CASE DESCRIPTION:
A 46-year-old previously healthy woman was admitted to the emergency
department complaining of mouth drooping and vertigo since that morning.
She also had a headache and pain on the right ear since the night
before. She denied fever, hearing loss, hyperacusia, tinnitus, nausea or
vomiting.
On physical examination, she was alert and oriented, with a Glasgow Coma
Scale score of 15, without focal neurologic deficits except for right
peripheral facial palsy [Figure 1]. Gait was not tested because of
her vertigo but she had no dysmetria on finger-to-nose and heel-to-knee
tests. She was hemodynamically stable and afebrile with no meningeal
signs. She had no visible vesicular eruptions nor any abnormalities on
otoscopy.
Lab work
[Table 1]
showed a total leukocyte count of 12.270/uL (normal range
4.000-12.000/uL). Other than that, blood routine examination was normal,
including a low level of C-reactive protein (4mg/L, normal range
<5mg/L).
Contrast-enhanced head CT scan
[Figure 2]
showed no signs of acute vascular, hemorrhagic or edematous events and
documented normal permeability of deep and superficial venous system.
Because of persistent headache, she underwent a lumbar puncture with
drainage of clear CSF. CSF analysis showed normal glycorrhachia, no
pleocytosis and slight proteinorrhachia (84 mg/dL, normal range
15-60mg/dL). Screening for varicella zoster DNA on CSF by polymerase
chain reaction was positive.
A clinical diagnosis of Ramsay-Hunt syndrome was established. The
patient was started on acyclovir 10 mg/kg every 8 hours for 14 days,
prednisolone 1mg/kg for 5 days, humidifying eye drops and right eye
protection. Physiotherapy for the face was initiated and the patient
slowly improved, maintaining at the time of discharge a class III palsy
on the House-Brackmann Facial Nerve Grading System.