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Year : 2021  |  Volume : 3  |  Issue : 1  |  Page : 33

Ramsay Hunt syndrome in a young COVID-19 patient

Tecnológico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Monterrey, México

Date of Submission01-Aug-2021
Date of Acceptance26-Aug-2021
Date of Web Publication22-Oct-2021

Correspondence Address:
Dr. Alejandro Rodriguez-Garcia
Instituto de Oftalmologia y Ciencias Visuales, Centro Medico Zambrano Hellion, Av. Batallon de San Patricio No. 112. Col. Real de San Agustin, N.L. CP. 66278, Monterrey
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/pajo.pajo_104_21

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The severe acute respiratory syndrome caused by coronavirus-2 can present with a broad spectrum of clinical manifestations, mainly respiratory, but also with different neurologic symptoms. On the other hand, the Ramsay Hunt syndrome (RHS) is a complication of varicella-zoster virus (VZV) reactivation presenting mainly in older patients, patients under stress, infection, or an immunocompromised state. We report a case of RHS in a young Mexican female patient who tested positive for SARS-CoV-2 in whom we believe that there is a strong possibility that VZV's unusual reactivation, presenting as RHS in a young patient, might have been a consequence of the immunological alterations induced by this coronavirus.

Keywords: COVID-19, Ramsay Hunt syndrome, SARS-CoV-2, varicella-zoster virus

How to cite this article:
Alonzo-Correa CP, Camacho-Martínez E, Bustamante-Arias A, Rodriguez-Garcia A. Ramsay Hunt syndrome in a young COVID-19 patient. Pan Am J Ophthalmol 2021;3:33

How to cite this URL:
Alonzo-Correa CP, Camacho-Martínez E, Bustamante-Arias A, Rodriguez-Garcia A. Ramsay Hunt syndrome in a young COVID-19 patient. Pan Am J Ophthalmol [serial online] 2021 [cited 2023 Sep 27];3:33. Available from: https://www.thepajo.org/text.asp?2021/3/1/33/329085

  Introduction Top

Initially described in 1907 by James Ramsay Hunt, Ramsay Hunt syndrome (RHS) is considered a complication of varicella-zoster virus (VZV) reactivation originated in the geniculate ganglion.[1],[2]

RHS incidence varies from 0.3% to 18%,[3] making it the second most common cause of nontraumatic peripheral facial nerve palsy,[4] affecting patients in the fifth decade of life or older, and rarely occurs in younger patients.[2]

The clinical presentation of RHS is characterized by the triad formed by herpes zoster oticus (herpetic vesicular rash in the ear), otalgia, and acute peripheral facial nerve palsy.[5]

The severe acute respiratory syndrome caused by coronavirus-2 (SARS-CoV-2) presents mainly with respiratory symptoms;[6] however, it is frequently accompanied by neurologic affections.[7]

We report a rare case of RHS in a young Mexican female patient who tested positive for SARS-CoV-2.

  Case Report Top

A 25-year-old female patient presents to the clinic with facial palsy complaints that do not entirely allow her to close her left eye, accompanied by tearing, foreign-body sensation, and eye pain.

The patient's family medical history was relevant for diabetes mellitus, skin melanoma, cervical and uterine cancer, and lung cancer.

The present illness started 5 days before consultation with neuropathic pain and a vesicular eruption on her left ear lobe, accompanied by ipsilateral jawline and neck pain. Forty-eight hours later, the patient developed left hypoacusis and consulted an ear, nose, and throat specialist, who prescribed her acyclovir (4 g per day PO) and intramuscular dexamethasone (8 mg/2 ml UD). The following day, she started to experience ageusia, paresthesia of the left hemiface, and left facial palsy that prevented her from closing the left eyelids [Figure 1]. For this reason, the patient sought ophthalmological care. The patient denied other symptoms such as fever, cough, shortness of breath, or anosmia.
Figure 1: Photograph at the initial visit showing left upper and lower facial motor paralysis with obliteration of the nasolabial fold on the left side and axis of the upper lip shifted to the right (a), inability to close the left eye and presence of Bell's phenomenon (b). Herpetiform skin rash on the left ear, jawline, and neck are also seen (c and d)

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The physical examination revealed scabbing lesions suggestive of shingles on the left jawline, neck, and antihelix, and a Grade-IV House–Brackman left peripheral facial palsy. Her visual acuity was 20/20 in both eyes. The left eye showed a 2 mm lagophthalmos associated with 2 + inferior superficial punctate keratitis (exposure pattern) and a preserved Bell's phenomenon. The rest of the ophthalmological examination was unremarkable.

