Herpes zoster involving the abducens and vagus nerves without typical skin rash: A case report and literature review

RATIONALE: Herpes zoster is characterized by unilateral vesicular eruption and it most often affects the trigeminal nerve. We would like to report a rare case of abducens and vagus nerves palsy caused by varicella zoster virus (VZV) without the typical vesicular rash. PATIENT CONCERNS: A 71-year-old woman presented with diplopia. Three days previously, she had experienced sore throat and hoarseness. DIAGNOSIS: At presentation, the prism cover test revealed esotropia of 10 prism diopters at primary gaze, and abduction was restricted in the right eye. No vesicular rash was observed on the patient's face, and magnetic resonance imaging of the brain showed no pathology. Flexible fiberoptic laryngoscopy revealed multiple ulcerations on the right side of the larynx—from the epiglottis to the arytenoid. After 1 day of hospitalization, a diffuse skin rash occurred on the patient's trunk, and polymerase chain reaction for VZV DNA was positive at the skin lesion. The patient was diagnosed as having herpes zoster associated with vagus and sixth nerve palsy. INTERVENTION AND OUTCOMES: She received famciclovir at a dose of 500 mg 3 times daily for 7 days and coadministered methylprednisolone. At the 4-month follow-up, her diplopia and eye movement had resolved completely. LESSONS: In patients with abducens nerve palsy without typical vesicular lesion, herpes zoster may not be detected early. In that case, systemic examination is very important for diagnosing herpes zoster.