2. 66-year old man Rash and pain in left

shoulder and arm in C5

dermatome

#3. 85-year old female Rash, pain and

impaired sensation in

Weakness in deltoid,

spinatus, biceps;

reflexes absent

left in C4–5 dermatomes

#4. 83-year old.

Pain in outer part of

Weakness in biceps, in

Fibrillations

and reduced interference

motor median velocity

reduced; absent

median sensory

neurogram

Fibrillations

moderately

interference

deltoid and supraspinatus

 patterns in

 reduced

 in deltoid,

Not reported

Not reported

Full motor recovery

after 2 years

 patterns,

 polyphasia

Not reported

Not reported

Incomplete

of hand after 1 year, full recovery in triceps

wrist extensors

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

 recovery

> triceps, fingers, hand

intrinsics; absent reflex

in triceps, depressed in

biceps, supinator

right arm and digitis

III-V, rash on posterior

forearm and digitis

> #5. 64-year old man

> Pain in right shoulder,

Weakness in

deltoideus,

supraspinatus;

impaired sensation in

C5 dermatome; reflexes absent in

whole arm Weakness in left

Reduced interference

Not reported

Not reported

Incomplete

after 7 months

 recovery

> pattern in left

deltoideus with polyphasic units

deltoid, spinatus, biceps; reflexes absent

in biceps, supinator

C#6. 52-year old

Pain and rash in left

arm (C5–6 distribution);

numbness in left

thumb

#7. 77-year old man

 Pain in right groin, rash

Weakness in hip

Fibrillations

muscles, reduced

patterns, polyphasic

units

 in thigh

Not reported

Not reported

Full recovery after

4 months

flexors, adductors, knee extensors; reflex

absent at knee

in anterior and medial

thigh

female

rash in C5 distribution

female

**Demographics,**

**Subjective complaints**

**Neurological**

**EMG findings**

 **Other tests**

**Treatment**

**Course/outcome**

**impairments**

Weakness in deltoid

Fibrillation,

and reduced interference

MUAP

Fibrillations

reduced interference

pattern in deltoid

 and

Not reported

Not reported

Minimal weakness after 4 years, residual

neuralgia

 patterns

 polyphasia

Not reported

Not reported

Complete recovery

after 4 months

and spinatus muscles


**Literature**

**57**

**medical history** **#2**. 67-year old man

 Pain and rash in low back and right leg in

distribution

sciatic nerve

[31]

 #1. 63-year old man

 Pain and rash in right

Weakness in shoulder,

Denervation

motor amplitudes decreased, velocity normal; absent sensory

neurograms

 in hand,

Complement

antibodies VZV in sera

was elevated

 fixing for

Physical therapy

 Significant recovery

except hand intrinsics

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

elbow flexors,

extensors, in hand

muscles; reflexes

absent

Weakness in knee

Not reported

CSF:

Not reported

Incomplete

foot drop and urinary

retention remained

 recovery:

hyperproteinorachia

flexors, ankle flexors

and extensors; reflexes

in ankles absent

#2. 80-year old

Pain from left knee to

foot, rash in L5-S2

dermatomes,

frequency and

incontinence

Pain-to-rash

3 days in 5 patients, 4–

6 days in 6, 7 days in 2,

unknown in 2; Rash-to-

weakness interval

 interval 2–

Distribution

paresis: C5–6 in 5, C5–7

in 1, C7-C8-T1 in 2;

L3-S1 in 7, L3-S1. Weakness severe in 10 patients, moderate in 3,

mild in 2; sensory

abnormalities

the patients; reflexes

diminished

Not reported

Not reported

Not reported

Not reported

Marked recovery

 in half of

 of motor

Denervation

patients

 in 12

Increased protein and

Not reported

Full recovery in 11

patients (5 arms and 6

legs). Mean recovery

time in arms 9 months, 7 months in

legs. 2 improved arms

and 1 in legs. Postherpetic

in 3 patients

 neuralgia

cell count in CSF of

one patient

[32]

 15 patients (9 females

and 6 males, mean age

66 years, range 48–

80) with rheumatoid

arthritis in 3, lymphosarcoma

and lymphatic

leukemia in 1

 in 1,

< 10 days in 1 patient,

10 to 28 days in 12,

42 days in 1, unknown

in 1 (similar in upper

and lower limbs)

> #1. 70-year old man

#2. 56-year old man

#3. 59-year old man

 Pain and rash in C5

myotome

 Pain and rash in L3

Diminished

reflexes

Absent reflexes

 Not reported

Not reported

Not reported

Full recovery

 knee

Not reported

Not reported

Not reported

Marked recovery

myotome

 Pain and rash in C5

myotome

 urinary

woman

shoulder, arm, and

hand

 of the

**Demographics,**

**Subjective complaints**

**Neurological**

**EMG findings**

 **Other tests**

**Treatment**

**Course/outcome**

**impairments**

Weakness in right hip

Not reported

Not reported

Paravertebral

Unknown

sympathetic

 block

*Extracranial Herpetic Paresis*

flexors; knee jerk

absent


### *Extracranial Herpetic Paresis DOI: http://dx.doi.org/10.5772/intechopen.90493*

**Literature**

**56**

**medical history**

#2. 85-year old female Pain and rash in left C5 Weakness and atrophia

#3. 79-year old female Pain and rash in right C

#4. 67-year old female Pain and rash in right

#5. 82/F

5,6

C5,7 dermatome

Pain and rash in

Weakness in projection

L1-S1 bilateral

dermatome

bilateral

#6. 80-year old man

#7. 76-year old female Pain and rash in right

#8. 83-year old male

#9. 7 year old female

#10. 72-year old

female

#11. 43-year old male

Rash and pain in right

Weakness in C5-Th1

distribution

C8-Th1 dermatome

bone marrow transplantation

[30]

 #1. 69-year old female

Pain and rash in right

Weakness and

Not reported

Not reported

Steroid, procaine,

Almost full recovery

> physical therapy

> impaired sensation in

shoulder, reflexes

diminished

 in right arm

arm, rash over face

with diabetes

 Pain and rash in right

L4-S1 dermatome

Pain and rash in right

C5–7 dermatome

 Pain and rash in right

C8-Th1 dermatome

 Pain and rash in left

Weakness in left

C5-Th1

Weakness in C6-Th1

distribution

Weakness in C7, 8

distribution

Weakness in right L1,

S1 distribution Weakness in right C5-Th1 distribution

C6,7

C6,7 dermatome

 L1-S2

**Demographics,**

**Subjective complaints**

**Neurological**

**EMG findings**

Denervation,

polyphasia,

conduction

 velocity

Denervation,

polyphasia

 normal

 **Other tests**

**Treatment**

**Course/outcome**

Poor recovery after

1 year and 7 months

Moderate recovery

after 2 months

Good outcome after 6

y+8m

Moderate recovery

after 3y + 8 m

Good recovery after

1y + 8 m

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

Good recovery after

7y

Good recovery after

5y + 9 m

Good recovery after

5y + 4 m

Moderate recovery

after 2 years and

10 month Uncertain 6y + 8 m

**impairments**

in left C5,6 distribution

Weakness in 5, 6

distribution

Weakness in C5–8

Denervation,

polyphasia


**Literature**

**59**

**medical history** leukemia in 1, diabetes

20 days in 5, 21–28

> in 3,

in 1

[34]

 #1. 45-year old

Pain in right thigh, rash

Decreased sensation in

7 years later- high

Lumbar/pelvic

and CSF normal

 X-ray

Not reported

Full recovery at

3 months after the

first episode;

moderate after each of

next relapses over

7 years Incomplete

in shoulder muscles

after 1.5 years

 recovery

L2-S1-S2 reflexes diminished; weakness in right ankle

dorsi/plantar

 flexors

dermatomes,

amplitude and

polyphasia on MUAP

along the sciatic nerve

woman

#2. 80-year old man

 Pain in all right arm,

rash over

part of arm

anterolateral

arm, reflexes

diminished,

atrophy and

subluxation

head

Weakness and atrophy

Not reported

Not reported

Analgesics,

therapy

 physical

Full recovery after

3–4 months

in quadriceps;

reflex absent

 knee

[35]

