Isolated facial palsy in varicella

G Raghu Rama Rao, A Amareswar, Y Hari Kishan Kumar, Radha Rani

 Surya Skin Care and Research Center, Maharanipeta, Visakhapatnam, AP, India

Correspondence Address:
G Raghu Rama Rao
Surya Skin Care and Research Center, 15-1-2, Nowroji Road, Maharanipeta, Visakhapatnam - 530 002, AP
India

Sir,

Isolated facial palsy as a neurological complication of varicella is reported. ^{[1],[2],[3],[4],[5]} As such neurological complications caused by varicella are estimated to occur in approximately 0.01-0.03% of infections. Frequent neurologic complications of varicella are cerebellar ataxia and encephalitis while the rare complications are transverse myelitis, aseptic meningitis, Guillain-Barrι syndrome, meningo-encephalitis, ventriculitis, optic neuritis, delayed contralateral hemiparesis, peripheral motor neuropathy, cerebral angiitis, Reye′s syndrome, and facial paralysis. ^[1]

Ten days after varicella (chicken pox), a 26-year-old house wife presented with a left facial palsy without any neurological symptoms. While she was recovering from varicella, she developed inability to close her left eye and deviation of mouth to the right side. There was no clinical history of retroauricular pain, hyperacusis, decreased production of tears, and altered taste. On examination, there were multiple discrete crusted lesions all over the trunk, back, extremities, and healed eroded lesions over the face. Complete neurological examination revealed lower motor neuron type of facial palsy without any other abnormal features [Figure - 1]. Other systemic examination revealed no abnormalities. Vital signs are normal. Patient is not hypertensive. Routine investigations were within normal limits. Serological tests for syphilis and human immunodeficiency virus (HIV) infection are nonreactive. Varicella zoster virus IgG (13.2 NTU) and VZV IgM (13.7 NTU) were positive. Computed tomography (CT) scan of brain revealed no abnormality. The patient was treated with acyclovir 800 mg five times/day for 7 days and prednisolone 10 mg three times/day in tapering doses for 3 weeks. The patient was examined after 3 weeks and complete recovery of facial palsy was noticed.

Facial paralysis in varicella can be seen either prior to or after the appearance of exanthem. It may occur 5 days before exanthema appears or during 16-day period after varicella is diagnosed. Facial palsy as a complication of varicella can be a result of preeruptive hematogenous or neurogenous spread of varicella zoster virus ^[1],[3],[4] Bilateral facial palsy can also occur rarely during varicella. ^[3] Though in our case facial nerve palsy developed during varicella infection with elevated V-Z IgG and IgM antibodies, it should be differentiated from closely identical conditions of facial palsy like Bell′s palsy and Ramsay Hunt syndrome. [Table - 1] summarizes the differentiating features of our case and these two conditions. Classically Bell′s palsy has been defined as idiopathic and the cause of the inflammatory process in the facial nerve remains uncertain. Recently attention has focused on infection with herpes simplex virus type 1 (HSV-1) as a possible cause because research has found elevated HSV-1 titers in affected patients. However, studies have failed to isolate viral DNA in biopsy specimens leaving the causative role of HSV-1 in question. ^[6] Ramsay Hunt syndrome is due to reactivation of varicella zoster virus affecting geniculate ganglia and facial nerve. Many conditions can produce isolated facial nerve palsy like cholesteatoma, salivary tumors, Guilliain Barre syndrome, Lyme disease, otitis media, sarcoidosis, and some influenza vaccines. These conditions usually have other distinguished features. ^[6]

The prognosis of facial palsy due to varicella is generally good and 80% cases recover with or without treatment, but specific acyclovir and prednisolone therapy may accelerate the complete recovery like in our case.

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