Neurological Complications of Herpes Zoster

  • Maija HaanpääEmail author


Varicella zoster virus (VZV) reactivation results in zoster, which may be complicated by postherpetic neuralgia. Other, less frequent complications are cranial nerve palsies, zoster paresis, meningoencephalitis, myelitis, and varicella zoster vasculopathy. All these neurological disorders produced by VZV reactivation can occur in the absence of rash. They are caused mainly by the direct spread of the virus. The risk of neurological complications is increased in immunocompromised patients, who are also likely to have more severe forms of central nervous system complications. To confirm VZV as the cause of the condition, detection of anti-VZV IgG antibody in cerebrospinal fluid with intrathecal synthesis and detection of VZV DNA in cerebrospinal fluid are used. For those diseases in which viral replication likely plays an important role in pathogenesis (e.g., meningitis, encephalitis, and myelitis and VZV vasculopathy), therapy with intravenous acyclovir is recommended. Outcome of the central nervous system complications varies from full recovery to death, being worse in immunocompromised. Most patients with segmental zoster paresis or cranial nerve involvement show good or complete recovery.


  1. 1.
    Adour KK (1994) Otological complications of herpes zoster. Ann Neurol 35:S62–S64CrossRefPubMedGoogle Scholar
  2. 2.
    Amlie-Lefond C, Mackin GA, Ferguson M, Wright RR, Mahalingham R, Gilden DH (1996) Another case of virologically confirmed zoster sine herpete, with electrophysiologic correlation. J Neurovirol 2:136–138CrossRefPubMedGoogle Scholar
  3. 3.
    Appelbaum E, Kreps SI, Sunshine A (1962) Herpes zoster encephalitis. Am J Med 32:25–31CrossRefPubMedGoogle Scholar
  4. 4.
    Aviel A, Marshak G (1982) Ramsay Hunt syndrome: a cranial polyneuropathy. Am J Otolaryngol 3:61–63CrossRefPubMedGoogle Scholar
  5. 5.
    Barrett AP, Katelaris CH, Morris JGL, Schifter M (1993) Zoster sine herpete of the trigeminal nerve. Oral Surg Oral Med Oral Pathol 75:173–175CrossRefPubMedGoogle Scholar
  6. 6.
    Broadbent WH (1866) Case of herpetic eruption in the course of branches of the brachial plexus, followed by partial paralysis in corresponding motor nerves. BMJ 2:460CrossRefGoogle Scholar
  7. 7.
    Chernev I, Dado D (2013) Segmental zoster abdominal paresis (zoster pseudohernia): a review of the literature. PM R 5:786–790CrossRefPubMedGoogle Scholar
  8. 8.
    Cioni R, Giannini F, Passero C, Paradiso C, Rossi S, Fimiani M, Battistini N (1994) An electromyographic evaluation of motor complications in thoracic herpes zoster. Electromyogr Clin Neurophysiol 34:125–128PubMedGoogle Scholar
  9. 9.
    Dayan AD, Ogul E, Graveson GS (1972) Polyneuritis and herpes zoster. J Neurol Neurosurg Psychiatry 35:170–175CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    de Ru JA, van Benthem PP (2011) Combination therapy is preferable for patients with Ramsay Hunt syndrome. Otol Neurotol 32:852–855CrossRefPubMedGoogle Scholar
  11. 11.
    Denny-Brown D, Adams RD, Fitzgerald PJ (1944) Pathologic features of herpes zoster. A note on geniculate herpes. Arch Neurol Psychiatry 51:216–231CrossRefGoogle Scholar
  12. 12.
    Derveaux L, Lacquet LM (1982) Hemidiaphragmatic paresis after herpes zoster. Thorax 37:870–871CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Devinsky O, Cho ES, Petito CK, Price RW (1991) Herpes zoster myelitis. Brain 114:1181–1196CrossRefPubMedGoogle Scholar
  14. 14.
    Devlin ME, Gliden DH, Mahalingham R, Dueland AN, Cohrs R (1992) Peripheral blood mononuclear cells of the elderly contain varicella-zoster virus DNA. J Infect Dis 165:619–622CrossRefPubMedGoogle Scholar
  15. 15.