 #1. 77-year old woman

with

hypertension

cardiomegaly

#2. 65-year old man

 Pain in left chest

Weakness in proximal

Not reported

Not reported

Symptomatic

Full recovery

treatment

and distal muscles of

left arm; reflexes

absent in arm Weakness in proximal

Denervation

and middle trunks of

the brachial plexus

 in upper

Chest X-ray normal

 Not reported

Full recovery after

6 months

and distal muscles of

right arm

radiating in left arm,

rash in left C5–6

dermatomes

#3. 74-year old female

Pain and rash in right

> with

osteoarthritis

shoulder (C5–7)

 and

thigh, decreased

sensation in L1–3

dermatomes

Pain and rash in right

 of humeral

 shoulder

Weakness in all right

Fasciculations,

action potentials in

deltoid, and biceps muscles

supraspinatus

changes

 rare

Neck and spine X-ray:

Not reported

spondyloarthritic

histoplasmosis

days in 2 patients,

29–35 days in 1

**Demographics,**

**Subjective complaints**

**Neurological**

**EMG findings**

 **Other tests**

**Treatment**

**Course/outcome**

are with leg distribution)

*Extracranial Herpetic Paresis*

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

**impairments**

patients (L2 to S1 at

decreased in number in

2 with large amplitudes;

and motor nerve

conduction

normal in all but 3

cases

 studies

 sensory

about similar

frequency);

weakness in 2 patients

 abdominal


#### *Extracranial Herpetic Paresis DOI: http://dx.doi.org/10.5772/intechopen.90493*

**Literature**

**58**

**medical history**

#4. 70-year old man

#5. 71-year old man

#6. 67-year old female Pain and rash in C7

#7. 91-year old

woman

#8. 65-year old female Pain and rash in C5

#9. 72-year old man

#10. 65-year old man Pain and rash in L2–3

#11. 56-year old man Pain and rash in L5

#12. 76-year old man Pain and rash in C5

#13. 62-year old

woman

#14. 70-year old

woman

[33]

 61 patients (39 men

and 22 women), mean

age 62 yrs. (range 18–

87); lymphoma in 6,

chronic lymphocytic

 Pain and rash in C5

Absent reflexes Absent knee reflexes

 Not reported

Not reported

Not reported

Marked recovery

 Not reported

Not reported

Not reported

Unknown

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

myotome

myotome

myotome

myotome

Pain and rash in L3

Absent knee reflex

 Not reported

Not reported

Not reported

Modest recovery

myotome

Pain and rash in L3

Absent knee reflex

 Not reported

Not reported

Not reported

Full recovery

myotome

Rash-to-weakness

Weakness in upper

EMG in 18 patients

CSF proteins and cell

Not reported

Limb recovery full in

55%, marked in 25%;

residual pain in 8

patients (4 of them

count increased in 2

patients

(9 of them are within

legs): fibrillations

present in all affected

muscles, MUAPs

limbs in 16 (C5 to T1

segments at about

equal frequency),

lower limbs in 15

interval in 51 patients: <3 days in 6, 3–6 days in 12, 7–10 days in 14,

11–14 days in 11, 15–

Not reported Absent SJ and BJ

 Not reported

Not reported

Not reported

Modest recovery

Not reported

Not reported

Not reported

No recovery

 Pain and rash in C5–6

Absent reflexes

 Not reported

Not reported

Not reported

Full recovery

myotome

myotome

Pain and rash in T1

Not reported Absent reflexes

 Not reported

Not reported

Not reported

Full recovery

Not reported

Not reported

Not reported

No recovery

myotome

myotome

Not reported

Not reported

Not reported

Not reported

Full recovery

 Pain and rash in C5

myotome

**Demographics,**

**Subjective complaints**

**Neurological**

**EMG findings**

 **Other tests**

**Treatment**

**Course/outcome**

**impairments**

Absent reflexes

 Not reported

Not reported

Not reported

Marked recovery


**Literature**

**61**

**medical history**

[1]

 80-year old female,

Pain in left part of neck Left facial palsy;

dementia

[37]

 #1. 61-year old man

 Painful rash on dorsum

Weakness of all parts

Fibrillation

reduced MUAP in muscles innervated by the distal sciatic nerve

 and

PCR of cutaneous crusted of right foot

lesions was positive for

VZV

of right leg, reduced

right ankle reflex

of right foot, sensory

loss over the lateral

right leg

> #2. 69-year old man

#3 83-year old woman Rash over right upper

#4 55-year old man

Rash on knee and

Left knee stretch reflex

absent

ankle, pain in left

buttock, thigh and knee

anterolateral

with migraine, restless

legs syndrome

[38]

[39]

 #1. 71-year old man

 Pain on right side of

Deep reflexes brisk

> chest weakness in both

leg and right hand

 60-year old man

 Pain in right leg, rash in

Weakness, atrophy and

fasciculation

quadriceps;

reflex absent

 right knee

right quadriceps

femoris

 of right

anteromedial

right thigh

 part of

limb

 Burning pain in right

Weakness in muscles

Fibrillation

and reduced MUAP

 potentials

MRI of arm

Gabapentin

Incomplete

improvementweakness with

residual pain After 11 months moderate residual weakness in median

innervated muscles

enlargement

within the median

nerve with gadolinium

contrast

 T2 signal

innervated by right median nerve (right

hand)

Weakness of right hand

Fibrillation

reduced MUAP in

distribution

roots; conduction

in the median nerve

Fibrillation

reduced MUAP in left

iliopsoas and rectus

femoris muscles

Reaction of

Thiamine

After 3 months

hydrochloride

three times a day

orally, heat and

electrical stimulation

Physiotherapy

 3 months later almost

full recovery

 10 mg.

incomplete

with atrophy of the

thigh and

fasciculations

 recovery

degeneration

 in the

 and

MRI T2 signal in left

femoral nerve

enlargement

 and

No clinical follow-up

 block

 of C7-T1

 and

grip

upper limb

**Demographics,**

**Subjective complaints**

**Neurological**

**EMG findings**

 **Other tests**

**Treatment**

**Course/outcome**

Gait was normal after

3 months, but left

facial palsy remained

*Extracranial Herpetic Paresis*

complete

No neurologic follow-

up

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

**impairments**

difficulty walking with

left lower limb


#### *Extracranial Herpetic Paresis DOI: http://dx.doi.org/10.5772/intechopen.90493*

**Literature**

**60**

**medical history**

#4. 67-year old female Pain and rash in distal

right arm, sensory loss

in C6–8/T1 segments

> #5. 64-year old man

 Rash over lower lateral

chest on left side,

T9–10 dermatome Rash and burning pain

over right lower

abdomen

#6. 80-year old man

with DM, myocardial

infarction, CVI

[14]

 58-year old female

 Pain over left side of

Weakness of left shoulder and left

deltoid muscle

neck, rash over left

shoulder, lateral left

arm, hand and wrist

[36]

 #1. 53-year old man

rash and general

malaise

Disseminated

 vesicular

Developed leg

Normal in arms and

Diagnosis of GBS was

One year later was

totally

asymptomatic

made and no specific

treatment was given

legs

weakness in 2 days

unable to stand; facial

diplegia; reflexes

depressed

Bilateral facial and

Mild cyanosis, reduced

Received course of

5 months later only

residual sign of mild

reduction of hip

power

plasmapheresis

lung capacity

truncal weakness; weakness in legs all

reflexes absent, loss of

light touch and position

sense

Weakness in the left

1000 mg orally three times daily

for 7 days

Valacyclovir

After 2 years- without

further pain resolved in three

months

complications;

deltoids and biceps

muscle and a

diminished

reflex; dyspnea

 left biceps

[21]

