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The main hazard in this form of the disease is herpetic involvement of the cornea and conjunctiva, resulting in corneal anesthesia and residual scarring Palsies of extraocular muscles, ptosis, and mydriasis are frequently associated, indicating that the third, fourth, and sixth cranial nerves are affected in addition to the gasserian ganglion A less common but also characteristic cranial nerve syndrome consists of a facial palsy in combination with a herpetic eruption of the external auditory meatus, sometimes with tinnitus, vertigo, and deafness Ramsay Hunt (whose name has been attached to the syndrome) attributed this syndrome to herpes of the geniculate ganglion Denny-Brown and Adams found the geniculate ganglion to be only slightly affected in a man who died 64 days after the onset of a so-called Ramsay Hunt syndrome (during which time the patient had recovered from the facial palsy); there was, however, in ammation of the facial nerve.

Like patients with other disorders of frontal lobe function, they are able to carry out the motions of stepping while supine or sitting but have dif culty in taking steps when upright or attempting to walk If these patients are carefully observed as they get on and off an examining table or in and out of bed, they display poor management of the entire axial musculature, moving their bodies without shifting the center of gravity or adjusting their limbs appropriately Changes in posture, even rolling over in bed, are made en bloc The erect posture is assumed in a very awkward manner with hips and knees only slightly exed and stiff and a delay in swinging the legs over the side of the bed Sudarsky and Simon have quanti ed these defects by means of high-speed cameras and computer analysis.

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Herpes zoster of the palate, pharynx, neck, and retroauricular region (herpes occipitocollaris) depends on herpetic infection of the upper cervical roots and the ganglia of the vagus and glossopharyngeal nerves Herpes zoster in this distribution may also be associated with the Ramsay Hunt syndrome Encephalitis and cerebral angiitis are rare but well-described complications of cervicocranial zoster, as discussed below, and a restricted but destructive myelitis is a similarly rare but often quite serious complication of thoracic zoster Devinsky and colleagues reported their ndings in 13 patients with zoster myelitis (all of them immunocompromised) and reviewed the literature on this subject The signs of spinal cord involvement appeared 5 to 21 days after the rash and then progressed for a similar period of time Asymmetrical paraparesis and sensory loss, sphincteric disturbances, and, less often, a Brown-Sequard syndrome were the usual clinical manifestations.

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The CSF ndings were more abnormal than in uncomplicated zoster (pleocytosis and raised protein) but otherwise similar The pathologic changes, which take the form of a necrotizing in ammatory myelopathy and vasculitis, involve not just the dorsal horn but also the contiguous white matter, predominantly on the same side and at the same segment(s) as the affected dorsal roots, ganglia, and posterior horns Early therapeutic intervention with acyclovir appeared to be bene cial Our experience with the problem includes an elderly man who was not immunosuppressed; he remained with an almost complete transverse myelopathy Another rare complication of zoster, taking the form of a subacute amyotrophy of a portion of a limb, is probably linked to a restricted form of VZV myelitis Many of the writings on zoster encephalitis give the impression of a severe illness that occurs temporally remote from the attack of shingles in an immunosuppressed patient.

They report a reduction in height of step, an increase in sway, and a decrease in rotation of the pelvis and counterrotation of the torso Tone in the leg muscles of the NPH patient is increased, with a tendency to cocontraction of exor and extensor muscle groups Walking is perceptibly slower than normal, the body is held stif y and moves en bloc, arm swing is diminished, and there is a tendency to fall backwards features that are reminiscent of the gait in Parkinson disease In general, the lack of arm swing and the stooped posture are more prominent in Parkinson disease than in NPH, and, of course, most of the other features of Parkinson disease are lacking, although an apathetic stare and slowness in shifting natural postures.

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