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Ramsay Hunt syndrome following COVID-19 vaccination

January 2022
Postgraduate Medical Journal 98(1164):postgradmedj-2021-141022

DOI:10.1136/postgradmedj-2021-141022

Authors:

The University of Hong Kong

The COVID-19 pandemic has caused profound social and economic upheaval. COVID-19 vaccines promise to prevent infection of the SARS-CoV-2 virus. However, due to their expedited approval, these vaccines need to be vigilantly monitored for their safety. Cases of Bell's palsy have also been reported after COVID-19 vaccine injection. In two phase III trials of COVID-19 vaccines involving around 38 000 patients, there were seven cases of Bell's palsy after vaccine compared with one case after receiving placebo.¹,² As the p value was 0.07 and this was a post hoc analysis, no definite association could be inferred. We recently diagnosed Ramsay Hunt syndrome (RHS) in a 37-year-old previously healthy man. Two days after his first dose of the Pfizer-BioNTech (BNT162b2) vaccine, he noticed fever and a pain in the right ear. Vesicles were then developed in his right ear and canal, together with vertigo, tinnitus and loss of hearing. He complained of facial palsy, tongue numbness and dysgeusia. On examination, he had grade 4 right facial nerve palsy of the lower motor neuron type with right sensorineural hearing loss (figure 1A). There were no other neurological deficits. Vesicles with serous discharge were found over the right concha and external auditory canal (figure 1B). A swab of the exudate was positive for varicella-zoster DNA on PCR, while throat saliva was negative for SARS-COV-2. A CT scan of the brain was normal. The diagnosis was RHS leading to peripheral facial nerve palsy, vestibulocochlear neuropathy and glossopharyngeal somatic sensory neuropathy. As his symptoms developed 2 days after vaccination, we suspected the vaccination triggered RHS. This would be the first reported case of RHS after COVID-19 vaccination.

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1Woo CJ, etal. Postgrad Med J 2022;0:1–2. doi:10.1136/postgradmedj-2021-141022

Adverse drug reactions

Ramsay Hunt syndrome following

COVID- 19vaccination

Chariene Jane Woo,1 Oscar Hou In Chou ,1 Bernard Man Yung Cheung 1,2,3

To cite: Woo CJ, Chou OHI,

Cheung BMY. Postgrad Med J

Epub ahead of print: [please

include Day Month Year].

doi:10.1136/

postgradmedj-2021-141022

1Department of Medicine, The

University of Hong Kong, Hong

Kong, People’s Republic of

China

2State Key Laboratory of

Pharmaceutical Biotechnology,

The University of Hong Kong,

Hong Kong, People’s Republic

of China

3Institute of Cardiovascular

Science and Medicine, The

University of Hong Kong, Hong

Kong, People’s Republic of

China

Correspondence to

Professor Bernard Man Yung

Cheung, Department of

Medicine, Li Ka Shing Faculty

of Medicine, The University

of Hong Kong, Hong Kong,

People’s Republic of China;

mycheung@ hku. hk

Received 15 August 2021

Accepted 24 December 2021

employer(s)) 2021. No

commercial re- use. See rights

and permissions. Published

by BMJ.

The COVID- 19 pandemic has caused profound

social and economic upheaval. COVID- 19

vaccines promise to prevent infection of the

SARS- CoV- 2 virus. However, due to their expe-

dited approval, these vaccines need to be vigi-

lantly monitored for their safety. Cases of Bell’s

palsy have also been reported after COVID- 19

vaccine injection. In two phase III trials of

COVID- 19 vaccines involving around 38 000

patients, there were seven cases of Bell’s palsy

after vaccine compared with one case after

receiving placebo.1 2 As the p value was 0.07 and

this was a post hoc analysis, no definite associa-

tion could be inferred.

We recently diagnosed Ramsay Hunt syndrome

(RHS) in a 37- year- old previously healthy man.