 48-year old woman

 Pain in left arm, rash

over the C5 to C7

dermatomes

#2. 69-year old man

Painful rash on right

buttock

with asthma

**Demographics,**

**Subjective complaints**

**Neurological**

**EMG findings**

 **Other tests**

**Treatment**

**Course/outcome**

**impairments**

Weakness and atrophy

Severe median and

CSF increased protein,

Analgesics,

therapy

 physical

Full recovery after

8 months

no cells

ulnar neuropathy

in hand muscles, reflexes diminished Weakness in left rectus

Denervation

external oblique

muscles

Fibrillations

positive waves in right

abdominal muscles

with later reinnervation

Splint

After 2 months mass

and power of the

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

deltoid had increased

 and

Not reported

Not reported

Full recovery after

4 months

 in

Not reported

Mild analgesia

> abdominis and oblique

muscles

Bulging of lateral and

anterior abdominal

wall


**Table2.**

 *Lists of studies that reviewed herpes zoster infection and motor paresis of arms and*

 *legs.* *3.1.1 Lower limb involvement*

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

*Extracranial Herpetic Paresis*

developed entire limb weakness.

teinorachia was discovered.

with lethal outcome.

*3.1.2 Diaphragmatic paralysis*

age of 67.13 11.50 years.

bypass [11].

**63**

found.

back pain [11].

in both legs.

There are 43 presented patients with isolated segmental zoster paresis of one leg in the total of 26 previously published papers. Nine of these papers present only zoster paresis of the lower limbs, while the rest of them describe affection of arms and torso, also. According to available information, mean age of this group of patients was 64.19 15.28, and the patient group was dominated by males (20/12). From medical history, these patients had: diabetes mellitus (4 patients), lymphatic leukemia [11], ulcerative colitis [11], myelofibrosis [11], renal failure [11], hypertension arterialis [43], dementia [11], restless legs syndrome, and chronic low

Almost all patients had weakness in one leg; but 3 of them developed weakness

In most cases, proximal muscles were affected (in 13 patients); then in much lesser number, distal muscles (6 patients) were affected; and only 4 of them had

Denervation has been the most common report (in 18 patients) among patients with electromyoneurography performed; reduced interference pattern was found in

Laboratory is sporadically performed in these patients: ELISA for HZV in sera done in 2 patients and were positive in IgG and IgM fraction in both of them, and in

A lumbar puncture was done in a small number of patients [44, 45]: cerebrospinal fluid (CSF) was normal in two cases, but in the other three patients, hyperpro-

The patient with flaccid paraparesis had elevated lymphocytes and hyperprotei-

MRI of lumbar spine performed in 4 patients did not explain the nature of deficit in these patients, and 2 patients were generally described by degenerative changes, 1 was normal, and in 1 enlargement and T2 signal in the left femoral nerve was

The most frequent treatments were physical therapy (4 patients), Acyclovir (2 patients), Methylprednisolone (2 patients), vitamins B1 and B12 [11], paravertebral

There is no information about outcome of the disease for some patients. However, among patients who were followed for a period of time, a majority of them (20 patients) fully or almost fully recovered in the period between 2 and 9 months; 11 patients recovered incompletely; 2 patients did not recover, and 2 patients had

Diaphragmatic paralysis due to phrenic nerve involvement with VZV is described in 24 previously published papers with a total of 26 patients with a mean

Among comorbidities in this population of patients are rheumatoid arthritis [11], leukemia [11], breast cancer [11], pyelonephritis and nephrectomy, hysterectomy [11], DM [11], hypertension [43], peptic ulcer [11], pancreatitis [11], and

Muscle atrophy was seen in 3 patients in this group (in *M. quadriceps*). With regard to other complications, 2 patients developed incontinency, 1 uri-

the third patient, performed VZV complement fixation was positive, also.

norachia in cerebrospinal fluid, while PCR for VZV was positive in this case.

sympathetic block [11], analgesics, and Gabapentin, lately [11].

nary retention, 1 ileus, and 2 abdominal wall weakness.

12 patients and polyphasia was present in 4 patients.

#### *3.1.1 Lower limb involvement*

There are 43 presented patients with isolated segmental zoster paresis of one leg in the total of 26 previously published papers. Nine of these papers present only zoster paresis of the lower limbs, while the rest of them describe affection of arms and torso, also. According to available information, mean age of this group of patients was 64.19 15.28, and the patient group was dominated by males (20/12).

From medical history, these patients had: diabetes mellitus (4 patients), lymphatic leukemia [11], ulcerative colitis [11], myelofibrosis [11], renal failure [11], hypertension arterialis [43], dementia [11], restless legs syndrome, and chronic low back pain [11].

Almost all patients had weakness in one leg; but 3 of them developed weakness in both legs.

In most cases, proximal muscles were affected (in 13 patients); then in much lesser number, distal muscles (6 patients) were affected; and only 4 of them had developed entire limb weakness.

Muscle atrophy was seen in 3 patients in this group (in *M. quadriceps*).

With regard to other complications, 2 patients developed incontinency, 1 urinary retention, 1 ileus, and 2 abdominal wall weakness.

Denervation has been the most common report (in 18 patients) among patients with electromyoneurography performed; reduced interference pattern was found in 12 patients and polyphasia was present in 4 patients.

Laboratory is sporadically performed in these patients: ELISA for HZV in sera done in 2 patients and were positive in IgG and IgM fraction in both of them, and in the third patient, performed VZV complement fixation was positive, also.

A lumbar puncture was done in a small number of patients [44, 45]: cerebrospinal fluid (CSF) was normal in two cases, but in the other three patients, hyperproteinorachia was discovered.

The patient with flaccid paraparesis had elevated lymphocytes and hyperproteinorachia in cerebrospinal fluid, while PCR for VZV was positive in this case.

MRI of lumbar spine performed in 4 patients did not explain the nature of deficit in these patients, and 2 patients were generally described by degenerative changes, 1 was normal, and in 1 enlargement and T2 signal in the left femoral nerve was found.

The most frequent treatments were physical therapy (4 patients), Acyclovir (2 patients), Methylprednisolone (2 patients), vitamins B1 and B12 [11], paravertebral sympathetic block [11], analgesics, and Gabapentin, lately [11].

There is no information about outcome of the disease for some patients. However, among patients who were followed for a period of time, a majority of them (20 patients) fully or almost fully recovered in the period between 2 and 9 months; 11 patients recovered incompletely; 2 patients did not recover, and 2 patients had with lethal outcome.

#### *3.1.2 Diaphragmatic paralysis*

Diaphragmatic paralysis due to phrenic nerve involvement with VZV is described in 24 previously published papers with a total of 26 patients with a mean age of 67.13 11.50 years.

Among comorbidities in this population of patients are rheumatoid arthritis [11], leukemia [11], breast cancer [11], pyelonephritis and nephrectomy, hysterectomy [11], DM [11], hypertension [43], peptic ulcer [11], pancreatitis [11], and bypass [11].

