**1. Introduction**

Herpes zoster (HZ) is an infection of dorsal root ganglion characterized by a painful cutaneous rash. It is believed that reactivated varicella zoster virus (VZV) migrate from dorsal root ganglion in retrograde direction along the sensory nerve to the skin, where it makes the characteristic dermatomal rash [1].

The initial infection caused by varicella or chickenpox occurs during childhood. After that, the virus then exists as a latent infection of sensory ganglia from which it may reactivate many years later and cause herpes zoster.

The virus can be recovered from skin lesion and can cause an inflammatory reaction in sensory ganglion, dorsal root, and posterior horn of spinal cord [2].

Postherpetic neuralgia is the most common complication associated with extracranial HZ. Pain persisting 90 days or longer after the onset of the shingles rash is called postherpetic neuralgia [3, 4]. Postherpetic neuralgia usually remits spontaneously, but some patients could have pain for all their life.

Beside postherpetic neuralgia, segmental herpetic paresis is another complication of HZ, and they often occur together.

Flaccid muscle paralysis rarely occurs due to the spread of the infection from the posterior horn of spinal cord to the anterior horn and the motor nerve root (**Figure 1**) when weakness generally corresponding to the dermatomes in which cutaneous lesions develop [5].

This finding supports the enhancement of spinal nerve roots on MRI that was clinically symptomatic [6], attributed to autoimmune inflammation or

confirmation of herpes zoster, electromyographic (EMG) findings, imagining,

55 women and 45 men and one patient who did not specify gender.

carcinoma mammae, 7 patients suffering from lymphoma, 4 were taking

inantly on the right side (42/26, 33 cases do not specify the affected side).

arm [40] or only distal muscles [41] were significantly less affected. Besides weakness, in 9 patients, muscle atrophy was detected.

"severe median and ulnar nerve neuropathy."

firmed by following fluoroscopy were performed.

patient among patients with lumbar puncture.

[43], Pregabalin [11], and Gabapentin [11].

5 months but with persisted neuralgia.

for HZ was found in 3 patients.

For clarity, segmental zoster paresis is classified into several categories: paresis of upper extremity, lower limb involvement, diaphragmatic involvement, and

Upper extremity involvement: In 37 previously published papers about patients with segmental zoster paresis of arms, there are 19 papers that are processed only as arms paresis (**Table 1**), while the rest of the 18 papers describe patients with segmental zoster paresis of arms and legs (**Table 2**). They include a total of 101 patients with segmental paresis of arms with a mean age of 68.56 11.97 and with

There are few comorbidities in this population of patients: 2 patients with

corticosteroids due to autoimmune diseases (2 patients with rheumatoid arthritis, 1 with polymyalgia rheumatica, and 1 with myasthenia gravis), and 4 of them were

Clinically, segmental zoster paresis is usually unilateral paresis of arm, predom-

Proximal muscles were affected in most cases (in 52 patients), while the entire

Phrenic nerve affection followed by dyspnea was observed in 6 patients. Electromyoneurography was performed in 58 patients, and denervation potential has been described in most cases (51 patients), often associated with reduced pattern and polyphasia of motor unit potentials in most cases (17 patients). Reduced motor or sensor velocity was seen in 4 patients. In some cases, neurophysiological finding was only descriptive: "lesion of nerve," "acute motor axonal lesion," and

Another test was performed in only small number of patients: neck MRI (unremarkable in 2 patients, foraminal stenosis in 1, and protruded disk in 1) and MRI of the affected arm in 1 patient with enlargement of T2 signal of the median

X-ray of the shoulder was performed in 2 patients (1 patient showed subluxation) and 2 X-rays of the neck (1 unremarkable and 1 with spondyloarthrosis) and 2 X-rays of the chest with 1 showing elevated hemidiaphragm and paralysis con-

Standard laboratory in 2 patients was unremarkable; positive sera antibody test

Hyperproteinorachia was found in 2 patients and normal CSF was found in 1

In 1 patient, surgical exploration was done and it was without compression. In almost all cases with a mentioned type of treatment were treated with physical therapy (24 reported patients). Some of them had other therapies: Valacyclovir 3 g/7 days (3 patients), Acyclovir 750 mg/7 days (2 patients iv and 1 per os); and Methylprednisolone 500 mg iv for 3 days (1 patient), and some of them were taking steroids [11], cervical epidural bloc [11], analgesics [42], opioids [43], Amitriptyline

Most reported patients recovered significantly: complete or near complete recovering is recorded in 8 patients that are reported during following periods: 3 weeks, 1 month, 2 months, 3 months, 6 months, and 2 years. Incomplete recovery was reported in 3 patients, minimal recovery in 1 patient after 2 months, and no recovery after 8 months in 1 patient. One patient recovered from weakness after

treatment, and course.

*Extracranial Herpetic Paresis*

*DOI: http://dx.doi.org/10.5772/intechopen.90493*

abdomen involvement.

diabetic.

nerve.