Two days after his first dose of the Pfizer-

BioNTech (BNT162b2) vaccine, he noticed fever

and a pain in the right ear. Vesicles were then

developed in his right ear and canal, together

with vertigo, tinnitus and loss of hearing. He

complained of facial palsy, tongue numbness

and dysgeusia. On examination, he had grade

4 right facial nerve palsy of the lower motor

neuron type with right sensorineural hearing

loss (figure 1A). There were no other neurolog-

ical deficits. Vesicles with serous discharge were

found over the right concha and external audi-

tory canal (figure 1B). A swab of the exudate

was positive for varicella- zoster DNA on PCR,

while throat saliva was negative for SARS-

COV- 2. A CT scan of the brain was normal. The

diagnosis was RHS leading to peripheral facial

nerve palsy, vestibulocochlear neuropathy and

glossopharyngeal somatic sensory neuropathy.

As his symptoms developed 2 days after vacci-

nation, we suspected the vaccination triggered

RHS. This would be the first reported case of

RHS after COVID- 19 vaccination.

Bell’s palsy is the most common cause of an

acute onset peripheral facial palsy. Some cases

were attributed to the reactivation of herpes-

simplex virus (HSV) and varicella- zoster virus

(VZV). The former is always underdiagnosed.

However, the blisters of herpes zoster (HZ)

allow a diagnosis to be made clinically. Reactiva-

tion of the VZV at the facial nerve leads to RHS

type 2 (herpes- zoster oticus). However, there

are also cases where RHS may manifest without

the skin lesions such that it cannot be differenti-

ated from Bell’s palsy without PCR or antibody

titre testing.3

HZ is associated with COVID- 19 vaccination.

The US Vaccine Adverse Event Reporting System

(VAERS) reported 232 HZ- related adverse

events among COVID- 19 vaccines among 1653

reports of vaccine- related complications since

July 1990. All reported cases so far affected

other dermatomes.4 VZV- specific CD8 cells may

be temporarily incapable of controlling the VZV

after the massive shift of naive CD8+ cells to

produce vaccine- targeting CD8+ cells.4 The

vaccine may also dampen the innate immunity

responsible for controlling VZV.5 Therefore,

vaccine- related immunomodulation may be

responsible for the RHS after vaccination.

RHS is rare for patients under 60 years old

with no previous history of HZ. Therefore,

COVID- 19 vaccination was likely to be the

stress causing reactivation of VZV. What we

have described is rare, and may be the missing

link between COVID- 19 vaccination and Bell’s

palsy, providing a plausible explanation for the

facial palsy.

Contributors CJW: data collection, ﬁgures, data analysis and

interpretation, manuscript drafting, critical revision of manuscript.

OHIC: data analysis and interpretation, literature review, manuscript

drafting, critical revision of manuscript. BC: study conception,

study supervision, project planning, data interpretation, manuscript

drafting, critical revision of manuscript.

Funding The authors have not declared a speciﬁc grant for this

research from any funding agency in the public, commercial or

not- for- proﬁt sectors.

Competing interests The authors declare no conﬂict of interest.

No funding was received to assist with the preparation of this

manuscript. OHIC was supported by the University of Hong Kong

Summer Research Programme.

Patient consent for publication Obtained.

Ethics approval This study involves human participants, but

this is a case report study that is exempted gaining approval from

the ethics committee(s) or institutional board(s). Participant gave

informed consent to participate in the study before taking part.

Figure 1 37- year- old male patient presented with

symptoms of Ramsay Hunt Syndrome type 2.

on January 6, 2022 by guest. Protected by copyright.http://pmj.bmj.com/Postgrad Med J: first published as 10.1136/postgradmedj-2021-141022 on 5 January 2022. Downloaded from

2Woo CJ, etal. Postgrad Med J 2022;0:1–2. doi:10.1136/postgradmedj-2021-141022

Adverse drug reactions

Provenance and peer review Not commissioned; internally peer reviewed.

Open access This article is made freely available for use in accordance with BMJ’s

website terms and conditions for the duration of the covid- 19 pandemic or until

otherwise determined by BMJ. You may use, download and print the article for any

lawful, non- commercial purpose (including text and data mining) provided that all

ORCID iDs

Oscar Hou InChou http://orcid.org/0000-0001-7058-4708

Bernard Man YungCheung http://orcid.org/0000-0001-9106-7363

REFERENCES

1 Polack FP, Thomas SJ, Kitchin N, etal. Safety and efﬁcacy of the BNT162b2 mRNA

Covid- 19 vaccine. N Engl J Med 2020;383:2603–15.