    Doyle PW, Gibson G, Dolman CL (1983) Herpes zoster ophthalmicus with contralateral hemiplegia: identification of cause. Ann Neurol 14:84–85PubMedGoogle Scholar
  16. 16.
    Easton HG (1970) Zoster sine herpete causing acute trigeminal neuralgia. Lancet 2:1065–1066CrossRefPubMedGoogle Scholar
  17. 17.
    Echevarria JM, Casas I, Martinez-Martin P (1997) Infections of the nervous system caused by varicella-zoster virus: a review. Intervirology 40:72–84CrossRefPubMedGoogle Scholar
  18. 18.
    Edgerton AE (1945) Herpes zoster ophthalmicus (Part II). Arch Ophthalmol 34:114–153CrossRefGoogle Scholar
  19. 19.
    Esposito MB, Arrington JA, Murtaugh FR, Coleman JM, Sergay SM (1993) MRI of the spinal cord in a patient with herpes zoster. AJNR Am J Neuroradiol 14:203–204PubMedGoogle Scholar
  20. 20.
    Fabian VA, Wood B, Crowley B, Kakulas BA (1997) Herpes zoster brachial neuritis. Clin Neuropathol 16:61–64PubMedGoogle Scholar
  21. 21.
    Fox RJ, Galetta SL, Mahalingam R, Wellish M, Forghani B, Gilden DH (2001) Acute, chronic, and recurrent varicella zoster virus neuropathy without zoster rash. Neurology 57:351–354CrossRefPubMedGoogle Scholar
  22. 22.
    Friedman DP (1992) Herpes zoster myelitis: MR appearance. AJNR Am J Neuroradiol 13:1404–1406PubMedGoogle Scholar
  23. 23.
    Fukumoto S, Kinjo M, Hokamura K, Tanaka K (1986) Subarachnoidal hemorrhage and granulomatous angiitis of the basilar artery: demonstration of the varicella-zoster-virus in the basilar artery lesions. Stroke 17:1024–1028CrossRefPubMedGoogle Scholar
  24. 24.
    Galil K, Choo PW, Donahue DVM, Platt R (1997) The sequelae of herpes zoster. Arch Intern Med 157:1209–1213CrossRefPubMedGoogle Scholar
  25. 25.
    Gardner-Thorpe C, Foster JB, Barwick DD (1976) Unusual manifestations of herpes zoster. J Neurol Sci 28:427–447CrossRefPubMedGoogle Scholar
  26. 26.
    Geny C, Yulis J, Azoulay A, Brugiers P, Saint-Val C, Degos JD (1991) Thalamic infarctation following lingual herpes zoster. Neurology 41:1846CrossRefPubMedGoogle Scholar
  27. 27.
    Gershorn A, Steinberg S, Borkowsky E, Lennette D, Lennette E (1982) IgM to varicella-zoster virus: demonstration in patients with and without clinical zoster. Pediatr Infect Dis 1:164–167CrossRefGoogle Scholar
  28. 28.
    Gilden DH, Wright RR, Schneck SA, Gwaltney JM, Mahalingham R (1994) Zoster sine herpete, a clinical variant. Ann Neurol 35:530–533CrossRefPubMedGoogle Scholar
  29. 29.
    Gilden DH, Kleinschmidt-De-Masters BK, LaGuardia JJ, Mahalingham R, Cohrs RJ (2000) Neurologic complications of the reactivation of varicella-zoster virus. N Engl J Med 342:635–645CrossRefPubMedGoogle Scholar
  30. 30.
    Gilden D, Cohrs RJ, Mahalingam R, Nagel MA (2009) Varicella zoster virus vasculopathies: diverse clinical manifestations, laboratory features, pathogenesis, and treatment. Lancet Neurol 8:731–740CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Golden LI, Deeb ZE, deFries H (1990) Atypical findings in cephalic herpes zoster polyneuritis: case reports and radiographic findings. Laryngoscope 100:494–497CrossRefPubMedGoogle Scholar
  32. 32.
    Gondivkar S, Parikh V, Parikh R (2010) Herpes zoster oticus: a rare clinical entity. Contemp Clin Dent 1:127–129CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Greenberg MK, McVey AL, Hayes T (1992) Segmental motor involvement in herpes zoster: an EMG Study. Neurology 42:1122–1123CrossRefPubMedGoogle Scholar
  34. 34.
