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LETTERS TO EDITOR
Year : 2019  |  Volume : 67  |  Issue : 1  |  Page : 272-273

A case of herpes zoster infection mimicking carpal tunnel syndrome


1 Department of Neurosurgery, Tekirdag State Hospital, Tekirdag, Turkey
2 Department of Neurology, Malkara State Hospital, Tekirdag, Turkey

Date of Web Publication7-Mar-2019

Correspondence Address:
Dr. Yavuz Samanci
Department of Neurosurgery, Tekirdag State Hospital, Eskicami-Ortacami Mahallesi, Hastane Sokak, No: 1, 59000 Merkez/Tekirdag
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.253607

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How to cite this article:
Samanci Y, Samanci B. A case of herpes zoster infection mimicking carpal tunnel syndrome. Neurol India 2019;67:272-3

How to cite this URL:
Samanci Y, Samanci B. A case of herpes zoster infection mimicking carpal tunnel syndrome. Neurol India [serial online] 2019 [cited 2019 May 23];67:272-3. Available from: http://www.neurologyindia.com/text.asp?2019/67/1/272/253607




Sir,

Herpes zoster is caused by reactivation of varicella zoster virus (VZV) that has remained dormant within dorsal root ganglia. Herpes zoster along the distribution of median nerve is extremely rare and might be misdiagnosed as carpal tunnel syndrome because of the prodrome that consists of itching, tingling, stubbing, or burning and an atypical pain in one or occasionally in neighboring dermatomes.

A 54-year old female patient presented with a 2-week history of severe tingling and burning pain radiating from the right wrist to the right thumb, index and middle fingers. Physical examination revealed severe pain in the median nerve distribution and significant numbness in her index finger (two-point discrimination test: right: 14 mm; left: 2.4 mm). A positive Tinel's sign was noted over the carpal tunnel area. There was no history of trauma and X-ray examination of the hand revealed no abnormality. Carpal tunnel syndrome was suspected and an electromyography (EMG) examination was carried out. The EMG was within normal limits, so she was prescribed nonsteroidal analgesics and asked for a follow-up examination 1 week later. However, she returned the following morning complaining of worsening pain. Magnetic resonance imaging (MRI) scans of the cervical spine and wrist were planned for determining a differential diagnosis. After 1 week, the patient brought MRI results and she was seen to have crusted vesicular lesions that were distributed on the dermatomal innervation of the median nerve [Figure 1]. The skin rash was suggestive of herpetic viral infection in its final stage, although it is more often seen in higher dermatomes and cranial nerves. A dermatologist recommended observation and analgesics. At 6 months follow-up, the patient showed no abnormalities or scarring skin lesions. No paresthesia or hyperesthesia was detected.
Figure 1: Crusted lesions along the distribution of median nerve

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The lifetime risk of herpes zoster is estimated to be approximately 30% and the incidence of the disease is known to increase with age. There are few published cases in the literature (English) involving median nerve distribution.[1],[2],[3],[4],[5] After the primary VZV infection, reactivation in ganglionic neurons can be triggered by numerous events, such as a declined cell-mediated immunity due to advanced age, neoplastic disease, and immunosuppression. Our patient reported no disease that would cause immunosuppression.

Establishing the cause of wrist and hand pain can be challenging, as they may result from synovitis, soft tissue inflammation, or mechanical nerve compression at the wrist, elbow, and cervical spine. Herpes zoster typically presents with a unilateral vesicular rash, usually limited to a single dermatome and may affect any sensory ganglion with the thoracic (56%) level being the most common site. It is extremely rare along the distribution of median nerve. However, before the observation of rash, there is a prodrome that consists of itching, tingling, stubbing, or burning and atypical pain in one or occasionally in the neighbouring dermatomes that may be constant or intermittent for days or weeks and present as acute neuritis, leading to a misdiagnosis, as occured in our case.

In conclusion, the presence of prodromal symptoms of herpes zoster can mimic the symptoms of carpal tunnel syndrome and one should keep in mind that the median nerve can also be a target for herpes zoster infection.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bekler H, Gökce A, Beyzadeoglu T. Presentation of varicella-zoster mimicking carpal tunnel syndrome. J Hand Surg Eur 2007;32:233.  Back to cited text no. 1
    
2.
La Casse AC. Herpes simplex virus infection associated with carpal tunnel syndrome: Report of case and review of the literature. J Am Osteopath Assoc 1983;82:870-1.  Back to cited text no. 2
    
3.
Nee PA, Lunn PG. Isolated anterior interosseous nerve palsy following herpes zoster infection: A case report and review of the literature. J Hand Surg Br 1989;14:447-8.  Back to cited text no. 3
    
4.
Reda H, Watson JC, Jones LK Jr. Zoster-associated mononeuropathies (ZAMs): A retrospective series. Muscle Nerve 2012;45:734-9.  Back to cited text no. 4
    
5.
Tahiri Y, Hamelin ND, Brutus JP. Herpes zoster in the median nerve distribution. J Plast Reconstr Aesthet Surg 2010;63:e195-6.  Back to cited text no. 5
    


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