Mumps, Cervical Zoster, and Facial Paralysis: Coincidence or Association?

Mumps, Cervical Zoster, and Facial Paralysis: Coincidence or Association?

Herpes zoster (shingles) refers to the re-activaiton of the varicella zoster virus (VZV), the same virus whose primary infection causes chicken pox (varicella). This computer-generated list may be inaccurate or incomplete. بعد ان فجعنا بالمصاب الاليم لمنطقتنا بشكل خاص ولاهالي العراق بشكل عام ، و بعد خسارتنا لما يقارب ال 400 مواطن عراقي بين معلوم… An 8-year-old girl simultaneously developed left peripheral facial paralysis, ipsilateral cervical herpes zoster, and bilateral mumps sialadenitis. Pain on palpation of the tragus and auricle manipulation or pulling are considered hallmark signs of AOE. Im Verlauf weniger Wochen erfolgte eine vollständige Rückbildung der Symptome einschließlich der neurologischen Defizite. A cold, allergy, or sore throat can cause the eustachian tube to swell shut.

Otitis Externa means inflammation/ infection of the EAR CANAL. These viruses include herpes simplex virus-1 (HSV-1), varicella zoster virus (VZV), Epstein-Barr virus, cytomegalovirus, and mumps virus. Increasing evidence suggests that idiopathic peripheral facial paralysis (Bell’s palsy), the most common clinical entity of facial paralysis, is caused by reactivation of HSV-1 [1, 2]. Similarly, it is well recognized that VZV reactivation is responsible for the development of Ramsay Hunt syndrome and zoster sine herpete [3]. However, the association of other viral infections with the pathogenesis of facial paralysis remains largely unclear because of the paucity of reports. We present here a patient who showed the simultaneous development of left peripheral facial paralysis, ipsilateral cervical herpes zoster, and mumps sialadenitis as evidenced by serological studies. Complaints of otalgia can range from mild pruritus to severe discomfort.

An 8-year-old Japanese girl was referred to our clinic for the evaluation of a left facial nerve paralysis, left cervical zoster, and swelling of the right submandibular area. A history of the illness should be obtained, including information about the symptoms accompanying the earache. furuncular otitis circumscribed otitis externa. She did not notice hearing loss or vertigo. She had been vaccinated against mumps at the age of 2 and had no obvious episode of mumps infection previously. Although she had also been vaccinated for chickenpox at the age of 2, she developed chickenpox at the age of 4. Another past medical history was notable for an operation for Fallot’s tetralogy at the age of 2.

Mumps, Cervical Zoster, and Facial Paralysis: Coincidence or Association?
At the first visit to our clinic on the tenth day of illness, a physical examination revealed a complete left facial paralysis (House-Brackmann grade VI). The patient should be asked whether discomfort radiates down the neck or into the jaw. Pure tone audiometry showed normal hearing in both ears. The oil of Calendula officinalis may be used in the same manner. The herpes zoster virus can lie dormant in nerve roots for decades. Computed tomography images of the neck that had been examined in the pediatric department on the eighth day of illness confirmed sialadenitis of the left parotid gland (Figure 2) and right submandibular gland. We also noted herpes zoster in the left parotid area and posterior cervical area corresponding to the C2-3 area (Figure 3).

Serologic tests done on the 17th day of illness revealed the elevation of both antimumps and anti-VZV IgM antibodies by an enzyme-linked immunosorbent assay (Table 1). Figure 1: An electroneurograph recorded from the orbicularis oris muscles on the tenth day of illness showing severe denervation of the left facial nerve. Supramaximal stimulation was provided through bipolar surface electrodes placed with the anode just outside the stylomastoid foramen and the cathode in front of the ear lobe. When consulting with patients about the severity of their illness, it is important to discuss their pain level in detail. Her left facial movement also gradually improved to be House-Brackmann grade 2 with slight synkinesis 7 months later. Several homeopathic remedies may also be helpful in treating earaches. Herpes zoster oticus (HZ oticus) is a viral infection of the inner, middle, and external ear.

In the present case, cervical zoster and facial paralysis developed six and seven days earlier than the development of sialadenitis, respectively. The electroneurography of the facial nerve revealed nearly complete denervation on the tenth day of illness. Based on the clinical and laboratory findings, this case may be clinically diagnosed as mumps-associated facial paralysis. In fact, a small number of previous reports have suggested the possible association of mumps viral infection with peripheral facial paralysis [4–6]. However, stapedial reflex in the present case was absent in the left ear, suggesting that the lesion responsible for facial paralysis was not located in the parotid gland but proximal to the root of the stapedius branch, which is commonly observed in cases of Bell’s palsy or Ramsay Hunt syndrome. It would be more likely that the facial paralysis was caused by the VZV reactivation. Although the patient did not show hearing loss, or vesicular eruptions in external ear canal, concha, or pimma, which is a dermatome of the geniculate ganglion, a combination of facial paralysis and upper cervical zoster has been recognized as a subgroup of Ramsay Hunt syndrome [7, 8] and speculated to be caused by the simultaneous reactivation of latent VZV in multiple sensory ganglia or the spread of infection through meningeal inflammation to adjacent ganglia [8].

The soak can be repeated two or three times a day as needed. Assuming that they were actually associated, it is reasonable to speculate that the mumps infection enabled the subsequent reactivation of VZV, since the herpes zoster is a result of reactivation, not the initial infection, of the VZV virus. The latency period of the mumps virus is usually 2-3 weeks, suggesting that mumps infection in our case may have occurred 1-2 weeks before the development of cervical zoster and facial paralysis. Recent molecular studies have provided mounting evidence that the mumps virus may dysregulate the immune system of the host so that the virus can proliferate in the infected host cells [9]. Such a dysregulation of immune system may have occurred in our patient, enabling the latent VZV infection to reactivate. A similar causative association has been suggested in EB virus infection and VZV reactivation [10]. Interestingly, besides the small number of case reports describing the development of peripheral facial paralysis in patients with mumps sialadenitis, the association of trigeminal herpes zoster and mumps parotitis has also been reported [11], as well as an increasing titer of mumps IgM in clinically diagnosed cases of Ramsay Hunt syndrome (without clinical sialadenitis) [12].

With the addition of our case, further speculation may be possible that these cases may represent the incomplete clinical presentation of mumps virus infection and subsequent VZV reactivation. The present case suggests that the reactivation of VZV may be associated with “mumps-induced” facial paralysis. Earaches can generally be relieved by attending to the underlying problem. This study was approved by the Institutional Review Board (Protocol no. 2487) of the University of Tokyo, Graduate School of Medicine. The authors declare that prior consent was obtained from the parents of the patient referred to in this report regarding the publication of all included information.

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