MNJ (Malang Neurology Journal) Vol. 9, No. 2, July 2023
Page 172 of 3 http://mnj.ub.ac.id/
DOI: 10.21776/ub.mnj.2023.009.02.19 eISSN: 2442-5001 pISSN: 2407-6724
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THE IMPORTANT OF NEUROPHYSIOLOGY
EXAMINATION IN DIAGNOSING SEGMENTAL ZOSTER PARESIS: CASE REPORT
Eric Hartono Tedyanto1, Ni Made Dwita Pratiwi1, I Komang Arimbawa1, I Putu Eka Widyadharma1 Correspondence: [email protected]
1 Department of Neurology, Faculty of Medicine, Universitas Udayana, Bali, Indonesia.
Article History:
Received: July 12, 2022 Accepted: April 27, 2023 Published: July 1, 2023
ABSTRACT
Background: Segmental zoster paresis (SZP) is a very uncommon complication characterized by localized weakening of the upper or lower limbs.
Case report: A 69-year-old man came with complaints of weakness in the right leg two months ago.
He had weakness in his right leg after two days of having herpes on his right leg. There was paresthesia and hypesthesia on neurological examination according to the L1-L3 dermatome. Neurophysiology examination revealed a neuropathy in the right femoral nerve.
Discussion: Varicella-zoster virus, being a neurotrophic virus, primarily invades and incubates in the dorsal root or cerebral ganglion nerve cells. Etiological investigations in SZP patients have revealed that the anterior root is the most prevalent location of inflammation and degeneration.
Conclusion: SZP is a rare complication following VZV infection that can lead to misdiagnosis and overtreatment in clinical practice. The neurophysiological examination is very important in diagnosing segmental zoster paresis.
Keywords: Herpes zoster, segmental zoster paresis, varicella zoster.
Cite this as:
Tedyanto EH, Pratiwi NMD, Arimbawa IK, Widyadharma IPK.
The Important of neurophysiology examination in diagnosing segmental zoster paresis: Case report. Malang Neurology Journal; 2023.9:172-174. DOI:
http://dx.doi.org/10.21776/ub.mnj .2023.009.02.19
Introduction
Herpes zoster is a disease with skin lesions in the form of vesicles caused by reactivation of the varicella-zoster virus (VZV) which initially occurs in childhood.1 The most frequent neurological symptom of herpes zoster is postherpetic neuralgia. SZP is rare, occurring about 0.5-5%
of cases, and is characterized by localized weakening of the upper or lower limbs.2 SZP is distinguished by localized motor weakness in the same segment as the skin eruption.3 The precise mechanism of SZP remains unknown.4 Several theories explain that the pathophysiology of paresis is thought to be caused by invasion of the varicella-zoster virus (VZV) from the dorsal ganglion to motor neurons and inflammation of the anterior horn motor nerves.5 Misdiagnosis or delays in therapy might occur since the condition is rarely recognized, even by a neurologist. As a result, neurologists must recognize this syndrome and include SZP in the differential diagnosis of acute-onset paresis.6
Case Report
A 69-year-old male patient came to be referred from a skin and genital clinic with complaints of weakness in the right leg in the last 2 months. He developed weakness in his right leg 2 days after developing herpes on his right thigh.
Weakness of the right leg is felt especially in the right thigh.
The patient feels unable to move the lower leg up. The
patient had a history of herpes in the past 2 months. Until now the patient has complained of stabbing pain, itching, and a burning sensation that is felt from the groin to the patient's right knee. This complaint was felt to improve after the patient underwent biolaser therapy for 3 times, accompanied by gabapentin, amitriptyline, and vitamin B complex drugs.
Figure 1. Crusted lesions of herpes zoster vesicles on right thigh according to L2-L3 dermatome (red arrow).
The patient complained of a neuropathic pain on the NPRS pain scale of 4/10. Examination of the patient's skin revealed a hyperpigmented macular lesion with crusts on the patient's right thigh. On neurological examination, the patient's right quadriceps femoris motor strength was found to be 2/5 and there was atrophy. Hypoactive right patellar tendon reflex,
CASE REPORT OPEN ACCESS
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MNJ (Malang Neurology Journal) Vol. 9, No. 2, July 2023 hyperalgesia according to L2-L3 dermatome. On
examination of the cranial nerves, no abnormalities were found. Examination of the upper extremities revealed no motor or sensory deficits. Lumbosacral MRI examination of the patient did not reveal any abnormalities. The patient was then planned for muscle electrophysiological examination.
