Spontaneous nystagmus, pathologic saccades and gait ataxia – again just a common acute unilateral peripheral vestibulopathy?

Introduction CNS manifestations in VZV infections are rare (approximately 0.1%). Typical symptoms of VZV encephalitis are focal neurological deficits, apathy and cranial nerve palsies, especially of the facial nerve.

Patient and Methods A 76-year-old patient presented to the emergency department with gait ataxia and nausea. Clinically and otoneurologically, an acute peripheral vestibulopathy on the right side was suspected due to a spontaneous nystagmus to the left side, pathologic saccades on the right side and missing skew deviation. A neurological evaluation including cCT because of an additional soft palate paresis on the right side, dysphagia and dysarthrophonia remained without conclusive findings, which is why an ENT-guided intravenous prednisolone therapy was initially initiated. On the following day, the patient’s general condition worsened and he developed a new vocal fold paresis on the right side. Therefore, he was transferred to the stroke unit because of a possible brainstem process.

Results The cMRI showed a lesion of the right medulla oblongata including contrast enhancement of the right vestibulocochlear nerve. The lumbar puncture with increased cell count and positive VZV detection led to the diagnosis of VZV-positive encephaloneuritis of the lower brainstem and therapy with aciclovir was initiated.

Discussion Differentiation between a peripheral or central genesis in vertigo requires good interdisciplinary collaboration between ENT and neurology. Even if the so-called "HINTS" lead to the suspicion of a peripheral-vestibular genesis, a renewed neurological co-evaluation is urgently required if additional symptoms occur as in the presented case.

Publication History

Article published online:
27 June 2023