**Literature**

**62**

**medical history**

#2. 58-year old man

[10]

 #1. 47-year old man

#2. 70-year old female

with DM #3. 63-year old male

Rash of the right foot

and a right L5-S1

plexopathy

with DM #4. 80–90-year

with DM #5. 87-year old male

Rash in right lateral

arm and forearm Rash in right buttocks

and lateral calf

with DM #6. 60-70-year

(nn gender)

#7. 61-year old male

 Rash in left thumb,

After 15 days weakness

in left C6–8 myotomes

index finger and

forearm

anterolateral

thumb

**Table 2.** *Lists of studies that reviewed herpes zoster infection and motor paresis of arms and legs.*

 arm and

Weakness in right C5

Denervation

distribution

 in right C5

Increased signal in the

C5 nerve roots on MRI

myotomes

#8. 80-year old female Rash in right shoulder,

 old

Rash in neck first

 After 22 days right C8

Denervation

plexus brachialis

Denervation

C6–8 distribution

 in right

Increased signal in the

C6–8 nerve roots

 in right

> myotome weakness

After 14 days right C6–

8 myotome weakness

Weakness in right L5

Right L5

radiculoplexopathy

with denervation

Left C7 with denervation

radiculopathy

Increased signal in

median and radial

nerve on MRI

myotome

 Rash in right shoulder

and Rash in right lateral

arm and forearm

anterolateral

 arm

myotomes

After 20 days weakness

Right brachial

Hyperintensity

spinal dorsal horns at

C4–5

 in

plexopathy

denervation

 with

in right C5–7

myotomes

Weakness in right L5-

S1 myotomes

 Rash left side of neck

and right upper arm

**Demographics,**

**Subjective complaints**

**Neurological**

**EMG findings**

 **Other tests**

**Treatment**

**Course/outcome**

**impairments**

Weakness in both legs

Fibrillation

affecting muscles of

right limb

Denervation

distribution

 in C5–6

 potentials

Velocities affecting in

Physiotherapy,

After 11 months little

residual deficit

Recovery in 3 months

No recovery after

2.0 years No recovery after

1.8 years No recovery after

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

1.9 years No recovery 1.0 year Partial recovery after

1.0 year

No recovery after

0.5 year Partial recovery after

0.5 year

tetracycline

right median and

popliteal nerves

and right arm; reflexes

absent in all limbs Weakness in right C5–6

Hemidiaphragmatic paresis is unilateral usually, predominantly on the left side [46], while in one patient, hemidiaphragmatic affection on both sides were recorded.

patient in each group and 1 in group with diaphragmatic paresis suffered from DM and as per 4 patient in both groups of patients with limb segmental paresis on

In clinical presentation of HZ infection, pain usually precedes the onset of the rash, and most patients have skin lesions that develop within 7 days of onset of

Motor palsy is usually segmental, with abrupt onset reaching its maximum within a few hours [31], corresponding to the dermatomes with cutaneous lesions [18]. Interval between skin eruptions and onset of muscle weakness is generally about 2 weeks in cases with developing segmental paresis [54], but there are some reports of weakness and rash developing simultaneously [55]. With reference to the literature, maximal rash-to-weakness interval in patients with segmental limb paresis was 19 days [37] although there are different experiences. Variations in rash-

to-weakness interval is best illustrated in a study of 51 patients: <3 days in 6 patients, 3–6 days in 12, 7–10 days in 14, 11–14 days in 11, 15–20 days in 5, 21–28 days in 2, and 29–35 days in 1 [33]. A delay of 4.5 months has been documented in a patient with diaphragmatic paralysis [56], when the average minimum duration of weakness was 193 days [57]. The fact that the phrenicus nerve is a motor nerve and is the longest in the body is the explanation for such a long period of time required for the development of paralysis of phrenic nerve. Limb involvement by segmental zoster paresis is seen from 0.5 to 0.8% of all

Phrenic nerve affection was described in 26 patients (**Table 4**).

exercise that may prevent muscle atrophy and contractures [17].

postherpetic neuralgia persisted in 2 and 6.6% [32, 33].

reported pain as the postherpetic neuralgia type (**Tables 1–3**).

Upper extremity involvement is the most common region of extracranial zoster paresis involvement. There are a total of 101 patients with segmental paresis of upper limbs in recently published papers: 55 women and 45 men (**Tables 1** and **3**). Segmental zoster paresis of the legs present in less than half the number (43 patients with leg involvement) dominated by males (20/12) (**Tables 2** and **3**).

Among patients with limb paresis, proximal muscle involvement usually predominates (C5, 6, 7 or L2, 3, 4). The most commonly affected muscle is deltoid in

Besides weakness in upper limbs affected by segmental zoster paresis, in 9 patients, muscle atrophy was detected and in 3 patients in group had leg affection

It is important to recognize severe muscle weakness and atrophy in herpes zoster paresis of limb because it can be so severe to cause marked dislocation of the joint. Because of that, except pain medication, treatment for segmental paresis includes

Risk of postherpetic neuralgia and pain after 3 months of HZ infection increased and occurs in 8–70% of patients with HZ. People above 50 years are 15 times more

In studies involving a larger number of patients with segmental zoster paresis,

Among the patients monitored over several months and multiyear period, 13 patients with segmental zoster paresis of arm and 6 patients with paresis of leg have

The clinical diagnosis makes pain followed by rash and by weakness at the end. Once the rash appears, diagnosis of HZ can be made and laboratory confirmation is

Some patients may have zoster sine herpete, and it is zoster infection without vesicular eruptions. In making this diagnosis benefit is from varicella zoster virus antibodies in sera or cerebrospinal fluid [13]. In rare cases with herpes sine herpete, cases with prolonged period between rash and muscular weakness and cases with

chronic steroid therapy because of autoimmune disorders.

patients with cutaneous zoster [10, 11].

likely to develop this complication [79].

upper limbs [78].

(in *M. quadriceps*).

not always required.

**65**

pain [32].

*Extracranial Herpetic Paresis*

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

Although EMNG of phrenic nerve is one of the reliable signs of affection in this nerve, it is rarely performed (1 patient). More often, fluoroscopy is performed when weakness of the diaphragm is suspected (7 patients). Although not a reliable sign of weakness of the diaphragm, X-ray is often done in the case of a suspected weakness of the diaphragm paresis (13 patients).

Phrenic nerve affection is usually followed by dyspnea, but there is a case with hemidiaphragmatic paresis on X-ray, but without visible dyspnea.

To the contrary, there are cases with normal hemidiaphragm position on non-CT chest, when dyspnea is present clinically.

Half of the patients [47] did not recover after significant a follow-up period (1 year and more). Partial recovery was seen in significantly smaller number of patients [48], while complete recovery was present in the fewest number of patients [42].

In most cases, the type of treatment of these patients was not mentioned: Acyclovir in 2 patients, Valacyclovir in 1 patient, physical therapy in 1 patient, and topical hydrocortisone in 1 patient.

The incidence of segmental zoster abdominal paresis mimicking an abdominal hernia is relatively rare. After review from 2013 [49] with 36 patients and segmental zoster paresis of abdominal muscle (14), 8 papers with 11 patients with this problem have been published.

Their mean age (66.5 years) is not much different from the average age of the patients in the review paper from 2013 (67.5 years).

As in the review paper, the predominant level of abdominal involvement of herpes zoster was Th11.

It is the most important to exclude organic disease of the abdomen in the case of abdominal herniation when beneficial are ultrasound or CT abdomen showing normal results.

This is particularly relevant when the abdominal herniation is complicated with, for example, ileus, which is described in 1 patient.

The presence of denervation potentials in EMG of paraspinal (3 patients), or abdominal muscles (2 patients), indicates the involvement of the abdominal musculature, which separates EMG as well as a particularly useful diagnostic method in this case.

Prognosis of these patients is generally good, and there is full recovery in almost all of them in just few months [42, 43, 50].

Acyclovir is rarely used as a therapy in these patients (2 patients).

### **4. Discussion**

Increasing rate of herpes zoster infection with increasing age particularly after age 50 years can be explained by natural decline in cell-mediated immunity to VZV with age [51]: the mean age of patients with the most frequent segmental paresis was for arms 68.56 11.97 years and for legs 64.19 15.28 years.

Healthy people can get HZ [31], although immunocompromised individuals are known to be at increased risk of reactivation and VZV infection [52].