**47**

#### **Figure 1.**

*Origin of segmental zoster paresis: the spread of varicella zoster infection from the posterior horn of spinal cord to the anterior horn and the motor nerve root.*

vasculitis [7]; brachial plexus inflammation; and myelin destruction with intact axons found postmortem [8].

The association of muscle paralysis and herpes zoster was first reported by Broadbent in 1866. When he described the case to zoster described as "frozen shoulder" [9], it is noted rarely between 0.5% [10] and 0.8% of segmental motor paralysis between all patients with HZ [11].

In patients with dissociation between motor and dermatomal involvement, a possible explanation could be viral spread to anterior roots without corresponding axonal transport through the sensory nerves [6, 12].

Some patients may have zoster infection without vesicular eruptions, which is called "zoster sine herpete." This diagnose is safer by a rise VZV antibodies. These patients may have the same neurologic manifestations, including muscular paralysis [13].

As there are no certain standards regarding diagnosis and treatment of segment zoster paresis, we have listed in this paper experiences from literature related to the topic.

The aim of this study was to summarize the experiences related to its clinical manifestation, applied diagnostics, treatment, and patient outcome.

#### **2. Methods**

We searched the PubMed database for literature on herpes zoster infection and extracranial motor paresis in adults (last search on September 2019).The search was limited to full-length articles written in English and a study population that included adults aged 18 years and older. A combination of the following search terms was used "herpes zoster, paresis, complications." As a result, 74 articles were retrieved.

The reference list was also searched for relevant manuscripts not retrieved from PubMed.

Studies included in the final review met the following criteria: (1) infection with herpes zoster virus, (2) motor paresis, and (3) adult study population.

They encompass original articles, technical reports, clinical observations, and single case reports.

#### **3. Results**

#### **3.1 Data extraction and synthesis**

For comparison across the reports, the sample size was extracted along with demographic information (gender and age), clinical presentation, laboratory

confirmation of herpes zoster, electromyographic (EMG) findings, imagining, treatment, and course.

For clarity, segmental zoster paresis is classified into several categories: paresis of upper extremity, lower limb involvement, diaphragmatic involvement, and abdomen involvement.

Upper extremity involvement: In 37 previously published papers about patients with segmental zoster paresis of arms, there are 19 papers that are processed only as arms paresis (**Table 1**), while the rest of the 18 papers describe patients with segmental zoster paresis of arms and legs (**Table 2**). They include a total of 101 patients with segmental paresis of arms with a mean age of 68.56 11.97 and with 55 women and 45 men and one patient who did not specify gender.

There are few comorbidities in this population of patients: 2 patients with carcinoma mammae, 7 patients suffering from lymphoma, 4 were taking corticosteroids due to autoimmune diseases (2 patients with rheumatoid arthritis, 1 with polymyalgia rheumatica, and 1 with myasthenia gravis), and 4 of them were diabetic.

Clinically, segmental zoster paresis is usually unilateral paresis of arm, predominantly on the right side (42/26, 33 cases do not specify the affected side).

Proximal muscles were affected in most cases (in 52 patients), while the entire arm [40] or only distal muscles [41] were significantly less affected.

Besides weakness, in 9 patients, muscle atrophy was detected.

Phrenic nerve affection followed by dyspnea was observed in 6 patients.

Electromyoneurography was performed in 58 patients, and denervation potential has been described in most cases (51 patients), often associated with reduced pattern and polyphasia of motor unit potentials in most cases (17 patients). Reduced motor or sensor velocity was seen in 4 patients. In some cases, neurophysiological finding was only descriptive: "lesion of nerve," "acute motor axonal lesion," and "severe median and ulnar nerve neuropathy."

Another test was performed in only small number of patients: neck MRI (unremarkable in 2 patients, foraminal stenosis in 1, and protruded disk in 1) and MRI of the affected arm in 1 patient with enlargement of T2 signal of the median nerve.

X-ray of the shoulder was performed in 2 patients (1 patient showed subluxation) and 2 X-rays of the neck (1 unremarkable and 1 with spondyloarthrosis) and 2 X-rays of the chest with 1 showing elevated hemidiaphragm and paralysis confirmed by following fluoroscopy were performed.

Standard laboratory in 2 patients was unremarkable; positive sera antibody test for HZ was found in 3 patients.

Hyperproteinorachia was found in 2 patients and normal CSF was found in 1 patient among patients with lumbar puncture.

In 1 patient, surgical exploration was done and it was without compression.

In almost all cases with a mentioned type of treatment were treated with physical therapy (24 reported patients). Some of them had other therapies: Valacyclovir 3 g/7 days (3 patients), Acyclovir 750 mg/7 days (2 patients iv and 1 per os); and Methylprednisolone 500 mg iv for 3 days (1 patient), and some of them were taking steroids [11], cervical epidural bloc [11], analgesics [42], opioids [43], Amitriptyline [43], Pregabalin [11], and Gabapentin [11].

