Bell's Palsy Gilden, Donald H
The New England journal of medicine,
09/2004, Letnik:
351, Številka:
13
Journal Article
Recenzirano
A healthy 50-year-old man notices that his face is drooping on the right side. On examination, facial asymmetry is evident, and some saliva has accumulated on the right side of the patient's mouth. ...When the patient attempts to close his eyes, his right eye does not close, although it rolls upward, and he is unable to show his teeth or inflate his cheek on the right. How should the patient be evaluated? Does he need immediate treatment?
A healthy 50-year-old man notices that his face is drooping on the right side. Does he need immediate treatment?
Foreword
This
Journal
feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations.
Stage
A healthy 50-year-old man notices that his face is drooping on the right side. On examination, facial asymmetry is evident, and some saliva has accumulated on the right side of the patient's mouth. When the patient attempts to close his eyes, his right eye does not close, although it rolls upward, and he is unable to show his teeth or inflate his cheek on the right. How should the patient be evaluated? Does he need immediate treatment?
The Clinical Problem
The most common causes of the abrupt onset of unilateral facial weakness are stroke and Bell's palsy. The patient's . . .
Varicella zoster virus (VZV) is an exclusively human neurotropic alphaherpesvirus. Primary infection causes varicella (chickenpox), after which virus becomes latent in cranial nerve ganglia, dorsal ...root ganglia, and autonomic ganglia along the entire neuraxis. Years later, in association with a decline in cell-mediated immunity in elderly and immunocompromised individuals, VZV reactivates and causes a wide range of neurologic disease. This article discusses the clinical manifestations, treatment, and prevention of VZV infection and reactivation; pathogenesis of VZV infection; and current research focusing on VZV latency, reactivation, and animal models.
Varicella–zoster virus is an exclusively human herpesvirus that causes chickenpox (varicella), becomes latent in cranial-nerve and dorsal-root ganglia, and frequently reactivates decades later to ...produce shingles (zoster) and postherpetic neuralgia. In immunocompetent elderly persons or immunocompromised patients, varicella–zoster virus may produce disease of the central nervous system.
Since the last major review of varicella–zoster virus in the
Journal,
1
,
2
advances in molecular biology have provided important new insights into the pathogenesis of infection with varicella–zoster virus. The detection of varicella–zoster virus in blood vessels and other tissues by methods based on the polymerase chain reaction (PCR) has widened the recognized . . .
Varicella zoster virus (VZV) becomes latent in human ganglia after primary infection. VZV reactivation occurs primarily in elderly individuals, organ transplant recipients, and patients with cancer ...and AIDS, correlating with a specific decline in cell-mediated immunity to the virus. VZV can also reactivate after surgical stress. The unexpected occurrence of thoracic zoster 2 days before space flight in a 47-year-old healthy astronaut from a pool of 81 physically fit astronauts prompted our search for VZV reactivation during times of stress to determine whether VZV can also reactivate after non-surgical stress. We examined total DNA extracted from 312 saliva samples of eight astronauts before, during, and after space flight for VZV DNA by polymerase chain reaction: 112 samples were obtained 234-265 days before flight, 84 samples on days 2 through 13 of space flight, and 116 samples on days 1 through 15 after flight. Before space flight, only one of the 112 saliva samples from a single astronaut was positive for VZV DNA. In contrast, during and after space flight, 61 of 200 (30%) saliva samples were positive in all eight astronauts. No VZV DNA was detected in any of 88 saliva samples from 10 healthy control subjects. These results indicate that VZV can reactivate subclinically in healthy individuals after non-surgical stress. Copyright 2004 Wiley-Liss, Inc.
Varicella zoster virus (VZV) causes varicella (chickenpox), after which virus becomes latent in ganglia along the entire neuraxis. Virus reactivation produces zoster (shingles). Infectious VZV is ...found in vesicles of patients with zoster and varicella, but virus shed in the absence of disease has not been documented. VZV DNA was previously detected in saliva of astronauts during and after spaceflight, a uniquely stressful environment in which cell mediated immunity (CMI) is temporally dampened. The decline in CMI to VZV associated with zoster led to the hypothesis that infectious VZV would also be present in the saliva of astronauts subjected to stress of spaceflight. Herein, not only was the detection of salivary VZV DNA associated with spaceflight validated, but also infectious virus was detected in saliva from 2 of 3 astronauts. This is the first demonstration of shed of infectious VZV in the absence of disease. J. Med. Virol. 80:1116-1122, 2008.
Fifty-four patients with herpes zoster were treated with valacyclovir. On treatment days 1, 8, and 15, pain was scored and saliva examined for varicella-zoster virus (VZV) DNA. VZV DNAwas found in ...every patient the day treatment was started and later disappeared in 82%. There was a positive correlation between the presence of VZVDNA and pain and between VZV DNA copy number and pain (P<.0005). VZV DNA was present in 1 patient before rash and in 4 after pain resolved and was not present in any of 6 subjects with chronic pain or in 14 healthy subjects. Analysis of human saliva has potential usefulness in the diagnosis of neurological disease produced by VZV without rash.
Herpesviruses cause various acute, subacute, and chronic disorders of the central (CNS) and peripheral (PNS) nervous systems in adults and children. Both immunocompetent and immunocompromised ...individuals may be affected. Zoster (shingles), a result of reactivation of varicella zoster virus (VZV), is the most frequent neurologic complication. Other neurological complications include encephalitis produced by type I herpes simplex virus (HSV‐1), and less frequently HSV‐2, as well as by VZV and cytomegalovirus (CMV). Acute meningitis is seen with VZV and HSV‐2, and benign recurrent meningitis with HSV‐2. Combinations of meningitis/ encephalitis and myelitis/radiculitis are associated with Epstein Barr Virus (EBV); myelitis with VZV, CMV, EBV, and HSV‐2; and ventriculitis/encephalitis with VZV and CMV. Brainstem encephalitis due to HSV and VZV, and polymyeloradiculitis due to CMV are well documented. HHV‐6 produces childhood exanthem subitum (roseola) and febrile convulsions. Immunocompetent and immunocompromised hosts manifest different incidences and patterns of herpesvirus infections. For example, stroke due to VZV‐mediated large vessel disease (herpes zoster ophthalmicus) occurs predominantly in immunocompetent hosts, while small vessel disease (leukoencephalitis) and ventriculitis develop almost exclusively in immunocompromised patients. EBV‐associated primary CNS lymphomas also are restricted to immunosuppressed individuals. Recent large CSF PCR studies have shown that VZV, EBV, and CMV more frequently produce meningitis, encephalitis, or encephalopathy in immunocompetent hosts than was formerly realized. We review herpesvirus infections of the nervous system and illustrate the expanding spectrum of disease by including examples of a 75‐year‐old male on steroid treatment for chronic lung disease with fatal HSV‐2 meningitis and an 81‐year‐old male with myasthenia gravis, long‐term azathioprine use, and an EBV‐associated primary CNS lymphoma.
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