The most immunocompromised patients with zoster paresis have a coexisting malignancy, diabetes mellitus, and chronic steroid therapy [53]: 7 patients suffering from lymphoma and 2 with carcinoma mammae in group with arm segmental paresis and 1 patient with segmental paresis of leg had lymphatic leukemia; as per 4

#### *Extracranial Herpetic Paresis DOI: http://dx.doi.org/10.5772/intechopen.90493*

Hemidiaphragmatic paresis is unilateral usually, predominantly on the left side

Although EMNG of phrenic nerve is one of the reliable signs of affection in this

Phrenic nerve affection is usually followed by dyspnea, but there is a case with

To the contrary, there are cases with normal hemidiaphragm position on non-CT

Half of the patients [47] did not recover after significant a follow-up period (1 year and more). Partial recovery was seen in significantly smaller number of patients [48], while complete recovery was present in the fewest number of

In most cases, the type of treatment of these patients was not mentioned: Acyclovir in 2 patients, Valacyclovir in 1 patient, physical therapy in 1 patient, and

The incidence of segmental zoster abdominal paresis mimicking an abdominal hernia is relatively rare. After review from 2013 [49] with 36 patients and segmental zoster paresis of abdominal muscle (14), 8 papers with 11 patients with this problem

Their mean age (66.5 years) is not much different from the average age of the

It is the most important to exclude organic disease of the abdomen in the case of

This is particularly relevant when the abdominal herniation is complicated with,

Prognosis of these patients is generally good, and there is full recovery in almost

Increasing rate of herpes zoster infection with increasing age particularly after age 50 years can be explained by natural decline in cell-mediated immunity to VZV with age [51]: the mean age of patients with the most frequent segmental paresis

Healthy people can get HZ [31], although immunocompromised individuals are

The most immunocompromised patients with zoster paresis have a coexisting malignancy, diabetes mellitus, and chronic steroid therapy [53]: 7 patients suffering from lymphoma and 2 with carcinoma mammae in group with arm segmental paresis and 1 patient with segmental paresis of leg had lymphatic leukemia; as per 4

Acyclovir is rarely used as a therapy in these patients (2 patients).

was for arms 68.56 11.97 years and for legs 64.19 15.28 years.

known to be at increased risk of reactivation and VZV infection [52].

The presence of denervation potentials in EMG of paraspinal (3 patients), or abdominal muscles (2 patients), indicates the involvement of the abdominal musculature, which separates EMG as well as a particularly useful diagnostic method in

As in the review paper, the predominant level of abdominal involvement of

abdominal herniation when beneficial are ultrasound or CT abdomen showing

[46], while in one patient, hemidiaphragmatic affection on both sides were

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

hemidiaphragmatic paresis on X-ray, but without visible dyspnea.

weakness of the diaphragm paresis (13 patients).

patients in the review paper from 2013 (67.5 years).

for example, ileus, which is described in 1 patient.

all of them in just few months [42, 43, 50].

chest, when dyspnea is present clinically.

topical hydrocortisone in 1 patient.

nerve, it is rarely performed (1 patient). More often, fluoroscopy is performed when weakness of the diaphragm is suspected (7 patients). Although not a reliable sign of weakness of the diaphragm, X-ray is often done in the case of a suspected

recorded.

patients [42].

have been published.

herpes zoster was Th11.

normal results.

this case.

**4. Discussion**

**64**

patient in each group and 1 in group with diaphragmatic paresis suffered from DM and as per 4 patient in both groups of patients with limb segmental paresis on chronic steroid therapy because of autoimmune disorders.

In clinical presentation of HZ infection, pain usually precedes the onset of the rash, and most patients have skin lesions that develop within 7 days of onset of pain [32].

Motor palsy is usually segmental, with abrupt onset reaching its maximum within a few hours [31], corresponding to the dermatomes with cutaneous lesions [18]. Interval between skin eruptions and onset of muscle weakness is generally about 2 weeks in cases with developing segmental paresis [54], but there are some reports of weakness and rash developing simultaneously [55]. With reference to the literature, maximal rash-to-weakness interval in patients with segmental limb paresis was 19 days [37] although there are different experiences. Variations in rashto-weakness interval is best illustrated in a study of 51 patients: <3 days in 6 patients, 3–6 days in 12, 7–10 days in 14, 11–14 days in 11, 15–20 days in 5, 21–28 days in 2, and 29–35 days in 1 [33]. A delay of 4.5 months has been documented in a patient with diaphragmatic paralysis [56], when the average minimum duration of weakness was 193 days [57]. The fact that the phrenicus nerve is a motor nerve and is the longest in the body is the explanation for such a long period of time required for the development of paralysis of phrenic nerve.

Limb involvement by segmental zoster paresis is seen from 0.5 to 0.8% of all patients with cutaneous zoster [10, 11].

Upper extremity involvement is the most common region of extracranial zoster paresis involvement. There are a total of 101 patients with segmental paresis of upper limbs in recently published papers: 55 women and 45 men (**Tables 1** and **3**).

Segmental zoster paresis of the legs present in less than half the number (43 patients with leg involvement) dominated by males (20/12) (**Tables 2** and **3**).

Phrenic nerve affection was described in 26 patients (**Table 4**).

Among patients with limb paresis, proximal muscle involvement usually predominates (C5, 6, 7 or L2, 3, 4). The most commonly affected muscle is deltoid in upper limbs [78].

Besides weakness in upper limbs affected by segmental zoster paresis, in 9 patients, muscle atrophy was detected and in 3 patients in group had leg affection (in *M. quadriceps*).

It is important to recognize severe muscle weakness and atrophy in herpes zoster paresis of limb because it can be so severe to cause marked dislocation of the joint. Because of that, except pain medication, treatment for segmental paresis includes exercise that may prevent muscle atrophy and contractures [17].

Risk of postherpetic neuralgia and pain after 3 months of HZ infection increased and occurs in 8–70% of patients with HZ. People above 50 years are 15 times more likely to develop this complication [79].

In studies involving a larger number of patients with segmental zoster paresis, postherpetic neuralgia persisted in 2 and 6.6% [32, 33].

Among the patients monitored over several months and multiyear period, 13 patients with segmental zoster paresis of arm and 6 patients with paresis of leg have reported pain as the postherpetic neuralgia type (**Tables 1–3**).

The clinical diagnosis makes pain followed by rash and by weakness at the end. Once the rash appears, diagnosis of HZ can be made and laboratory confirmation is not always required.

Some patients may have zoster sine herpete, and it is zoster infection without vesicular eruptions. In making this diagnosis benefit is from varicella zoster virus antibodies in sera or cerebrospinal fluid [13]. In rare cases with herpes sine herpete, cases with prolonged period between rash and muscular weakness and cases with


**Literature**

**67**

**medical history**

[64]

 60-year old man with

Burning pain along the

Weakness of the right

Fibrillations

positive sharp waves in

the right

 and

MRI of lumbosacral

area: changes; ELISA test

degenerative

oral gabapentin

900 mg/day

ankle plantar flexors

(3/5 on MRC scale)

and diminished

jerk

 ankle

gastrocnemius

paravertebral

(S1 root); polyphasic

MUAP during activation of right foot,

nerve conduction

unchanged

[65]

 74-year old with

5-day history of

Vesicular rash in the L2/3 region with MRC

grading 3/5 in the right

hip flexors

Worsening

baseline residual muscle strength in the

right lower limb

shortly after herpes

zoster eruption

 of her

EMG: denervation L3-L4 and moderate

axonal affecting both lower

limbs

polyneuropathy

 in

paraesthesia

 starting in

diabetes mellitus,

hypertension,

ischemic heart disease

[40]

 37-year old-female with

history of paresis in

both legs secondary to

spinal cord atrophy and

Vogt-Koyanagi-Harada

disease and with

chronic

and

treatment of ulcerative

colitis

**Table 3.**

*Lists of studies that reviewed herpes zoster infection and motor paresis of only lower limbs.*

azathioprine

corticosteroid

 and

the right foot and

ascending up the right

lower limb

 was MRI:

unremarkable

 Acyclovir i.v.

