Herpes zoster opthalmicus (HZO) is the reactivation of varicella along the V1 distribution, typically occurring in older or immunocompromised patients. Previous literature reports isolated involvement of other cranial nerves, including the oculomotor or abducens nerve. The utility of antivirals and steroids remain unclear. Here, we describe an atypical presentation of HZO with multi-cranial nerve involvement (III, IV, V1, V2 and VI) in an immunocompetent individual treated with acyclovir and steroids. 

A 42-year-old man presented with a painful vesicular rash on the right side of his scalp for 4 days. He was treated with oral famcyclovir for trigeminal distribution of varicella zoster infection and was discharged. He returned after 5 days with eye pain, diplopia, blurry vision and right ptosis. Neurological examination showed severe right eye ptosis, dilated right pupil, restricted adduction, upward, and downward gaze of the right eye, and decreased light touch sensation on the right V1 and V2 distribution. Brain/ orbits MRI with and without contrast exhibited enhancement of cisternal segment of right CN VI, cisternal and cavernous segment of right CN V1 and V2 segment, and right superior ophthalmic fissure involving CN III, IV and VI.  Patient was started on IV acyclovir. Lumbar puncture revealed normal glucose 70 mg/dL, slightly elevated WBC 12/cmm with lymphocytic predominance, and protein 57 mg/dL. Varicella zoster PCR was negative. He was discharged on valacyclovir and tapering dose of prednisone 30 mg twice daily. The symptoms fully resolved during his 6 weeks follow up.