2019 Research Forum

Applicant: Carlos D’Assumpcao MD R1 Principal Investigator: Arash Heidari MD

Ramsay-Hunt Syndrome Complicated by Bacterial Meningitis, Subarachnoid Hemorrhage and Cerebellar Stroke

Golriz Asefi MD Graduate RA, Carlos D’Assumpcao MD R1, Greti Petersen MD, Arash Heidari MD

INTRODUCTION Herpes zoster oticus, known as Ramsay Hunt syndrome, is the reactivation of the varicella zoster virus in the geniculate ganglion. Reported complications include meningoencephalitis, posterior circulation strokes, and dysphagia. PURPOSE To share with the medical community an unusual case of Ramsay Hunt syndrome complicated by bacterial meningitis, subarachnoid hemorrhage, and cerebellar stroke. HIPAA/IRB review and approval for the case report was obtained. DISCUSSION An 88-year-old Filipino woman with several comorbidities presented to Kern Medical with a three-day history of right ear pain associated with pinna swelling, fever, chills, and right facial droop. The family noted vesicular lesions in the right ear and her trunk prior on presentation. On exam, she was found to have purulent discharge from the ear canal. Neuroimaging showed localized enhancement of the external auditory canal and mastoid. Vancomycin, piperacillin/tazobactam, otic ciprofloxacin, intravenous acyclovir, and methylprednisolone were started. Ear drainage grew methicillin- susceptible Staphylococcus aureus. On hospital day three, she developed fever; antibiotics were switched to ampicillin and cefepime. Lumbar puncture revealed opening pressure 11 cmH20, glucose 78, protein 480, white blood cell 1100 with 63% neutrophils consistent with bacterial meningitis picture. Methylprednisolone was stopped after seven days, but her leukocytosis with left shift persisted. Repeat neuroimaging found a right cerebellar hemorrhagic stroke, subarachnoid hemorrhages in the right sylvian fissure around the foramen magnum and superior cervical spinal canal, and the left temporal lobe. Repeat LP found glucose 104, protein 366, RBC 16000, WBC 140 (99% lymphocytes). VZV DNA PCR was negative. Serial CT images showed improvement in subarachnoid bleeds. She was discharged to an acute rehabilitation facility. She completed a 14-day course of acyclovir and a 21-day course of cefepime and ampicillin. At ten month follow up, the patient had persistent right eye ptosis with cranial nerve VII paralysis. CONCLUSION Multiple intracranial complications in Ramsay Hunt syndrome is rare and devastating with long term persistent symptoms. Physicians should be aware of the risks of intracranial complications as well long recovery period in the elderly with Ramsay Hunt syndrome and manage the patient with vigilance.

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