Motor paresis that

recovered fully with

resolution of the rash

 muscles

positive for IgM and

IgG

 and

on VZV in sera

inner aspect of the right

lower leg (6/10) and

rash, weakness of the

right foot

lymphatic leukemia

**Demographics,**

**Subjective complaints**

**Neurological**

**EMG findings**

 **Other tests** highly positive; X-

transfusions;

acyclovir i.v.

Physical therapy and

 high-dose

complicated

pneumonia

Motor weakness completely resolved

about 6 months after

the onset of

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

neurologic symptoms

but the pain was

sporadic but mild

 and death

*Extracranial Herpetic Paresis*

 by

> ray: ileus

**Treatment**

**Course/outcome**

**impairments**


### *Extracranial Herpetic Paresis DOI: http://dx.doi.org/10.5772/intechopen.90493*

**Table 3.**

 *limbs.*

**Literature**

**66**

**medical history**

[58]

 40-year old women; in

Rash on left buttock, burning pain in lower

back, hip, and left leg

contact with a child

with chicken pox

[59]

 20-year old man,

Numbness in left foot;

Weakness in left ankle

Not reported

Not reported

 B1 and B12 injections

 Full recovery after

2 months

dorsiflexors

pain and rash over left

gluteal region Rash and pain in right

The right ankle plantar

Not reported

ELISA test on HZV in

Not reported

Unknown recovery of

leg function, some

bladder recovery

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

sera was positive for

IgM and IgG, which

confirmed the

presence of HZ

infection

flexors (3/5 on MRC

scale) and diminished

ankle jerk

lower back, urinary

retention, weakness in

right leg, diminished

sensation in lumbar and

sacral segments

chicken pox at age 7

[60]

 31-year old man,

diabetes, end stage

renal failure with

maternal renal allograft, autonomic

neuropathy,

[61]

 57-year old man

 Rash over left T8–9

Flaccid paralysis of

Not reported

CPK: mild transient

Not reported

Full recovery after

3 months

elevation; VZV

complement

positive

 fixation

both legs, reflexes

absent

dermatomes,

hyperalgesia

legs, unable to walk,

fasciculations

legs

Pain in buttocks and

Moderate weakness in

Diffuse denervation

leg and paraspinal

muscles in L3–5

myotomes

 in

X-ray: mild

acetaminophen,

Near complete

recovery

oxytocin, bed rest,

bupivacaine

epidural catheter;

parenteral meperidine

 via L4–5

narrowing of L5-S1

disc space; spine

MRI: right L4–5 facet

joint disease

knee flexors/

extensors, mild in

ankle flexors; reflexes

[62]

 70-year old woman,

with

hypertension

legs; rash over left knee,

thigh, buttocks;

hyperesthesia

urinary

[63]

 78-year old man,

Sudden weakness in both legs; rash in right

lower leg involving

knee and thigh

idiopathic

myelofibrosis

cytoreductive

 therapy

 receiving

 in left leg;

incontinence

absent in left knee,

ankle

Bilateral leg paralysis

 Not reported

CSF: increased

Wide spectrum

After initial improvement,

progressive

 worsening

antibiotic, granulocyte

lymphocytes,

monocytes,

glucose; PCR on VZV

 protein,

colony stimulating factor and erythrocyte

 in both

 in both

 blindness

**Demographics,**

**Subjective complaints**

**Neurological**

**EMG findings**

 **Other tests**

**Treatment**

**Course/outcome**

**impairments**

Moderate weakness in

Normal

Blood and CSF

Intrathecal

Complete motor

recovery after

9 months

Methylprednisolone,

analgesics, bed rest,

sodium iodide and

oxytetracycline

hydrocortisone

ointment for rash

 i.v.;

normal, chest and

spine X-ray normal

left ankle plantar

flexors

*Lists of studies that reviewed herpes zoster infection and motor paresis of only lower*


**Literature**

**69**

**medical history**

[70]

 74-year old

female

[71]

 80-year old

HZ in C3-6

 Dyspnea, upper limb muscle

weakness

female,

hypertension,

histerectomy

[72]

 74-year old male,

HZ in C2-5

 deltoid muscle weakness, dyspnoea

pulmonary

emphysema

[16]

 #2. 60-year old

Rash and

coughing; enlarged liver;

 Not reported

 Chest X-ray: elevated

right paralysis confirmed on

fluoroscopia

hemidiaphragm,

Complete

Recovery

after 1 month

not

alleviated

after 4 month After 12 months not

alleviated

After 4 month not alleviated

One year after

muscle strength returned

to normal, but

radiographic

 and electrophysiologic

of diaphragm paralysis were

unchanged.

 findings

hypersensitivity

 in

man with lymphatic

right C5

dermatome

leukemia

[56]

[73]

 79-year old male,

HZ in cervix

dyspnea,

orthopnea

hypertension,

region

carotid

endarterectomy,

bypass

[56]

[42]

 A 73-year old

herpes zoster of

left shoulder and

proximal arm

woman

 74-year old male HZ in cervix

 cough, dyspnea

weakness of left shoulder and

involvement

C5-6 myotomes and

the upper trunk of the

brachial plexus

 of the

Chest X-ray and

electromyographic

studies paralysis of the left.

documented

proximal arm muscles 3 weeks

after a diagnosis of herpes zoster

 74-year old male HZ in 1st cervix

 cough, dyspnea

**Demographics,**

**Subjective**

**Neurological**

**impairments**

 **EMG findings**

 **Other tests**

**Treatment**

**Course/Outcome**

*Extracranial Herpetic Paresis*

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

**complaints**

HZ in C3,4

 dysponea


## *Extracranial Herpetic Paresis DOI: http://dx.doi.org/10.5772/intechopen.90493*

**Literature**

**68**

**medical history**

[66]

[67]

 80-year old

Pain and rash over

weakness of left sholder and

denervation

infraspinatus

supraspinatus

 and

 of

Rtg- paretic left

hemidiaphragm

proximal muscles, atrophy of

supraspinatus

muscles; dyspnoea on left

hemidiaphragm

 and

infraspinatus

left shoulder and

anterior part of

chest

female,

nephrectomy

because

pyelonephritis

[44, 45]

 56-year old male

rash and pain in

general weakness of right arm

X-ray and

fluoroscopy-complete

paralysis of rigth

hemidiaphragm

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

and hand, atrophy of right part

of neck, paralysis right

hemidiaphragm

later aspect of

right arm and 3

middle fingers Rash and pain in

paralysis right

hemidiaphragm

C3-5 dermatome

[68]

 77, F

rheumatoid

artritis, DM

[46]

 72-year old

Rash and pain in

dyspnoea

right C3,4

dermatome

female, RA, hypertension

[69]

 66-year old

HZ of left C3,4,5

 after 12 months dyspnoea

X-ray

–elevated left

hemidiaphragm;

Radioscopy-paralysis

of left

X-ray

–elevated left

hemidiaphragm

hemidiaphragm

female

[50]

 56, male

HZ in 1st cervix

none

dermatome

bronchitis

62-year old

HZ in 1st cervix

dysponea

dermatome

female astma

67-year old

HZ in 1st cervix

 dysponea

 dysponea

female

57-year old female HZ in 1st cervix

with peptic ulcer

 M, 53-year old

 HZ in C3,4

dyspnoea

dermatome

**Demographics,**

**Subjective**

**Neurological**

**impairments**

 **EMG findings**

 **Other tests**

**Treatment**

**Course/Outcome**

**complaints**


**Literature**

**71**

**medical history**

[77]

 85-year old female

breast cancer at

age 84,

pancreatitis,

choleatitis

[48]

**Table 4.**

*Lists of studies that reviewed herpes zoster infection and motor paresis of* 

*diaphragmatic*

 *paralysis.*

 43-year old man Rash on right neck

and apper right

hiccups

hemithorax

 C3-5

**Demographics,**

**Subjective**

**Neurological**

**impairments**

 **EMG findings**

 **Other tests** A chest X-ray elevated

Famciclovir

days at a dose of

no alleviation

*Extracranial Herpetic Paresis*

750 mg per day.

