Delayed Superior Orbital Fissure Syndrome Arising More than One Month after Herpes Zoster Ophthalmicus and Meningitis

Abstract

A 79-year-old woman developed herpes zoster ophthalmicus (HZO) with a vesicular rash on the nasal root, which developed soon after intravenous acyclovir therapy. Although varicella zoster virus DNA was undetectable in the cerebrospinal fluid, she presented with ophthalmoplegia without optic nerve dysfunction 32 days after the onset of HZO. We diagnosed the patient with superior orbital fissure syndrome and administered intravenous immunoglobulin and systemic corticosteroids. Ophthalmoplegia did not immediately respond to these therapies but resolved 4 months later. We should be aware that ophthalmoplegia can occur, even after HZO and meningitis are completely treated.

Keywords: herpes zoster ophthalmicus; meningitis; multiple cranial neuropathies; superior orbital fissure syndrome; varicella zoster virus.

Figure 1.

The clinical course of the patient. ACV: acyclovir, CSF: cerebrospinal fluid, FCV: famciclovir, IVIg: intravenous immunoglobulin, IVMP: intravenous methylprednisolone, OCB: oligoclonal band, PSL: oral prednisolone, TP: total protein, VZV: varicella-zoster virus

Figure 2.

(A) A ruptured vesicle in the right root of the nose known as the Hutchinson sign (arrow). (B) At 32 days after the onset, abduction is moderately restricted, while adduction and elevation are slightly restricted in the right eye.