Objective:

To present an atypical case of multiple cranial nerve involvement of suspected atypical Ramsay Hunt Syndrome versus MRI-negative stroke.

Background:

Ramsay Hunt Syndrome (RHS) is a rare disorder caused by reactivation of varicella zoster virus in the geniculate ganglion. It classically presents with a triad of otalgia, vesicles in the ear, and ipsilateral facial paralysis. While typically affecting cranial nerves VII and VIII, more complex cases may involve cranial nerves III, V, IX, X, and XII.

Design/Methods:

N/A

Results:

A 56-year-old male with a history of myocardial infarction and migraines presented with acute onset of left facial numbness (V2/V3), left lower facial weakness, and mild dysarthria. He was last known well at 1800 and awoke at 0100 with symptoms. Stroke alert was initiated at 0258 (NIHSS 4). Initial CT and CTA were unremarkable. MRI suggested a possible right parietal infarct. He received tenectaplase at 0315. Upon further neuroradiology review, initial MRI finding was deemed artifact. Repeat MRI showed no infarct, but symptoms continued to persist. He also reported dysgeusia, otalgia, and vesicles were found in the left ear canal, raising concern for RHS. He was started on valacyclovir for 7 days. At 5-month follow up, he reported all symptoms persisted for the first few days following hospital discharge but eventually completely resolved with the exception of persistent left lower facial numbness.

Conclusions:

This case highlights an atypical presentation of suspected Ramsay Hunt Syndrome with partial facial weakness and involvement of multiple cranial nerves, initially mimicking stroke. Despite negative imaging, the presence of vesicles and symptom improvement with antivirals support a viral etiology. Clinicians should consider RHS in the differential diagnosis of cranial neuropathies, especially when imaging is inconclusive or symptoms are atypical for stroke.