conditions.

2. **Initial Symptoms:**
   - The patient initially developed right upper limb weakness and right ptosis (drooping of the upper eyelid) with a miotic pupil (constricted pupil) one week after undergoing oral therapy for zoster on the right T2 dermatome.

3. **Diagnosis:**
   - The right pupil was found to be dilated with the instillation of 1% apraclonidine, indicating Horner's syndrome.
   - Horner's syndrome is a neurological condition characterized by a combination of symptoms that result from disruption of sympathetic nerve pathways. One of the hallmark signs is a constricted (miotic) pupil.

4. **Treatment:**
   - The patient received intravenous acyclovir, which is an antiviral medication used to treat herpes zoster (shingles) and other viral infections.
   - She also received methylprednisolone, which is a corticosteroid medication with anti-inflammatory properties.

5. **Outcome:**
   - The focal weakness related to zoster, referred to as segmental zoster paresis, improved over a period of five months.
   - However, the Horner's syndrome persisted even after the improvement in other neurological symptoms.

6. **Clinical Implication:**
   - The case suggests that in rare instances where zoster (shingles) is associated with the development of Horner's syndrome, an aggressive intravenous treatment approach, including antiviral and anti-inflammatory medications, should be considered.

This case highlights the complexity of neurological manifestations associated with herpes zoster (shingles) in an immunocompromised individual. While the segmental zoster paresis improved over time with treatment, the Horner's syndrome remained a persistent condition, underscoring the importance of prompt and appropriate medical intervention in such cases.

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