RHS was diagnosed based on the clinical findings. Treatment with oral acyclovir 4 g per day was continued for a total of 14 days, with the addition of oral prednisone (1 mg/kg/day) tapered weekly, and unpreserved 1.5% hyaluronic acid drops every 2 h for the left eye, 5% dexpanthenol gel every 6 h, and nightly hydroxypropyl methylcellulose ointment with left eye patching.

A laboratory workup consisting of a complete blood count, Chem-7 test, C-reactive protein, erythrocyte sedimentation rate, and HIV serologic test was ordered to rule out a systemic condition that might have triggered the VZV reactivation. A SARS-CoV-2 polymerase chain reaction (PCR) test was also ordered as part of the clinic's guidelines and RHS presentation at a younger age in the context of the pandemic. HIV and other tests came out negative or within normal ranges; however, the SARS-CoV-2 PCR test came out positive.

Absolute isolation and remote COVID-19 clinical follow-up were initiated. Video conferences were performed for close ophthalmologic follow-up. Apart from mild fatigue, the patient was COVID-19 asymptomatic throughout the clinical course of the RHS convalescence. Regarding RHS, the patient experienced a significant clinical improvement after 1 month of therapy. The skin lesions resolved, and the patient could now fully close her eyelids spontaneously and at will; superficial keratopathy improved significantly, as well as her facial expressions [Figure 2]. The patient was discharged after 2 months of follow-up with no sequelae.
Figure 2: Following treatment, the patient showed a significant improvement in motor weakness, including the symmetry of the facial expression (a), ability to fully close eyelids (b), herpetic skin lesions resolved (c), and there was a significant improvement in punctate superficial keratopathy (d)

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  Discussion Top

The diagnosis of RHS is based mainly on clinical signs and symptoms, and although PCR can be used to confirm VZV infection, its use is uncommon.[8] The most common risk factors for VZV reactivation are older age, with most patients being between the fifth and sixth decade of life, having some immunocompromised state, under significant stress, chemotherapy, or infection. Although this case presented classic RHS signs and symptoms, it differed in the age and lack of previous chronic illnesses or an immunocompromised state.

In December 2019, the first pneumonia cases caused by a new RNA beta-coronavirus strain were reported in Wuhan, China. This new agent was later called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and quickly spread globally, declaring a pandemic and global health emergency by the World Health Organization.[9]

COVID-19 has a broad spectrum of clinical manifestations, the most common being respiratory symptoms;[6] however, it has been reported to have neurotropism affecting the central nervous system and manifesting as headache, ataxia, cerebrovascular disease, seizures, and peripheral nervous system manifestations such as hyposmia and hypogeusia.[7],[10]

Cranial nerve neuropathies associated with respiratory symptoms caused by SARS-CoV-2 infection have also been noticed.[10],[11] Other authors have reported Bell's palsy associated with COVID-19.[12],[13] These findings suggest a correlation between neurologic symptoms development and COVID-19, with these being the first or only manifestations of the disease. Since our patient had a positive SARS-CoV-2 test, there is a strong possibility that VZV's reactivation, presenting unusually as RHS in a young patient, might have been a consequence of the immunological alterations caused by this coronavirus.

To our knowledge, this is the first case report of a young patient with COVID-19 related to VZV reactivation presenting as RHS. The question remains if the RHS and the COVID-19 infection could be coincident simultaneous entities in this patient; nonetheless, given the current pandemic scenario and the previous reports of neurologic and cranial nerve affection secondary to SARS-CoV-2 infection, this seems unlikely.

This case of atypical neurologic affection, and the previously reported ones, indicates that SARS-CoV-2 infection should be included in the differential diagnosis of neurologic affections amid the current pandemic to prevent delay in diagnosis and treatment of the disease, but most importantly, to avoid the spread of COVID-19 by respiratory “asymptomatic” patients.