On X-ray

intravenous

admitted to the hospital

 acyclovir and

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

paralysis of the

right

hemidiaphragm,

HIV +

 for 7

After 14 months dyspnea and

> left diaphragm

**Treatment**

**Course/Outcome**

**complaints**

Rash and pain in

her left neck, chest, and arm in

C4,5 dermatome


**Table 4.**

*Lists of studies that reviewed herpes zoster infection and motor paresis of diaphragmatic paralysis.*

**Literature**

**70**

**medical history**

[74]

[75] [76]

 54-year old male thoracic herpes

zoster,

bilateral associated with brachial

neuritis,

orthopnea,

deltoid and biceps

brachii muscle

weakness

weakness of left shoulder and

EMG – reduced recruitment

od MUP

denervation,

Chest X-ray- paralysis

Weakness of arm return to

normal after one year but

X-ray of paralysis

hemidiaphragm

unchanged

 was

of the left diaphragm.

proximal arm muscles 3 weeks

after HZ was diagnosed and

paralysis of left

hemidiaphragm

Phrenic nerve

conduction

denervation

MUP

CT of chest normal,

1000 mg

Pain resolved three

months

later,

follow-up for

valacyclovir

orally

three times daily

for seven days.

2 years

*…*

without further

complications.

[21]

 A 48-year old

rash and vesicles

weakness in the left deltoids and

biceps muscles, diminished

biceps reflex. dyspnoea with

paradoxical

movement

 abdominal wall

 left in spinal cord at C5

level

MRI-hyper-intensity

over left C5-7

dermatomes

female

 without

 study-

[42]

 73-year old

HZ and pain of left

shoulder

woman

diaphragmatic

 paralysis

> 1st chest, neck,

bilateral shoulders

HZ in left side of

Dyspnea after 3 months

neck

 74-year old man

 HZ on left

Left

hemidiaphragm

 paralysis

 Axonal changes in left

CT and

Acyclovir

 not allevia after 18 months

X-ray- left

hemidiaphragmatic

relaxation

X-ray- left

hemidiaphragm

relaxation;

Pulmo-rary

restriction

Fluoroscopy

not allevia after 19 months

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

 functions-

nervus phrenicus

shoulder and neck

**Demographics,**

**Subjective**

**Neurological**

**impairments**

 **EMG findings**

 **Other tests**

**Treatment**

**Course/Outcome**

**complaints**

dissociation between motor segment and level of dermatomal involvement recommended laboratory confirmation of VZV infection because herpes zoster paresis may be difficult to recognize in these cases.

Possible explanation for zoster sine herpete and for herpes zoster paresis without associated dermatome eruption could be viral spread to anterior roots without corresponding axonal transport through the sensory nerve [6, 12].

r-

Electrophysiologic study of segmental zoster paresis found reinnervation of muscles, absence of fasciculations in involved muscles, and slow motor nerve conduction velocity suggesting motor axon injury rather than anterior horn cells [80].

In electromyoneurography of 58 patients with arm paresis, 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) and reduced motor or sensor velocity in 4 patients.

Denervation has been the most common report (in 18 patients) among patients who had electromyoneurography of leg paresis; reduced interference pattern in 12 patients and polyphasia in 4 patients were present.

Although EMNG of phrenic nerve is one of the reliable signs of affection in this nerve, it is rarely performed (1 patient).

The presence of denervation potentials in electromyography of paraspinal (3 patients), or in abdominal muscles (2 patients), indicates involvement of the abdominal musculature, which separates EMG as well as a particularly useful diagnostic method in case of abdominal wall zoster paresis (**Table 5**). Because of its selflimited nature and good prognosis, recognition of this complication is important to prevent unnecessary diagnostic studies and procedures, and because of that, abdominal hernia needs no surgery. Thus, electrodiagnostic studies can be effectively used to confirm the diagnosis.

The treatment for segmental zoster paresis includes physical therapy for weakened muscles and protection contractures with graduated exercise. This program may prevent muscle atrophy. Muscle weakness and atrophy can be so severe to cause marked dislocation of the involved joint [17].

In segmental paresis of arm, in most cases, a way of treating these patients is not mentioned. In others, physical therapy was the most common way of treating these patients (24 reported patients) and patients with leg affection, also (4 patients).

Beside physical therapy, for these patients, it is often necessary to provide pain medication, and therefore they are usually given analgesics, opioids, Amitriptyline, Pregabalin, and Gabapentin.

According to some recommendations, initiating treatment with antiviral agents as soon as the rash appears is the key to improve the outcome of herpes zoster. A 3 week course of oral corticosteroids (prednisone 60 mg/day for first week, 30 mg/ day for second week, and 15 mg/day for third week) administered with the antiviral medication also has some effect on severity and duration of pain and may decrease the incidence of postherpetic neuralgia [87]. Local, epidural, and sympathetic blocks, if administered within the first 2 weeks of disease, have been reported to decrease pain and the incidence of postherpetic neuralgia [88, 89].

Initiating treatment with antiviral agents as soon as the rash appears is the key to improve the outcome of herpes zoster. As the effect of this therapy on the development of segmental paresis is not known, despite such recommendations, it appears that very small number of patients from the literature with segmental zoster paresis was treated with antiviral medication and corticosteroids. Among the antiviral drugs, Valacyclovir and Acyclovir (in total 13 patients) and corticosteroids in total 5 patients were usually used.

Previous experience in groups with a higher number of patients with segmental zoster paresis shows that the outcome of lower motor neuron involvement is

**Abominal**

**73**

**Demographics,**

 **medical**

**Subjective complaints**

**Neurological**

**EMG findings**

 **Other tests**

 **Treatment**

Orthosis Exercise

After 4 months of

rehabilitation,

improvement

*Extracranial Herpetic Paresis*

 marked

**Course/outcome**

**impairments**

**wall**

[81]

 73-year old man with L3

vertebral fracture and RA

(Prednisolone)

[82]

[83] [43]

[47]

 35 articles that described

The most affected

In 88.9% of the patients,

herpetic rash preceded abdominal weakness. The

mean latent period from

rash to onset of abdominal muscle weakness was 3.5 weeks.

dermatome

rash is T11. The left and

right sides were

approximately

affected

 equally

 was with

36 individuals;

was 67.5 years. The ratio

of men to women was 4:1.

 mean age

 62-year old male

Cutaneous vesicular

Abdominal

and paralytic ileus

because of a visceral

neuropathy

 distention

> eruption on the left side

of the abdominal wall

 72-year old man

Herpes zoster infection

in T11-T12 left

dermatomes

compression

Rash and pain with

T12 and L1 segmental

Denervation

T12 myotomal muscles, and MUAP

markedly decreased

 in right

> paresis caused abdominal

wall scoliosis, and standing

and gait disturbance

Segmental abdominal

Denervation

external oblique

muscle and left paraspinal muscles at

T11-T12 level MRI- increased

Full recovery

> signal intensity in

abdominal wall

muscles. Ultrasound-

 normal

X-rays and CT

Acyclovir iv,

Full recovery abdominal

distention gradually resolved over the next 7

oral Valacyclovir,

Gabapentin

after admission

Electrodiagnostic

studies confirmed the diagnosis in 95%

of tested patients.

