Concurrent tonic pupil and trochlear nerve palsy in COVID-19.

Since COVID-19 was first reported, different neurological complications have been acknowledged, but their description is constantly evolving. We report a case of concurrent tonic pupil and trochlear nerve palsy in this context. A 62-year-old man reported a 5-day history of binocular vertical diplopia and blurred vision in his left eye, noticing that his left pupil was dilated. He had suffered a flu-like syndrome 2 weeks before. Clinical exam showed a right trochlear nerve palsy and a left mydriatic pupil. MRI, X chest ray, and analytical results were normal. Antibodies for SARS-CoV-2 were positive (low IgM and high IgG titers). Antiganglioside antibodies were negative. A 0.125% pilocarpine test confirmed Adie's pupil diagnosis. The patient was treated with a tapered prednisone dose with resolution of his diplopia but no change in Adie's pupil. This is the first case reporting Adie's pupil as a postinfectious manifestation of COVID-19. An immune-mediated mechanism is presumed.

Herpes zoster ophthalmicus and strabismus: a unique cause of secondary Brown syndrome.

Herpes zoster ophthalmicus can be associated with a variety of ocular and visual sequelae, including isolated or even multiple cranial neuropathies, potentially affecting the oculomotor, trochlear, or abducens nerves. We report a case of a secondary Brown syndrome following resolution of a unilateral isolated trochlear nerve palsy associated with herpes zoster ophthalmicus in an immunocompetent 57-year-old man.

Fourth and sixth nerve palsies due to Herpes Simplex 1 infection.

Ocular motor cranial nerve palsies of viral etiology are uncommon and, when accompanied by skin lesions, zoster ophthalmicus is the most frequent diagnosis. We describe the case of a 68-year-old woman who developed fourth and sixth nerve palsies 3 days after appearance of a painful vesicular skin rash on the left side of her forehead. Neuroimaging was normal but polymerase chain reaction (PCR) testing of the cerebrospinal fluid was positive for Herpes Simplex 1 and negative for Varicella Zoster. The patient was treated with intravenous acyclovir, and the cranial nerve palsies resolved over 7 weeks. Although the similarity of the cutaneous vesicular eruption in our patient to that seen with zoster might have led to an incorrect diagnosis, acyclovir seems to be safe and effective for both viral etiologies.

Central nervous system involvement after herpes zoster ophthalmicus.

PURPOSE: To report central nervous system involvement after varicella zoster virus infection. METHODS: We evaluated the frequency and type of neurological complications in patients initially presenting with ophthalmic herpes zoster at an ophthalmological department in a Danish university hospital, over a 7-year period. RESULTS: Of the 110 immunocompetent patients who presented with initial ophthalmic zoster, six (5.5%) suffered from neurological complications other than post-herpetic neuralgia. Four experienced isolated cranial motor nerve palsies, one patient had meningitis with a favourable outcome and one patient had severe encephalitis with a poor clinical outcome. CONCLUSIONS: Central nervous system involvement after varicella zoster virus infection is an uncommon, but potentially life-threatening, complication. Early recognition of neurological complications prompts acute, appropriate antiviral treatment.