    Haanpää M, Häkkinen V, Nurmikko T (1997) Motor involvement in acute herpes zoster. Muscle Nerve 20:1433–1438CrossRefPubMedGoogle Scholar
  35. 35.
    Haanpää M, Dastidar P, Weinberg A, Levin M, Miettinen A, Lapinlampi A, Laippala P, Nurmikko T (1998) Cerebrospinal fluid and magnetic resonance imaging findings in patients with acute herpes zoster. Neurology 51:1405–1411CrossRefPubMedGoogle Scholar
  36. 36.
    Haanpää M, Laippala P, Nurmikko T (1999a) Pain and somatosensory dysfunction in acute herpes zoster. Clin J Pain 15:78–84CrossRefPubMedGoogle Scholar
  37. 37.
    Haanpää M, Laippala P, Nurmikko T (1999b) Thermal and tactile perception thresholds in patients with herpes zoster. Eur J Pain 3:375–386CrossRefPubMedGoogle Scholar
  38. 38.
    Haanpää M, Laippala P, Nurmikko T (2000) Allodynia and pinprick hypoaesthesia in acute herpes zoster, and the development of postherpetic neuralgia. J Pain Symptom Manage 20:50–58CrossRefPubMedGoogle Scholar
  39. 39.
    Haargaard B, Lund-Andersen H, Milea D (2008) Central nervous system involvement after herpes zoster ophthalmicus. Acta Ophthalmol 86:806–809CrossRefPubMedGoogle Scholar
  40. 40.
    Hanakawa T, Hashimoto S, Kawamura J, Nakamura M, Suenaga T, Matsuo M (1997) Magnetic resonance imaging in a patient with segmental zoster paresis. Neurology 49:631–632CrossRefPubMedGoogle Scholar
  41. 41.
    Hokkanen L, Launes J, Poutiainen E, Valanne L, Salonen O, Sirén J, Iivanainen M (1997) Subcortical type cognitive impairment in herpes zoster encephalitis. J Neurol 244:239–245CrossRefPubMedGoogle Scholar
  42. 42.
    Hu S, Walker M, Czartoski T, Cheng A, Forghani B, Gilden DH, Garden GA (2004) Acyclovir responsive brain stem disease after the Ramsay Hunt syndrome. J Neurol Sci 217:111–113CrossRefPubMedGoogle Scholar
  43. 43.
    Hung CH, Chang KH, Kuo HC, Huang CC, Liao MF, Tsai YT, Ro LS (2012) Features of varicella zoster virus myelitis and dependence on immune status. J Neurol Sci 318:19–24CrossRefPubMedGoogle Scholar
  44. 44.
    Hwang YM, Lee BI, Chung JW, Ahn JH, Kim KW, Kim DI (1991) A case of herpes zoster myelitis: positive magnetic resonance imaging finding. Eur Neurol 31:164–167CrossRefPubMedGoogle Scholar
  45. 45.
    Izzat M, Sharma PD (1992) Isolated bilateral paralysis of the soft palate in an adult. J Laryngol Otol 106:839–840CrossRefPubMedGoogle Scholar
  46. 46.
    Jellenik EH, Tulloch WS (1976) Herpes zoster with dysfunction of bladder and anus. Lancet 2:1219–1222CrossRefGoogle Scholar
  47. 47.
    Jemsek J, Greenberg SB, Taber L, Harvey D, Gershorn A, Couch RB (1983) Herpes zoster-associated encephalitis: clinicopathologic report of 12 cases and review of the literature. Medicine 62:81–97CrossRefPubMedGoogle Scholar
  48. 48.
    Kang JH, Ho JD, Chen YH, Lin HC (2009) Increased risk of stroke after a herpes zoster attack: a population-based follow-up study. Stroke 40:3443–3448CrossRefPubMedGoogle Scholar
  49. 49.
    Kawajiri S, Tani M, Noda K, Fujishima K, Hattori N, Okuma Y (2007) Segmental zoster paresis of limbs: report of three cases and review of literature. Neurologist 13:313–317CrossRefPubMedGoogle Scholar
  50. 50.