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Ramsay Hunt Syndrome in Asymptomatic COVID-19 Infection: A Case Report and a Literature Review

Article

Full-text available

Nov 2023

Abstract: (1) Background: COVID-19 infection has affected almost 6 million people worldwide. Geniculate Ganglion Zoster resulting in Ramsay Hunt Syndrome (RHS) has been rarely described in this context. (2) Methods: Here, a case of RHS in the context of asymptomatic COVID-19 infection is reported followed by a literature review of the previously published cases (PubMed research combining "COVID-19" and "Ramsay Hunt Syndrome" or their abbreviations/synonyms, searching for data published at any time till October 2023). (3) Results: Five cases have been previously published (age range: 25-67 years; n = 3 males). Three patients were known to be immunocompetent prior to infection, one was receiving corticotherapy for lung disease, and one had an unspecified immune status. RHS predominantly involved both facial and vestibulocochlear nerves, with one case exclusively involving the facial nerve as the presented case. Regarding facial nerve palsy, three were right-sided (like the current report) and two were left-sided. Two cases were asymptomatic to COVID-19 (like the present patient), one had mild fatigue, and two had classical COVID-19 symptoms preceding RHS symptoms. Workup included serological testing against Varicella Zoster Virus and PCR assays that can detect the viral DNA in saliva, blood, tears, exudates, and cerebrospinal fluid. The treatment combined antiviral and corticosteroid therapies which yielded heterogeneous outcomes that might be related to some demographic and clinical data. (4) Conclusions: RHS rarely occurs in the context of COVID-19. Early recognition is important. Management seems to be similar to the classical condition. Some data may help predict facial nerve recovery.

Varicella-zoster virus reactivation following covid-19 vaccination: A Tunisian case series

Article

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Mar 2023

In this study, we aimed to present and analyze the characteristics of VZV reactivation cases after COVID-19 vaccination

Varicella-Zoster Virus reactivation following COVID-19 vaccination: A Tunisian case series

Preprint

Mar 2023

Introduction: Reactivation of varicella-zoster virus (VZV) most commonly manifests as shingles. A few months after the start of the COVID-19 vaccination campaign cases of shingles were reported. Objective: We aimed to report cases of VZV reactivation reported after COVID-19 vaccination to the Tunisian National Centre of pharmacovigilance (NCPV). Method: This is a retrospective study of cases of VZV reactivation reported to the CNPV after COVID-19 vaccination from March 2021 to May 2022. Results: We included 20 patients with shingle. The sex ratio (M/F) was 0.8. The median age was 68.5 years. Nine patients were over 70 years of age. The administered vaccines were an mRNA vaccine for 15 patients. The onset delay ranged between one and 30 days (mean of 4.5 days). All patients recovered within a few days and no severe cases have been reported. Two patients received the second dose; One patient did not experience a recurrence of the symptomatology. The other patient, had aggravation of symptomatology and occurrence of facial paralysis; noting that the initial symptomatology did not entirely disappear when the patient received the second dose. The patient was diagnosed with Ramsay Hunt Syndrome. Conclusion: Our study draws attention to the chronological association between SARS-CoV-2 vaccine and VZV reactivation, which should be investigated.

Ramsay-hunt-syndrome associated with unilateral parotitis following COVID-19 vaccine: a case report

Article

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Apr 2025
Eur Arch Oto Rhino Laryngol

Background Varicella-zoster-virus (VZV) reactivation is a recognized complication following COVID-19 vaccination; however, Ramsay-hunt-syndrome (RHS) rarely has been reported. Case presentation This case presents a 36-year-old immunocompetent man with features of RHS three weeks following the second dose of the BBIBP-CorV (Sinopharm) vaccine. Interestingly, he developed acute unilateral parotitis on his left side and the ultrasonography showed a 55*44*18 mm parotid gland with decreased parenchymal echogenicity. He was treated with valacyclovir, and after seven days he was discharged. Also, his parotitis was resolved by day 29 following the presentation of the first symptoms with no further complications. Conclusion The possibility of VZV reactivation after COVID-19 vaccination is an important point and it should be noted that this reactivation might present in unusual clinical scenarios.

