Persistent hemicrania as onset manifestation of Ramsay Hunt Syndrome
Context: Ramsay Hunt Syndrome (RHS), also named Optic Herpes Zoster is caused by the reactivation of Varicella-Zoster Virus that occurs in the geniculate ganglion. The classic syndrome is composed of vesicular lesions in the ear, ipsilateral otalgia and peripheral facial palsy. The onset of the syndrome with persistent hemicrania is absolutely atypical as a manifestation of RHS. Case report: A 69 year old woman with subacute onset of left exclusive hemicrania in moderate strong intensity without autonomic signs. Eight days after the onset of headache, she presented left peripheral facial paralysis and after 4 days, she noticed the appearance of vesicles in the left ear and pain in swallowing. She has developed nausea with several episodes of vomiting, important imbalance that made impossible gait. On physical examination she presented vesicles in the left ear and oropharynx, left peripheral facial paralysis House Brackmann grade IV, left hypoacusis, nystagmus and vestibular gait. The brain CT and cerebrospinal fluid analysis were normal. The patient has progressive improvement with Acyclovir. Conclusions: Otalgia or even intermediate neuralgia are more frequent painful manifestations of RHS. This case report highlights the need to consider the diagnosis of SRH in patients with persistent hemicrania, even if without initial classic signs of the syndrome.