Horner's Syndrome and Contralateral Abducens Nerve Palsy Associated with Zoster Meningitis
A 55-year-old woman presented with diplopia that had developed 12 days prior. The diplopia was preceded five days earlier by malaise and two days earlier by tingling sensation and pain in the right shoulder. The paresthesia spread along the whole right arm, and then arm weakness developed. Three days after the occurrence of paresthesia, the patient developed multiple painful vesicular eruptions on the right shoulder. After three more days, the tingling sensation involved the right lower leg.\nOn presentation, she was found to have 35 prism diopters of esotropia, which worsened on left gaze at distance and near in the primary position. There was an abduction limitation in the left eye (). The pupils were isocoric and reactive in both eyes. Visual acuity, the margin-reflex distance, levator function of the eyelid, anterior segments and fundi were normal in both eyes. The ocular and medical histories were unremarkable.\nOn neurological examination, right upper extremity strength was decreased to Medical Research Council grade II. Electromyography revealed a right C4 and C5 radiculopathy. Sensation was also decreased in the right C3 to C5 dermatomes. Although mental status was intact and brain magnetic resonance imaging (MRI) was normal, an analysis of cerebrospinal fluid (CSF) showed pleocytosis of 26 cells/mm3 and immunoglobulin (Ig) G varicella zoster virus (VZV) antibody. IgG and IgM VZV antibodies were detected in the serum as well. The patient was diagnosed as having zoster meningitis and was admitted for antiviral treatment. Acyclovir was administered intravenously and analgesics by mouth. With treatment, the skin lesions and shoulder weakness improved within one week.\nOn the 14th day after admission, she newly developed right blepharoptosis. The marginal reflex distance 1 was 1.5 mm in the right eye and 3.5 mm in the left eye. The levator function was 12 mm in both eyes. The patient complained of hemifacial anhidrosis on the right side. Pupils were reactive in both eyes, however were anisocoric with the pupil size of 3 mm in the right eye and 4 mm in the left eye in light. Anisocoria increased in the darkness to 3 mm in the right eye and to 4.5 mm in the left eye (). She was diagnosed as having Horner's syndrome in the right eye. There was no change in the abduction limitation of the left eye. By the 22nd day, the motor and sensory functions recovered considerably and the patient was discharged.\nWhen she returned to clinic one month after discharge, she demonstrated improvement of the abduction limitation in the left eye (), but anisocoria and blepharoptosis were still persistent.\nSix months after discharge, the abduction limitation and diplopia were completely restored. Anisocoria, blepharoptosis, and hemifacial anhidrosis resolved. The only remaining symptom was a mild paresthesia of the right arm.