Pathophysiology of oral lesions subsequent to SARS-CoV-2 vaccination: A systematic review

Article

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J Oral Maxillofac Pathol

Amidst worldwide reports of adverse oral lesions subsequent to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination, the current systematic review planned to determine the prevalence of adverse oral events in adult individuals (≥18 years) after SARS-CoV-2 vaccination, emphasizing upon the type and dose of vaccine, time of onset, and underlying pathophysiology. The registered protocol (PROSPERO CRD42023421307), conforming with PRISMA guidelines, included an all-inclusive literature search through online databases, consisting of Scopus, PubMed/MEDLINE, Web of Science, Lilacs, Livivo, and PROSPERO, completed on 2 May 2023, followed by assessment of risk of bias by Joana Briggs Institute Evaluation Checklist. Due to the paucity of literature, case reports and case series were included. Self-reported lesions were excluded. Qualitative synthesis employing Microsoft Excel software 2019 revealed low prevalence (43 subjects) from 26 case reports and two case series. There were multiple erosive oral ulcers on gingiva, palate, burning pain in the mouth, xerostomia, tongue fissuring and glossitis, palatal petechiae, diffuse erythematous lesions and loss of smell (16.2%), primary herpetic gingivostomatitis (21%), oral lichen planus (16.2%), Stevens-Johnson syndrome (6.9%), Bell’s palsy in four cases where two cases were Guillain-Barré syndrome (9.3%), erythema multiforme (11.6%), pemphigus (4.6%), idiopathic thrombocytopenic purpura (6.9%), unilateral hypoglossal nerve palsy (4.6%), and trigeminal neuralgia (2.3%). Maximum cases (22 subjects) presented oral lesions after Pfizer (BNT162b2) SARS-CoV-2 vaccine. No association was found between the vaccine type and dose with oral side effects. Dentists must be aware of the oral adverse effects after coronavirus disease 2019 vaccination to better understand the pathogenesis and the risk factors associated with such reactions.

A Narrative Review of Neurological Complications of SARS-CoV-2 Vaccination

Article

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May 2024

Adverse reactions to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine depict a tropism for neural structures. This narrative review was aimed to discuss published data on the spectrum of neurological side effects of SARS-CoV-2 vaccines, which were accorded emergency use authorization. The majority of the neurological manifestations of SARS-CoV-2 vaccination are usually mild, brief, self-limiting, and easily manageable. Rarely, these side effects can be of serious nature and require hospitalization. High vigilance helps in early identification and treatment of these complications leading to good outcomes. The reported incidence of neurological complications in vaccinated population is a miniscule, and the overall benefits of the vaccine outweigh the risks of side effects. However, it is crucial to conduct larger collaborative multicenter studies to prove or reject the causal association between the SARS-CoV-2 vaccines and the postvaccination neurological side effects. Herein, we have tried to summarize the various neurological manifestations related to SARS-CoV-2 vaccines published in the literature from 2021 to mid-2023.

The Impact of the COVID-19 Pandemic on Bell’s Palsy and Ramsay-Hunt Syndrome: A Multicenter Retrospective Study

Article

Full-text available

Apr 2024

Background: This article presents a comprehensive review of data on the impact of facial palsy during the coronavirus disease 2019 (COVID-19) pandemic. The possible causes and pathophysiological mechanisms of changes in the epidemiology of facial palsy during the COVID-19 pandemic are also discussed. Methods: This multicenter retrospective cohort study included 943 patients diagnosed with Bell's palsy or Ramsay Hunt syndrome. This study compared patient demographics, comorbidities, symptoms, and treatments before the COVID-19 pandemic (from 2017 to 2019) and during the COVID-19 pandemic, from 2020 to 2022). Results: Following the COVID-19 outbreak, there has been a significant increase in the number of cases of Bell's palsy, particularly among elderly individuals with diabetes. Bell's palsy increased after the COVID-19 outbreak, rising from 75.3% in the pre-COVID-19 era to 83.6% after the COVID-19 outbreak. The complete recovery rate decreased from 88.2% to 73.9%, and the rate of recurrence increased from 2.9% to 7.5% in patients with Bell's palsy. Ramsay Hunt syndrome showed fewer changes in clinical outcomes. Conclusion: This study highlights the impact of the COVID-19 pandemic on the presentation and management of facial palsy, and suggests potential associations with COVID-19. Notably, the observed increase in Bell's palsy cases among elderly individuals with diabetes emphasizes the impact of the pandemic. Identifying the epidemiological changes in facial palsy during the COVID-19 pandemic has important implications for assessing its etiology and pathological mechanisms of facial palsy disease.