Most reported patients recovered significantly: complete or near complete recovering is recorded in 8 patients that are reported during following periods: 3 weeks, 1 month, 2 months, 3 months, 6 months, and 2 years. Incomplete recovery was reported in 3 patients, minimal recovery in 1 patient after 2 months, and no recovery after 8 months in 1 patient. One patient recovered from weakness after 5 months but with persisted neuralgia.

vasculitis [7]; brachial plexus inflammation; and myelin destruction with intact

*Human Herpesvirus Infection - Biological Features,Transmission, Symptoms, Diagnosis …*

*Origin of segmental zoster paresis: the spread of varicella zoster infection from the posterior horn of spinal cord*

The association of muscle paralysis and herpes zoster was first reported by Broadbent in 1866. When he described the case to zoster described as "frozen shoulder" [9], it is noted rarely between 0.5% [10] and 0.8% of segmental motor

In patients with dissociation between motor and dermatomal involvement, a possible explanation could be viral spread to anterior roots without corresponding

Some patients may have zoster infection without vesicular eruptions, which is

As there are no certain standards regarding diagnosis and treatment of segment zoster paresis, we have listed in this paper experiences from literature related to

The aim of this study was to summarize the experiences related to its clinical

We searched the PubMed database for literature on herpes zoster infection and extracranial motor paresis in adults (last search on September 2019).The search was limited to full-length articles written in English and a study population that included adults aged 18 years and older. A combination of the following search terms was used "herpes zoster, paresis, complications." As a result, 74 articles were retrieved. The reference list was also searched for relevant manuscripts not retrieved

Studies included in the final review met the following criteria: (1) infection with herpes zoster virus, (2) motor paresis, and (3) adult study population.

They encompass original articles, technical reports, clinical observations, and

For comparison across the reports, the sample size was extracted along with demographic information (gender and age), clinical presentation, laboratory

called "zoster sine herpete." This diagnose is safer by a rise VZV antibodies. These patients may have the same neurologic manifestations, including muscular

manifestation, applied diagnostics, treatment, and patient outcome.

axons found postmortem [8].

*to the anterior horn and the motor nerve root.*

paralysis [13].

the topic.

**Figure 1.**

**2. Methods**

from PubMed.

single case reports.

**3.1 Data extraction and synthesis**

**3. Results**

**46**

paralysis between all patients with HZ [11].

axonal transport through the sensory nerves [6, 12].


**Literature**

**49**

**medical history** #2. 60-year old man,

lymphatic leukemia

**Demographics,**

**Subjective**

**Neurological**

**EMG findings**

Not reported

Chest X-ray: elevated

right

hemidiaphragm,

paralysis confirmed

on fluoroscopy

 **Other tests**

**Treatment**

**Course/Outcome**

Complete recovery

after 1 month

*Extracranial Herpetic Paresis*

**impairments**

**complaints**

Rash and hypersensitivity

right C5 dermatome

after weeks of coughing; enlarged

liver

[17]

[18]

 59-year old man,

Pain and rash in left C7

Weakness in whole arm;

Fibrillations,

interference

atrophied muscles;

conduction

normal

 velocities

 pattern in

 reduced

X-ray: spine normal;

Not reported

> CSF: normal

marked atrophy in

almost all arm muscles,

reflexes diminished

dermatome;

hyperalgesia

half of left hand

 in inner

diabetes, mild

hypertension

[13]

 #1. 81-year old man

 Pain in left arm and

Complete flaccid

Not reported

Not reported

 Physical therapy

 Complete recovery

after 3 months

weakness of left arm

left lateral chest wall;

rash in C5–7 dermatomes

#2. 75-year old female,

Pain and rash in right

Marked weakness in

Denervation

infraspinatus,

 deltoid,

 in

Not reported

 Not reported

Minimal recovery after

2 months

deltoid, biceps,

infraspinatus;

absent in biceps Severe weakness in

wrist and hand intrinsic

muscles

 reflexes

biceps; conduction

velocities normal Lesion of anterior

Surgical

Not reported

No recovery after

8 months

exploration‑no

compression

interosseus

 nerve

shoulder and over back

of the head

diabetes

[5]

 64-year old female

 Pain and rash in left inner arm and fingers

after 4 months of an

episode of shingles Pain in left shoulder;

Moderate atrophy of

Acute motor axonal

Neck MRI: no spinal

Acyclovir, opioid

Slight deltoid weakness

after 2 years

analgesics,

amitriptyline,

therapy, home exercises

 physical

cord, root

compression

lesion in C5–6

dermatomes

deltoid; weakness in

biceps and

infraspinatus;

 reflexes

rash over biceps,

brachioradialis

[19]

 73-year old man, left

biceps rupture 10 yrs.

earlier with full

recovery

 25-year old female

 Rash over shoulder

 Weakness in deltoid

 Not reported

X-ray: shoulder

Not reported

Full recovery after

*DOI: http://dx.doi.org/10.5772/intechopen.90493*

unspecified

of months Unknown

 number

subluxation

 in

