2019 Research Forum

RAMSAY-HUNT SYNDROME COMPLICATED BY BACTERIAL MENINGITIS, SUBARACHNOID HEMORRHAGE & CEREBELLAR STROKE Golriz Asefi 1 MD Graduate RA, Carlos D'Assumpcao MD R1 1 ; Greti Petersen MD 1 ; Arash Heidari MD 1 1. Department of Internal Medicine, Kern Medical, Bakersfield , CA

Introduction

Case Presentation 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. This is an unusual case of Ramsay Hunt syndrome complicated by bacterial meningitis, subarachnoid hemorrhage, and cerebellar stroke. 88-year-old Filipino woman with several comorbidities presented 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 to 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.

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Figure 3 . CT showing hemorrhage in right sylvian fissure

Image 5 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. Vancomycin, piperacillin/tazobactam, otic ciprofloxacin, intravenous acyclovir,

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Figure 5 and 6. Sagittal and coronal CT showing improvement of right sylvian fissure hemorrhage

Discussion

Multiple intracranial complications in Ramsay Hunt syndrome is rare. Physicians should be aware of the risks of intracranial complications in the elderly with Ramsay Hunt syndrome.

References

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Acknowledgement 1-Yamashiro N, Nagasaka T, Ooishi N, Tsuchiya M, Takaki R, Kobayashi F, Shindo K, Takiyama Y. [An Autopsy Case of Meningoencephalitis and Cerebral Infarction that Developed with Ramsay Hunt Syndrome and Disseminated Herpes Zoster]. Brain Nerve. 2018 Mar;70(3):253-258. doi: 10.11477/mf.1416200990. Japanese. PMID: 29519969 The authors would like to acknowledge the contributions of the patient care team and research support staff for their roles in bringing awareness to this rare condition for the medical community.

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Figure 4. MRI showing fluid in right mastoid air cells indicating mastoiditis

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Results 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.

Figure 1 and 2. Initial CT showing periauricular area thickening consistent with otitis external

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