A systematic review and meta‐analysis of herpes zoster occurrence/recurrence after COVID‐19 infection and vaccination

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Apr 2024

To inform surveillance, prevention, and management strategies for the varicella zoster virus (VZV) during the COVID‐19 pandemic, this study aimed to evaluate the risk of herpes zoster (HZ) occurrence/recurrence following COVID‐19 infection and vaccination. A comprehensive search across seven databases was conducted up to January 31, 2024, to identify studies relevant to the occurrence of HZ following COVID‐19 infection and vaccination. The meta‐analysis included five studies on postinfection HZ and 13 studies on postvaccination HZ. Patients infected with COVID‐19 had a 2.16‐fold increased risk of HZ (95% confidence interval [CI]: 1.24–3.76) than uninfected individuals. However, there was no significant association between COVID‐19 vaccination and the risk of HZ compared to controls, with a relative risk (RR) of 1.08 (95% CI: 0.84–1.39). Furthermore, a descriptive analysis of 74 postinfection and 153 postvaccination HZ studies found no significant differences on gender or age (<50 and ≥50 years) following COVID‐19 infection. Notably, 44.0% of the HZ cases postinfection appeared within the first week, with 69.5% resolving within 10 days, predominantly presenting as skin lesions. In the postvaccination group, the majority (60.1%) developed HZ after the first dose and 66.7% occurred within 1 week. Moreover, 44.6% resolved within 10 days and 50.0% within a month, primarily exhibiting skin lesions and postherpetic neuralgia. The study found that COVID‐19 infection increases the risk of HZ, but the COVID‐19 vaccine does not. Further study is needed to explore the association between COVID‐19 and HZ.

Otologic disease trends in Japan post-COVID-19 outbreak: A retrospective time-series analysis

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Mar 2024

An extensive basal ganglia hemorrhage in a preexisting neonatal asphyxiated lesion after mRNA-based SARS-CoV-2 vaccination: A fatal adult case of cerebral palsy

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Reactivation of Varicella Zoster Virus after Vaccination for SARS-CoV-2

Article

Full-text available

Jun 2021

Seven immunocompetent patients aged > 50 years old presented with herpes zoster (HZ) infection in a median of 9 days (range 7–20) after vaccination against SARS-CoV-2. The occurrence of HZ within the time window 1–21 days after vaccination defined for increased risk and the reported T cell-mediated immunity involvement suggest that COVID-19 vaccination is a probable cause of HZ. These cases support the importance of continuing assessment of vaccine safety during the ongoing massive vaccination for the COVID-19 pandemic and encourage reporting and communication of any vaccination-associated adverse event.

Efficacy and Safety of the mRNA-1273 SARS-CoV-2 Vaccine

Article

Full-text available

Dec 2020

Background Vaccines are needed to prevent coronavirus disease 2019 (Covid-19) and to protect persons who are at high risk for complications. The mRNA-1273 vaccine is a lipid nanoparticle–encapsulated mRNA-based vaccine that encodes the prefusion stabilized full-length spike protein of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes Covid-19. Methods This phase 3 randomized, observer-blinded, placebo-controlled trial was conducted at 99 centers across the United States. Persons at high risk for SARS-CoV-2 infection or its complications were randomly assigned in a 1:1 ratio to receive two intramuscular injections of mRNA-1273 (100 μg) or placebo 28 days apart. The primary end point was prevention of Covid-19 illness with onset at least 14 days after the second injection in participants who had not previously been infected with SARS-CoV-2. Results Download a PDF of the Research Summary. The trial enrolled 30,420 volunteers who were randomly assigned in a 1:1 ratio to receive either vaccine or placebo (15,210 participants in each group). More than 96% of participants received both injections, and 2.2% had evidence (serologic, virologic, or both) of SARS-CoV-2 infection at baseline. Symptomatic Covid-19 illness was confirmed in 185 participants in the placebo group (56.5 per 1000 person-years; 95% confidence interval [CI], 48.7 to 65.3) and in 11 participants in the mRNA-1273 group (3.3 per 1000 person-years; 95% CI, 1.7 to 6.0); vaccine efficacy was 94.1% (95% CI, 89.3 to 96.8%; P<0.001). Efficacy was similar across key secondary analyses, including assessment 14 days after the first dose, analyses that included participants who had evidence of SARS-CoV-2 infection at baseline, and analyses in participants 65 years of age or older. Severe Covid-19 occurred in 30 participants, with one fatality; all 30 were in the placebo group. Moderate, transient reactogenicity after vaccination occurred more frequently in the mRNA-1273 group. Serious adverse events were rare, and the incidence was similar in the two groups. Conclusions The mRNA-1273 vaccine showed 94.1% efficacy at preventing Covid-19 illness, including severe disease. Aside from transient local and systemic reactions, no safety concerns were identified. (Funded by the Biomedical Advanced Research and Development Authority and the National Institute of Allergy and Infectious Diseases; COVE ClinicalTrials.gov number, NCT04470427.)

Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine

Article

Full-text available

Dec 2020

Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the resulting coronavirus disease 2019 (Covid-19) have afflicted tens of millions of people in a worldwide pandemic. Safe and effective vaccines are needed urgently. Methods Download a PDF of the Research Summary. In an ongoing multinational, placebo-controlled, observer-blinded, pivotal efficacy trial, we randomly assigned persons 16 years of age or older in a 1:1 ratio to receive two doses, 21 days apart, of either placebo or the BNT162b2 vaccine candidate (30 μg per dose). BNT162b2 is a lipid nanoparticle–formulated, nucleoside-modified RNA vaccine that encodes a prefusion stabilized, membrane-anchored SARS-CoV-2 full-length spike protein. The primary end points were efficacy of the vaccine against laboratory-confirmed Covid-19 and safety. Results A total of 43,548 participants underwent randomization, of whom 43,448 received injections: 21,720 with BNT162b2 and 21,728 with placebo. There were 8 cases of Covid-19 with onset at least 7 days after the second dose among participants assigned to receive BNT162b2 and 162 cases among those assigned to placebo; BNT162b2 was 95% effective in preventing Covid-19 (95% credible interval, 90.3 to 97.6). Similar vaccine efficacy (generally 90 to 100%) was observed across subgroups defined by age, sex, race, ethnicity, baseline body-mass index, and the presence of coexisting conditions. Among 10 cases of severe Covid-19 with onset after the first dose, 9 occurred in placebo recipients and 1 in a BNT162b2 recipient. The safety profile of BNT162b2 was characterized by short-term, mild-to-moderate pain at the injection site, fatigue, and headache. The incidence of serious adverse events was low and was similar in the vaccine and placebo groups. Conclusions A two-dose regimen of BNT162b2 conferred 95% protection against Covid-19 in persons 16 years of age or older. Safety over a median of 2 months was similar to that of other viral vaccines. (Funded by BioNTech and Pfizer; ClinicalTrials.gov number, NCT04368728.)

Manipulation of the Innate Immune Response by Varicella Zoster Virus

Article

Full-text available

Jan 2020

Varicella zoster virus (VZV) is the causative agent of chickenpox (varicella) and shingles (herpes zoster). VZV and other members of the herpesvirus family are distinguished by their ability to establish a latent infection, with the potential to reactivate and spread virus to other susceptible individuals. This lifelong relationship continually subjects VZV to the host immune system and as such VZV has evolved a plethora of strategies to evade and manipulate the immune response. This review will focus on our current understanding of the innate anti-viral control mechanisms faced by VZV. We will also discuss the diverse array of strategies employed by VZV to regulate these innate immune responses and highlight new knowledge on the interactions between VZV and human innate immune cells.

