CASE DESCRIPTION:
A 46-year-old previously healthy woman was admitted to the emergency department complaining of mouth drooping and vertigo since that morning. She also had a headache and pain on the right ear since the night before. She denied fever, hearing loss, hyperacusia, tinnitus, nausea or vomiting.
On physical examination, she was alert and oriented, with a Glasgow Coma Scale score of 15, without focal neurologic deficits except for right peripheral facial palsy [Figure 1]. Gait was not tested because of her vertigo but she had no dysmetria on finger-to-nose and heel-to-knee tests. She was hemodynamically stable and afebrile with no meningeal signs. She had no visible vesicular eruptions nor any abnormalities on otoscopy.
Lab work [Table 1] showed a total leukocyte count of 12.270/uL (normal range 4.000-12.000/uL). Other than that, blood routine examination was normal, including a low level of C-reactive protein (4mg/L, normal range <5mg/L).
Contrast-enhanced head CT scan [Figure 2] showed no signs of acute vascular, hemorrhagic or edematous events and documented normal permeability of deep and superficial venous system.
Because of persistent headache, she underwent a lumbar puncture with drainage of clear CSF. CSF analysis showed normal glycorrhachia, no pleocytosis and slight proteinorrhachia (84 mg/dL, normal range 15-60mg/dL). Screening for varicella zoster DNA on CSF by polymerase chain reaction was positive.
A clinical diagnosis of Ramsay-Hunt syndrome was established. The patient was started on acyclovir 10 mg/kg every 8 hours for 14 days, prednisolone 1mg/kg for 5 days, humidifying eye drops and right eye protection. Physiotherapy for the face was initiated and the patient slowly improved, maintaining at the time of discharge a class III palsy on the House-Brackmann Facial Nerve Grading System.