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Ramsay-Hunt Syndrome Complicated by Bacterial Meningitis, Subarachnoid Hemorrhage and Cerebellar Stroke
Golriz Asefi, Carlos D'Assumpcao, Greti Petersen, Arash Heidari. Internal Medicine, Kern Medical-UCLA, Bakersfield, California, United States

Purpose of Study Herpes zoster oticus, known as Ramsay Hunt syndrome, is the reactivation of the varicella zoster virus in the geniculate ganglion. Reported complications include meningoencephalitis, posterior circulation strokes, and dysphagia. This is an unusual case of Ramsay Hunt syndrome complicated by bacterial meningitis, subarachnoid hemorrhage, and cerebellar stroke.
Methods Used Retrospective case report
Summary of Results 88-year-old Filipino woman with several comorbidities presented with a three-day history of right ear pain associated with pinna swelling, fever, chills, and right facial droop. The family noted vesicular lesions in the right ear and her trunk prior to presentation. On exam, she was found to have purulent discharge from the ear canal. Neuroimaging showed localized enhancement of the external auditory canal and mastoid. Vancomycin, piperacillin/tazobactam, otic ciprofloxacin, intravenous acyclovir, and methylprednisolone were started. Ear drainage grew methicillin-susceptible Staphylococcus aureus. On hospital day three, she developed fever; antibiotics were switched to ampicillin and cefepime. Lumbar puncture revealed opening pressure 11 cmH20, glucose 78, protein 480, white blood cell 1100 with 63% neutrophils consistent with bacterial meningitis picture. Methylprednisolone was stopped after seven days, but her leukocytosis with left shift persisted. Repeat neuroimaging found a right cerebellar hemorrhagic stroke, subarachnoid hemorrhages in the right sylvian fissure around the foramen magnum and superior cervical spinal canal, and the left temporal lobe. Repeat LP found glucose 104, protein 366, RBC 16000, WBC 140 (99% lymphocytes). VZV DNA PCR was negative.
Serial CT images showed improvement in subarachnoid bleeds. She was discharged to an acute rehabilitation facility. She completed a 14-day course of acyclovir and a 21-day course of cefepime and ampicillin. At ten month follow up, the patient had persistent right eye ptosis with cranial nerve VII paralysis.
Conclusions Multiple intracranial complications in Ramsay Hunt syndrome is rare. Physicians should be aware of the risks of intracranial complications in the elderly with Ramsay Hunt syndrome.


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