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Case Report

Herpes zoster internuclear ophthalmoplegia

Vijayashankar Paramanandam, Sowmini Perumal, Malcolm Jeyaraj, Sakthi Velayutham, Gobinathan Shankar
Department of Neurology, Stanley Medical College & Hospital, Chennai 600001, Tamilnadu, India.

A B S T R AC T
Internuclear ophthalmoplegia (INO) is caused by a lesion in the medial longitudinal fasciculus. Patients with INO are usually
asymptomatic but may have diplopia and oscillopsia. The most common causes of INO are ischemia and demyelination. Occurrence
of INO due to infectious etiologies like tuberculosis, AIDS, brucellosis, cysticercosis and syphilis is well known. However, clinical
presentation of INO associated with herpes zoster is very rare. The possible pathogenic mechanism for varicella zoster virus
(VZV) induced INO could be demyelination or microinfarction in the brainstem. In the present study, a case of 56 years old male
with double vision, with a recent history of herpes zoster, has been reported. Clinical examination revealed right INO. VZV IgM
antibodies were positive and patient recovered fully after treatment with acyclovir and steroids.

Key words: Demyelination; herpes zoster virus; internuclear ophthalmoplegia; medial longitudinal fasciculus; varicella zoster virus

INTRODUCTION gaze was admitted. The diplopia worsened while looking
at the distant objects. Occular examination revealed
In Internuclear ophthalmoplegia (INO) there is damage that he had right INO showing restriction of adduction
to the medial longitudinal fasciculus (MLF) between in the right eye with nystagmus on abduction in the left
the 3rd and 6th cranial nerve nuclei which impairs the eye. His vertical eye movements and convergence were
transmission of neural impulses to the ipsilateral medial normal. Pupil and fundus examination were normal.
rectus muscle. It is clinically characterized by failure to Rest of the neurological examination was also normal.
[1]
adduct the ipsilateral medial rectus and nystagmus of the Neck stiffness was not present. He had no fever. Healed
abducting eye. Tuberculosis, brucellosis, cysticercosis, herpetic scars were present in the left maxillary region.
syphilis and multiple sclerosis are the common
infectious diseases which are responsible to cause INO Two weeks before the onset of diplopia he was diagnosed
in a patient. Herpes zoster is a relatively rare etiology with herpes zoster and was under treatment with oral
[2]
of INO. To the best of our knowledge, only two studies acyclovir. He did not have any other co-morbid illness. A
focusing on the association between herpes zoster and previous history of chicken pox infection at the age of 10
INO have been published so far. In agreement to the years was reported.
previous publications; we report here the case of a patient
with INO, who also had herpes zoster vasculopathy. The Routine blood examination including complete blood
goal of this report is to highlight the rare case of herpes count, renal function test and electrolytes were normal.
zoster leading to INO. Chest x-ray and electrocardiogram were also normal.
Magnetic resonance images (MRI) scans of the brain with
CASE REPORT contrast revealed no abnormality. Cerebro-spinal fluid
analysis showed pleocytosis and elevated protein with
A 56 years old male presented with diplopia in the left normal sugar level. Serum Varicella zoster IgM antibody
was positive.
Corresponding Author: Dr. Vijayashankar Paramanandam,
Department of Neurology, Stanley Medical College, Old jail The patient was treated with intravenous (IV) acyclovir
road, Chennai 600001, Tamilnadu, India.
E-mail: drvijayashankar@gmail.com
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How to cite this article: Paramanandam V, Perumal S, Jeyaraj M,
Velayutham S, Shankar G. Herpes zoster internuclear ophthalmoplegia.
DOI:
10.20517/2347-8659.2015.41 Neuroimmunol Neuroinflammation 2016;3:102-3.
Received: 29-09-2015; Accepted: 20-12-2015

102 © 2016 Neuroimmunology and Neuroinflammation | Published by OAE Publishing Inc.