    Kleinschmidt-DeMasters BK, Gilden DH (2001) The expanding spectrum of herpesvirus infections of the nervous system. Brain Pathol 11:440–451CrossRefPubMedGoogle Scholar
  51. 51.
    Kleinschmidt-DeMasters BK, Amlie-Lefond C, Gilden DH (1996) The patterns of varicella zoster virus encephalitis. Hum Pathol 27:927–938CrossRefPubMedGoogle Scholar
  52. 52.
    Kuo MJ, Drago PC, Prooprs DW, Chavda SV (1995) Early diagnosis and treatment of Ramsay Hunt syndrome: the role of magnetic resonance imaging. J Laryngol Otol 109:777–780CrossRefPubMedGoogle Scholar
  53. 53.
    Kuroiwa Y, Furukawa T (1981) Hemispheric infarction after herpes zoster ophthalmicus: computed tomography and angiography. Neurology 31:1030–1032CrossRefPubMedGoogle Scholar
  54. 54.
    Lee CY, Tsai HC, Lee SS, Chen YS (2015) Orbital apex syndrome: an unusual complication of herpes zoster ophthalmicus. BMC Infect Dis 15:33CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Lin HC, Chien CW, Ho JD (2010) Herpes zoster ophthalmicus and the risk of stroke: a population-based follow-up study. Neurology 74:792–797CrossRefPubMedGoogle Scholar
  56. 56.
    Mainka C, Fuss B, Harmut G, Höfelmayr H, Wolff MH (1998) Characterization of viremia at different stages of varicella-zoster virus infection. J Med Virol 56:91–98CrossRefPubMedGoogle Scholar
  57. 57.
    Martin JR, Mitchell WJ, Henken DB (1990) Neurotropic herpesviruses, neural mechanism and arteritis. Brain Pathol 1:6–10CrossRefPubMedGoogle Scholar
  58. 58.
    Mayo DR, Booss J (1989) Varicella zoster-associated neurologic disease without skin lesions. Arch Neurol 46:313–315CrossRefPubMedGoogle Scholar
  59. 59.
    Mazur DH, Dolin R (1978) Herpes zoster at the NIH: a 20 year experience. Am J Med 65:738–744CrossRefPubMedGoogle Scholar
  60. 60.
    McKendrick MW, Care CC, Kudesia G, Bates CJ, Oxley MK, Eley A (1999) Is VZV reactivation a common cause of unexplained unilateral pain? Results of a prospective study of 57 patients. J Infect 39:209–212CrossRefPubMedGoogle Scholar
  61. 61.
    Merchut MP, Gruener G (1996) Segmental zoster paresis of limbs. Electromyogr Clin Neurophysiol 36:369–375PubMedGoogle Scholar
  62. 62.
    Mizock BA, Bartt R, Agbemazdo B (2000) Herpes zoster oticus with pontine lesion: segmental brain-stem encephalitis. Clin Infect Dis 30:229–231CrossRefPubMedGoogle Scholar
  63. 63.
    Mondelli M, Scarpini C, Malandrini A, Romano C (1997) Painful polyneuropathy after diffuse herpes zoster. Muscle Nerve 20:229–231CrossRefPubMedGoogle Scholar
  64. 64.
    Murakami S, Honda N, Mizobuchi M, Nakashiro Y, Hato N, Gyo K (1998a) Rapid diagnosis of varicella zoster virus infection in acute facial palsy. Neurology 51:1202–1205CrossRefPubMedGoogle Scholar
  65. 65.
    Murakami S, Nakashiro Y, Mizobuchi M, Hato N, Honda N, Gyo K (1998b) Varicella-zoster virus distribution in Ramsay Hunt syndrome revealed by polymerase chain reaction. Acta Otolaryngol (Stockh) 118:145–149CrossRefGoogle Scholar
  66. 66.
    Mustonen K, Mustakangas P, Smeds M, Mannonen L, Uotila L, Vaheri A, Koskiniemi M (1998) Antibodies to varicella zoster virus in the cerebrospinal fluid of neonates with seizures. Arch Dis Child Fetal Neonatal Ed 78:F57–F61CrossRefPubMedPubMedCentralGoogle Scholar
  67. 67.