Bell’s palsy and herpes zoster oticus

Article

Apr 2012

Mark J. Morrow

– •Normal facial movement is required for chewing, swallowing, speaking, and protecting the eye. Bell’s palsy causes most cases of acute, unilateral facial palsy; infection with herpes simplex virus (HSV) type 1 may be its major cause. Varicella zoster virus (VZV) reactivation (Ramsay Hunt syndrome) is less common, but may appear without skin lesions in a form indistinguishable from Bell’s palsy. Symptoms improve in nearly all patients with Bell’s palsy, and most patients with Ramsay Hunt syndrome, but many are left with functional and cosmetic deficits. – •Steroids are frequently used to optimize outcomes in Bell’s palsy, but proof of their effectiveness is marginal. Oral prednisone has been studied extensively, although some reports have suggested a higher recovery rate with intravenous steroids. Given the existing data, we support the use of oral prednisone in those patients with complete facial palsy, and no contraindications to their use (Fig. 1). In this author’s opinion, the greatly increased cost and inconvenience of intravenous steroids cannot be justified by the data available. Antiviral agents may also be effective in treatment of Bell’s palsy; HSV is susceptible to acyclovir and related agents. There have been few investigations of acyclovir treatment in Bell’s palsy, but one controlled study showed added benefit when the drug was used with prednisone. The risk and cost of acyclovir is low enough that we support its use, with oral steroids, in those patients with complete facial paralysis. – •Several small studies have implied that oral acyclovir improves the outcome of facial palsy for patients with Ramsay Hunt syndrome. Although these studies do not prove efficacy, evidence for the benefits of antiviral agents in other forms of zoster is strong enough to recommend their use when the facial nerve is involved. VZV is less sensitive to acyclovir than HSV, so higher doses are recommended to treat Ramsay Hunt syndrome. Because some Ramsay Hunt syndrome patients with partial facial palsy do not fully recover, we recommend oral antiviral agents in all patients suspected of having zoster. There is weak evidence to suggest additional benefit of oral steroids in facial zoster, and their use can be supported in immunocompetent individuals. – •Facial nerve decompression surgery for Bell’s palsy and herpes zoster oticus has experienced varying levels of enthusiasm over the years. Recent work implies that early, extensive decompression of the nerve through a middle fossa craniotomy may benefit patients at high risk for persistent deficits. However, until this procedure is subjected to a rigorous, controlled trial comparing it with maximal medical therapy, it is difficult to justify the very high costs and risk.

Bell's Palsy and Herpes Zoster Oticus

Article

Oct 2000

MJ Morrow

Normal facial movement is required for chewing, swallowing, speaking, and protecting the eye. Bell's palsy causes most cases of acute, unilateral facial palsy; infection with herpes simplex virus (HSV) type 1 may be its major cause. Varicella zoster virus (VZV) reactivation (Ramsay Hunt syndrome) is less common, but may appear without skin lesions in a form indistinguishable from Bell's palsy. Symptoms improve in nearly all patients with Bell's palsy, and most patients with Ramsay Hunt syndrome, but many are left with functional and cosmetic deficits. Steroids are frequently used to optimize outcomes in Bell's palsy, but proof of their effectiveness is marginal. Oral prednisone has been studied extensively, although some reports have suggested a higher recovery rate with intravenous steroids. Given the existing data, we support the use of oral prednisone in those patients with complete facial palsy, and no contraindications to their use (Fig. 1). In this author's opinion, the greatly increased cost and inconvenience of intravenous steroids cannot be justified by the data available. Antiviral agents may also be effective in treatment of Bell's palsy; HSV is susceptible to acyclovir and related agents. There have been few investigations of acyclovir treatment in Bell's palsy, but one controlled study showed added benefit when the drug was used with prednisone. The risk and cost of acyclovir is low enough that we support its use, with oral steroids, in those patients with complete facial paralysis. Several small studies have implied that oral acyclovir improves the outcome of facial palsy for patients with Ramsay Hunt syndrome. Although these studies do not prove efficacy, evidence for the benefits of antiviral agents in other forms of zoster is strong enough to recommend their use when the facial nerve is involved. VZV is less sensitive to acyclovir than HSV, so higher doses are recommended to treat Ramsay Hunt syndrome. Because some Ramsay Hunt syndrome patients with partial facial palsy do not fully recover, we recommend oral antiviral agents in all patients suspected of having zoster. There is weak evidence to suggest additional benefit of oral steroids in facial zoster, and their use can be supported in immunocompetent individuals. Facial nerve decompression surgery for Bell's palsy and herpes zoster oticus has experienced varying levels of enthusiasm over the years. Recent work implies that early, extensive decompression of the nerve through a middle fossa craniotomy may benefit patients at high risk for persistent deficits. However, until this procedure is subjected to a rigorous, controlled trial comparing it with maximal medical therapy, it is difficult to justify the very high costs and risk.