A 32-year-old caucasian male with no significant past medical history presented to the emergency room with a four-day history of right-sided facial weakness. The weakness was associated with headaches. One week before this event, the patient experienced right-sided earache, sore throat, and neck pain. In the emergency department (E.D.), we received the patient vitally stable (temperature of 36.5 C, heart rate of 82 beats per minute, blood pressure of 134/80 mmHg, respiratory rate of 18 breaths per minute, SpO 2 of 97%). Physical examination revealed tenderness to palpation on the right preauricular region and angle of the mandible, absent furrows on the right side of the forehead, incomplete right eye closure at the effort, and asymmetric mouth at maximum effort (House-Brackman scale IV). Notably, the external auditory meatus did not exhibit a rash, and otoscopic examination by ENT exhibited an erythematous and non-bulging tympanic membrane with no vesicles.
C.T. scan of the temporal bone revealed right mastoid air cells showing changes consistent with possible infection or inflammation (Fig. 1).
A lumbar puncture was performed for concern of varicella infection and to rule out CNS infection. Dexamethasone and valacyclovir were started. MRI of the head was performed to characterize further the inflammatory changes found on the C.T. scan. It revealed enhancement involving the labyrinthine and the anterior genu of the right facial nerve, right glossopharyngeal nerve, and mild thickening/enhancement of the pituitary infundibulum. (Fig. 2). These findings were nonspecific for granulomatous diseases such as neurosarcoid, tuberculosis, lymphoproliferative disease, or atypical infections. Relevant workup was sent. The headache improved, but the patient complained of chest pain on hospital day 3. C.T. chest with IV contrast was obtained, and a sub-segmental pulmonary embolus (P.E.) in the anterior segment of the right lower lobe was reported (Fig. 3). Echocardiography and duplex scan of the lower extremities were unremarkable. MRV of the brain with and without contrast was negative for venous sinus thrombosis. Cerebrospinal fluid (CSF) PCR analysis was positive for Varicella zoster virus (Table 1, Table 2). Varicella-Zoster Antibodies (IgG and IgM) were also elevated. Diagnosis of Zoster Sine Herpete was confirmed.
Anticoagulation therapy with low molecular weight heparin 50mg twice a day was initiated. Antiviral was switch to IV Acyclovir, and steroids were given. Coagulation analysis for Anti-cardiolipin antibody, Silica Clotting Time Interpretation and Dilute Russell viper venom time (DRVVT) screen ratio were negative. The patient successfully responded to therapy with the residual moderate facial dysfunction (House-Brackman scale III) and was discharged home on the 7th day of hospitalization with apixaban and valacyclovir for 14 more days. The patient was reported doing well on telehealth follow-up 4 weeks later.