Neurophysiological examination (Needle EMG) of the right vastus lateralis muscle found PSW+4, fibrillation +4, MUAP: normal amplitude, widened duration, polyphasic phase, incomplete IP recruitment, denervation was found, so it was concluded that there was neuropathy in the right femoral nerve.
Figure 2. Electrophysiological examination (Needle EMG) of the right vastus lateralis muscle showing the presence of fibrillation
(blue arrow) and positive sharp wave (red arrow).
Discussion
Segmental zoster paresis is a radiculopathy with manifestations of muscle weakness due to peripheral neuropathy of motor nerves. More than 90% of radicular pain symptoms are found in the same dermatome as the skin lesion. As in our patient, he had muscle weakness in the same dermatome as the skin lesion, namely L2-L4.5 The pathogenesis of segmental zoster paresis is thought to be the result of viral invasion that spreads to motor neurons and anterior horn cells, which causes inflammation of the nerves according to the level of the spinal cord, causing rash lesions on the skin. As a neurotrophic virus, varicella zoster invades and incubates in dorsal root ganglion nerve cells.7 According to one study, the anterior root may be the most prevalent location of inflammation and degeneration in SZP patients.
The anterior horn, brachial plexus, lumbar plexus, and peripheral nerve cells may also be affected.8,9 The inflammation first reaches the spinal cord and then spreads to the nerve roots, from the dorsal root ganglion to the anterior spinal nerve roots. It remains unclear whether inflammation occurs as a result of viral infection or an immune-mediated reaction.10
Muscle weakness in segmental zoster paresis usually appears within two to three weeks of the herpes rash, but in some rare cases, weakness may precede the rash. Establishing a diagnosis of SZP in a patient without a preexisting herpetic lesion is extremely difficult. The diagnosis is often confused with spinal problems such as herniated nucleus pulposus (HNP).11 The diagnosis of HNP can be excluded by MRI. An MRI that cannot explain signs of radiculopathy, such as radiating pain, numbness, and muscle weakness can rule out the diagnosis of HNP. When the MRI examination shows no abnormalities or cannot explain the patient's symptoms, electrophysiological EMG examination can help establish the diagnosis.12
Positive sharp waves and fibrillation were observed in 40%
to 50% of cutaneous zoster patients in an EMG investigation, indicating that subclinical motor involvement is not uncommon. Electrophysiological studies are useful as a diagnostic tool in SZP. Examination of conduction velocity
reveals decreased sensory nerve action potentials and muscle action potentials in the affected segment. Needle EMG shows abnormal spontaneous activity, such as fibrillation and PSW in the affected muscle. The timing of the evaluation is critical since aberrant spontaneous activity appears after two weeks and lasts for 1 to 3 months.6
Electrophysiological examination of previous studies also revealed the presence of viral motor nerve lesions. Liu et al.
examined the electrophysiology of eight SZP patients and found that all had reduced muscle action potential (CMAP) or sensory nerve action potential (SNAP) amplitudes.13 According to these findings, all of these individuals showed motor and sensory neuron axon injury. These findings are consistent with the study of Sachs et al, who conducted EMG investigations on SZP patients with affected lower limbs for 22 months and discovered full denervation and muscular re- innervation processes. Complete or near complete improvement of motor strength can occur weeks and even months after healing of skin lesions in a review study.14
Conclusion
Segmental zoster paresis is an uncommon herpes zoster condition that is seldom recognized by a neurologist, which can lead to misdiagnosis and overtreatment in clinical practice. Improving clinical understanding of SZP allows patients to receive speedier assessment and care and begin functional rehabilitation sooner. SZP is an uncommon condition not well-identified by doctors, and no clinical treatment recommendations are available. Additional diagnostic approaches for SZP include EMG and MRI investigations. The neurophysiological investigation is crucial in the diagnosis of segmental zoster paresis.
Acknowledgement
The authors would like to express their gratitude to the patient and the entire team of the Department of Neurology, Faculty of Medicine, Universitas Udayana in Bali, Indonesia, for their assistance in preparing this report.
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