Conservative

Complete recovery with

conservative

occurred in 79.3% patients, with a mean

time of 4.9 months

 measures

measures

 8 d

days and pain subsided

showed distended

small bowel

Abdominal

postherpetic pseudohernia

 wall

 in left

SSEPs- no response

After 3 months

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

abdominal wall protrusion had

completely resolved

in the left side at T12

dermatome

wall protrusion

pseudohernia,

blisters on his right flank

**history**


r-

### *Extracranial Herpetic Paresis DOI: http://dx.doi.org/10.5772/intechopen.90493*

dissociation between motor segment and level of dermatomal involvement recommended laboratory confirmation of VZV infection because herpes zoster

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

associated dermatome eruption could be viral spread to anterior roots without

Electrophysiologic study of segmental zoster paresis found reinnervation of muscles, absence of fasciculations in involved muscles, and slow motor nerve conduction velocity suggesting motor axon injury rather than anterior horn cells [80]. In electromyoneurography of 58 patients with arm paresis, 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) and

Denervation has been the most common report (in 18 patients) among patients who had electromyoneurography of leg paresis; reduced interference pattern in 12

Although EMNG of phrenic nerve is one of the reliable signs of affection in this

The treatment for segmental zoster paresis includes physical therapy for weakened muscles and protection contractures with graduated exercise. This program may prevent muscle atrophy. Muscle weakness and atrophy can be so severe to

In segmental paresis of arm, in most cases, a way of treating these patients is not mentioned. In others, physical therapy was the most common way of treating these patients (24 reported patients) and patients with leg affection, also (4 patients). Beside physical therapy, for these patients, it is often necessary to provide pain medication, and therefore they are usually given analgesics, opioids, Amitriptyline,

According to some recommendations, initiating treatment with antiviral agents as soon as the rash appears is the key to improve the outcome of herpes zoster. A 3 week course of oral corticosteroids (prednisone 60 mg/day for first week, 30 mg/ day for second week, and 15 mg/day for third week) administered with the antiviral medication also has some effect on severity and duration of pain and may decrease the incidence of postherpetic neuralgia [87]. Local, epidural, and sympathetic blocks, if administered within the first 2 weeks of disease, have been reported to

Initiating treatment with antiviral agents as soon as the rash appears is the key to improve the outcome of herpes zoster. As the effect of this therapy on the development of segmental paresis is not known, despite such recommendations, it appears that very small number of patients from the literature with segmental zoster paresis was treated with antiviral medication and corticosteroids. Among the antiviral drugs, Valacyclovir and Acyclovir (in total 13 patients) and corticosteroids in total 5

Previous experience in groups with a higher number of patients with segmental

zoster paresis shows that the outcome of lower motor neuron involvement is

decrease pain and the incidence of postherpetic neuralgia [88, 89].

The presence of denervation potentials in electromyography of paraspinal (3 patients), or in abdominal muscles (2 patients), indicates involvement of the abdominal musculature, which separates EMG as well as a particularly useful diagnostic method in case of abdominal wall zoster paresis (**Table 5**). Because of its selflimited nature and good prognosis, recognition of this complication is important to prevent unnecessary diagnostic studies and procedures, and because of that, abdominal hernia needs no surgery. Thus, electrodiagnostic studies can be effec-

corresponding axonal transport through the sensory nerve [6, 12].

Possible explanation for zoster sine herpete and for herpes zoster paresis without

*…*

paresis may be difficult to recognize in these cases.

reduced motor or sensor velocity in 4 patients.

nerve, it is rarely performed (1 patient).

tively used to confirm the diagnosis.

Pregabalin, and Gabapentin.

patients were usually used.

**72**

patients and polyphasia in 4 patients were present.

cause marked dislocation of the involved joint [17].


 **5.** *Lists of studies that reviewed herpes zoster infection and motor paresis of abdominal*

 *wall.* elatively good [55]. Motor paralysis is recovered completely or nearly completely in 50–70% of cases usually within 12 months, spontaneously [11]. The time of recovery

Among presented patients with known clinical outcomes, complete or near complete recovery is recorded in 9 patients with arm involvement and in 20

Incomplete recovery was reported in 3 patients with arm affection and in 11 patients with leg affection (**Tables 1–3**). Two patients from each group, with segmental paresis of arms and legs, had no clinical recovery. As possible explanation of absence of a complete recovery after motor segmental paralysis caused by herpes

Prognosis in patients with diaphragmatic paralysis is not good because of prolonged reinnervation of diaphragm due to relatively long course of phrenic nerve affection, and the lack of spontaneous recovery is not surprising [74]. It is common for zoster phrenic nerve affection and associated diaphragmatic paralysis

There are interesting experiences related to Piramat. It may reverse phrenic nerve paralysis in patients with diabetes, but there are no data about its use in

It is important to distinguish segmental zoster paresis of abdominal wall from real abdominal wall hernia because abdominal wall hernia is mainly treated by surgery, while segmental zoster abdominal paresis needs no surgery. Ultrasonography or computed tomography (CT) is necessary to do in this case. Electromyographic testing revealed denervation in the affected dermatome and pseudohernia caused by abdominal wall paresis and is of great benefit in defining the problem and

Segmental zoster paresis is a rare complication of VZV infection. Increasing rate of herpes zoster infection and its segmental paresis is confirmed by the mean age of

Recognizing segmental zoster paresis is important in the differential diagnosis of

Physical therapy is the most common therapy for these patients, although a lot

Prognosis for these patients is generally good, and there is full recovery in most cases, except VZV infection of phrenic nerve and diaphragmatic paresis, where there is no significant recovery of muscle weakness in significant number of

muscle weakness of other origin—it is of particular importance to perform

of patients did not conducted any specific way of treatment.

to be permanent, but occasionally, recovery has been reported after 7 and

varies from 1 to 2 years [90]. Only 15% have significant deficit [33].

zoster is glial scar polyradiculitis evident on MRI [91].

patients with zoster-induced diaphragmatic paralysis [90].

patients with leg affection.

*Extracranial Herpetic Paresis*

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

12 months [92].

**5. Conclusion**

patients.

**75**

recommended in these situations.

presented patients‑it is above 65 years.

electromyoneurography of paretic muscle.

#### *Extracranial Herpetic Paresis DOI: http://dx.doi.org/10.5772/intechopen.90493*

elatively good [55]. Motor paralysis is recovered completely or nearly completely in 50–70% of cases usually within 12 months, spontaneously [11]. The time of recovery varies from 1 to 2 years [90]. Only 15% have significant deficit [33].

Among presented patients with known clinical outcomes, complete or near complete recovery is recorded in 9 patients with arm involvement and in 20 patients with leg affection.

Incomplete recovery was reported in 3 patients with arm affection and in 11 patients with leg affection (**Tables 1–3**). Two patients from each group, with segmental paresis of arms and legs, had no clinical recovery. As possible explanation of absence of a complete recovery after motor segmental paralysis caused by herpes zoster is glial scar polyradiculitis evident on MRI [91].

Prognosis in patients with diaphragmatic paralysis is not good because of prolonged reinnervation of diaphragm due to relatively long course of phrenic nerve affection, and the lack of spontaneous recovery is not surprising [74]. It is common for zoster phrenic nerve affection and associated diaphragmatic paralysis to be permanent, but occasionally, recovery has been reported after 7 and 12 months [92].

There are interesting experiences related to Piramat. It may reverse phrenic nerve paralysis in patients with diabetes, but there are no data about its use in patients with zoster-induced diaphragmatic paralysis [90].

It is important to distinguish segmental zoster paresis of abdominal wall from real abdominal wall hernia because abdominal wall hernia is mainly treated by surgery, while segmental zoster abdominal paresis needs no surgery. Ultrasonography or computed tomography (CT) is necessary to do in this case. Electromyographic testing revealed denervation in the affected dermatome and pseudohernia caused by abdominal wall paresis and is of great benefit in defining the problem and recommended in these situations.