  Conclusion Top

Patients with COVID-19 can initially present neurologic symptoms and sometimes as the only clinical manifestation of the disease. In this case, a VZV reactivation as RHS was presumably attributed to the immune response secondary to the SARS-CoV-2 infection. Further studies regarding SARS-CoV-2 neurologic manifestations are needed to grasp the disease's clinical spectrum of presentation fully.

Credit authorship contribution statement

Alonzo-Correa: Patient management, literature investigation, writing-original draft and preparation; Camacho-Martinez: Patient management, literature investigation, and co-writing-original draft, Bustamante-Arias: Patient's online consultations, literature investigation, editing and reviewing the manuscript, and photograph editing. Rodriguez-Garcia: Conceptualization, main patient's management and consultation, manuscript revision and editing, project supervision, and manuscript preparation for submission.

Declaration of patient consent

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


  • SARS-CoV-2 presents mainly with respiratory symptoms; however, it is frequently accompanied by neurologic affections
  • There may be a correlation between the development of neurologic symptoms and COVID-19 infection, with these being the first or only manifestations of the disease
  • SARS-CoV-2 infection should be included in the differential diagnosis of neurologic affections amid the current pandemic.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Paiva AL, Araujo JL, Ferraz VR, Veiga JC. Facial paralysis due to Ramsay Hunt syndrome – A rare condition. Rev Assoc Med Bras (1992) 2017;63:301-2.  Back to cited text no. 1
Wagner G, Klinge H, Sachse MM. Ramsay Hunt syndrome. J Dtsch Dermatol Ges 2012;10:238-44. [doi: 10.1111/j. 1610-0387.2012.07894.x].  Back to cited text no. 2
Gondivkar S, Parikh V, Parikh R. Herpes zoster oticus: A rare clinical entity. Contemp Clin Dent 2010;1:127-9.  Back to cited text no. 3
[PUBMED]  [Full text]  
Chodkiewicz HM, Cohen PR, Robinson FW, Rae ML. Ramsay hunt syndrome revisited. Cutis 2013;91:181-4.  Back to cited text no. 4
Robillard RB, Hilsinger RL Jr., Adour KK. Ramsay Hunt facial paralysis: Clinical analyses of 185 patients. Otolaryngol Head Neck Surg 1986;95:292-7.  Back to cited text no. 5
Guan W, Ni Z, Hu Yu, Liang W, Ou C, He J, et al. Characteristics of Coronavirus Disease 2019 in China. N Eng J Med 2020;382:1708-1720. doi: 10.1056/NEJMoa2002032.  Back to cited text no. 6
Montalvan V, Lee J, Bueso T, De Toledo J, Rivas K. Neurological manifestations of COVID-19 and other coronavirus infections: A systematic review. Clin Neurol Neurosurg 2020;194:105921.  Back to cited text no. 7
Kunitomo K. Ramsay Hunt syndrome. Postgrad Med J 2020;96:168.  Back to cited text no. 8
“WHO Director-General's Opening Remarks at the Media Briefing on COVID-19 – 11 March 2020.” Available from: https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-March-2020. [Last accessed on 2020 Dec 05].  Back to cited text no. 9
Mao L, Jin H, Wang M, Hu Y, Chen S, He Q, et al. Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol 2020;77:683-90.  Back to cited text no. 10
Wei H, Yin H, Huang M, Guo Z. The 2019 novel cornoavirus pneumonia with onset of oculomotor nerve palsy: A case study. J Neurol 2020;267:1550-3.  Back to cited text no. 11
Figueiredo R, Falcão V, Pinto MJ, Ramalho C. Peripheral facial paralysis as presenting symptom of COVID-19 in a pregnant woman. BMJ Case Rep 2020;13:e237146.  Back to cited text no. 12
Wan Y, Cao S, Fang Q, Wang M, Huang Y. Coronavirus disease 2019 complicated with Bell's palsy: A case report. [doi: 10.21203/rs. 3.rs-23216/v1].  Back to cited text no. 13


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