    Nagel MA, Gilden D (2014) Neurological complications of varicella zoster virus reactivation. Curr Opin Neurol 27:356–360CrossRefPubMedPubMedCentralGoogle Scholar
  68. 68.
    Nagel MA, Cohrs RJ, Mahalingam R, Wellish MC, Forghani B, Schiller A, Safdieh JE, Kamenkovich E, Ostrow LW, Levy M, Greenberg B, Russman AN, Katzan I, Gardner CJ, Häusler M, Nau R, Saraya T, Wada H, Goto H, de Martino M, Ueno M, Brown WD, Terborg C, Gilden DH (2008) The varicella zoster virus vasculopathies: clinical, CSF, imaging, and virologic features. Neurology 70:853–860CrossRefPubMedPubMedCentralGoogle Scholar
  69. 69.
    Nagel MA, Traktinskiy I, Azarkh Y, Kleinschmidt-DeMasters B, Hedley-Whyte T, Russman A, Van Egmond EM, Stenmark K, Frid M, Mahalingam R, Wellish M, Choe A, Cordery-Cotter R, Cohrs RJ, Gilden D (2011) Varicella zoster virus vasculopathy: analysis of virus-infected arteries. Neurology 77:364–370CrossRefPubMedPubMedCentralGoogle Scholar
  70. 70.
    Nagel MA, Bennett JL, Khmeleva N, Choe A, Rempel A, Boyer PJ, Gilden D (2013) Multifocal VZV vasculopathy with temporal artery infection mimics giant cell arteritis. Neurology 80:2017–2021CrossRefPubMedPubMedCentralGoogle Scholar
  71. 71.
    Nau R, Lantsch M, Stiefel M, Polak T, Reiber H (1998) Varicella zoster virus-associated focal vasculitis without herpes zoster: recovery after treatment with acyclovir. Neurology 51:914–915CrossRefPubMedGoogle Scholar
  72. 72.
    Orme HT, Smith AG, Nagel MA, Bert RJ, Mickelson TS, Gilden DH (2007) VZV spinal cord infarction identified by diffusion-weighted MRI (DWI). Neurology 69:398–400CrossRefPubMedGoogle Scholar
  73. 73.
    Ormerod IEC, Cockerell OC (1993) Guillain-Barré syndrome after herpes zoster infection: a report of 2 cases. Eur Neurol 33:156–158CrossRefPubMedGoogle Scholar
  74. 74.
    Osaki Y, Matsubayashi K, Okumiya K, Wada T, Doi Y (1995) Polyneuritis cranialis due to varicella-zoster virus in the absence of rash. Neurology 45:2293CrossRefPubMedGoogle Scholar
  75. 75.
    Osumi A, Tien RD (1990) MR findings in a patient with Ramsay Hunt syndrome. J Comput Assist Tomogr 14:901–903CrossRefGoogle Scholar
  76. 76.
    Payten RJ, Dawes DK (1972) Herpes zoster of the head and neck. J Laryngol Otol 86:1031–1055CrossRefPubMedGoogle Scholar
  77. 77.
    Peterslund NA, Hansen JA (1989) Electroencephalographic changes in patients with herpes zoster. Acta Neurol Scand 79:407–411CrossRefPubMedGoogle Scholar
  78. 78.
    Powell KF, Wilson HG, Croxson MC, Marshall MR, Wong EH, Anderson NE, Thomas MG (1995) Herpes zoster meningoencephalitis without rash: varicella zoster virus DNA in CSF. J Neurol Neurosurg Psychiatry 59:198–199CrossRefPubMedPubMedCentralGoogle Scholar
  79. 79.
    Ragozzino MW, Melton LJ, Kurland LT, Chu CP, Perry HO (1982) Population-based study on herpes zoster and its sequelae. Medicine 61:310–316CrossRefGoogle Scholar
  80. 80.
    Reda H, Watson JC, Jones LK Jr (2012) Zoster-associated mononeuropathies (ZAMs): a retrospective series. Muscle Nerve 45:734–739CrossRefPubMedGoogle Scholar
  81. 81.
