A 70-year-old gentleman with past medical history significant for chronic hypoxic and hypercapneic respiratory failure from chronic obstructive pulmonary disease (FEV1 of 0.76 liters, 22% of predicted), hyperlipidemia, and hypertension presented with worsening exertional shortness of breath of four days duration. He also had dry cough. He denied fever, chills, chest pain, paroxysmal nocturnal dyspnea or orthopnea. A few days before onset of shortness of breath, he had developed sharp pain on the left side of his neck and left shoulder. Two days later, it was followed by painful rash and blisters in the same area. Physical examination revealed heart rate of 115 beats per minute. He was afebrile and had blood pressure of 110/70 mmHg. He had oxygen saturation of 95% on supplemental oxygen at 2 liters/minute via nasal cannula, his baseline requirement. On auscultation, lungs were clear bilaterlly with prolonged expiration and there was decreased breath sound at the left base. Vesicular rash was noted on the left side of his neck, and left shoulder involving dermatomes C3, C4, C5 and C6. The area was extremely tender. He was unable to abduct his left arm. He had mild leukocytosis with WBC count of 12400/microL with normal electrolytes, proBNP and renal function. A chest X-ray showed elevated left hemi-diaphragm while the right hemi-diaphragm was flattened and the lungs were emphysematous. Spirometry showed a significant reduction in his forced vital capacity. Fluoroscopic evaluation confirmed paralysis of the left hemi diaphragm. He was started on Valacyclovir. He also was offered incentive spirometry. There was gradual resolution of rash with improvement in pain, left arm weakness and shortness of breath. Repeat Chest X-ray after eighteen months showed the left hemi-diaphragm in normal position.
Discussion:
Shingles or Herpes Zoster (HZ) is caused by reactivation of varicella zoster virus (VZV) latent in the cranial nerve ganglion or dorsal root ganglion. It usually presents with neuropathic pain followed by rash in dermatomal (sensory) distribution. In about 3% of patients with shingles, it can also spread to contiguous motor horn and produce segmental paresis or paralysis of involved muscle group. Diaphragmatic palsy from shingles is rare and can present with dyspnea. Cervical ganglion when involved may rarely result in brachial neuritis and diaphragmatic palsy from motor involvement. Weakness appears approximately around the same time as pain and rash. Treatment is usually supportive and with antivirals like acyclovir, valacyclovir and famciclovir. Diaphragmatic function recovery period ranges from a few weeks to many months.
Conclusions:
When a patient with cervical involvement of shingles presents with arm weakness and dyspnea, one should be aware that motor horn might be inolved and diaphragmatic palsy could be a possibility.