    Reske-Nielsen E, Oster S, Pedersen B (1986) Herpes zoster ophthalmicus and the mesencephalic nucleus. Acta Pathol Microbiol Immunol Scand 94:263–269Google Scholar
  82. 82.
    Robillard RB, Hilsinger AL Jr, Adour KK (1986) Ramsay Hunt facial paralysis: clinical analysis of 185 patients. Otolaryngol Head Neck Surg 95:292–297CrossRefPubMedGoogle Scholar
  83. 83.
    Ross MH, Abend WK, Schwartz RB, Samuels MA (1991) A case of C2 herpes zoster with delayed bilateral pontine infarction. Neurology 41:1685–1686CrossRefPubMedGoogle Scholar
  84. 84.
    Rothschild MA, Drake W III, Scherl M (1994) Cephalic zoster with laryngeal paralysis. ENT J 73:850–852Google Scholar
  85. 85.
    Ruppenthal M (1980) Changes of the central nervous system in herpes zoster. Acta Neuropathol (Berl) 52:59–68CrossRefGoogle Scholar
  86. 86.
    Sarazin L, Duong H, Bourgouin PM, Melanson M, Chalk C, Richardson J, Vézina JL (1995) Herpes zoster vasculitis: demonstration by MR angiography. J Comput Assist Tomogr 19:624–627CrossRefPubMedGoogle Scholar
  87. 87.
    Sartoretti-Schefer S, Kollias S, Valavanis A (1999) Ramsay Hunt syndrome associated with brain stem enhancement. Am J Neuroradiol 20:278–280PubMedGoogle Scholar
  88. 88.
    Schmidbauer M, Budka H, Pilz P, Kurata T, Hondo R (1992) Presence, distribution and spread of productive varicella zoster virus infection in nervous tissue. Brain 115:383–398CrossRefPubMedGoogle Scholar
  89. 89.
    Silver B, Nagel MA, Mahalingam R, Cohrs R, Schmid DS, Gilden D (2012) Varicella zoster virus vasculopathy: a treatable form of rapidly progressive multi-infarct dementia after 2 years’ duration. J Neurol Sci 323:245–247CrossRefPubMedPubMedCentralGoogle Scholar
  90. 90.
    Thomas JE, Howard FM (1972) Segmental zoster paresis – a disease profile. Neurology 22:459–466CrossRefPubMedGoogle Scholar
  91. 91.
    Tien RD, Felsberg GJ, Osumi AK (1993) Herpesvirus infections of the CNS: MR findings. AJR Am J Roentgenol 161:167–176CrossRefPubMedGoogle Scholar
  92. 92.
    Wackym PA (1997) Molecular temporal bone pathology: II. Ramsay Hunt syndrome (herpes zoster oticus). Laryngoscope 107:1165–1175CrossRefPubMedGoogle Scholar
  93. 93.
    Watson CPN, Deck HJ, Morshead C, Van der Kooy D, Evans RJ (1991) Post-herpetic neuralgia: further post-mortem studies of cases with and without pain. Pain 44:105–117CrossRefGoogle Scholar
  94. 94.
    Weitzman D, Shavit O, Stein M, Cohen R, Chodick G, Shalev V (2013) A population based study of the epidemiology of herpes zoster and its complications. J Infect 67:463–469CrossRefPubMedGoogle Scholar
  95. 95.
    Worme M, Chada R, Lavallee L (2013) An unexpected case of Ramsay Hunt syndrome: case report and literature review. BMC Res Notes 6:337CrossRefPubMedPubMedCentralGoogle Scholar
  96. 96.
    Xiao Z, Lu Z, Pan S, Liang J, Liu Z (2015) Orbital apex syndrome and meningoencephalitis: a rare complication of herpes zoster. Int J Clin Exp Med 8:14260–14263PubMedPubMedCentralGoogle Scholar
  97. 97.
    Yoshida T, Fujisaki N, Nakachi R, Sueyoshi T, Suwazono S, Suehara M (2014) Persistent hiccups and vomiting with multiple cranial nerve palsy in a case of zoster sine herpete. Intern Med 53:2373–2376CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  1. 1.Department of NeurosurgeryHelsinki University HospitalHelsinkiFinland
  2. 2.Mutual Insurance Company EteraHelsinkiFinland

Personalised recommendations