Diaphragmatic paralysis following cervical herpes zostera rarely recognized association

An 83-year-old woman was found to have a para lyzed hem idiaphragm less than three weeks after developing ce rvical herpes zoste r. The d iaphragm was radiogrnphica lly normal the day be fore lhe sk in rash appeared. T he re lative ly short time frame and lack of evidence to indicate othe r etiologies suggests herpes zoster as the likely caus . of the paralysis . Diaphragmat ic paralys is foll owing cerv ica l herpes zoster is probably unde rrecogni zed and the association between the two cond itions can be eas il y missed , especially if the interval between their detec tion is long.

Paralysie du diaphragme suivant un zona cervical -une association rarement reconnue R ESUME : Un diagnostic de paralysic de l ' hemidiaphragme a ete porte chez une femme de 83 ans a la suite d'un zona cervical s 'etant developpe chez ceue demiere moins de trois semaines auparavant.La radiogra phic du tliaphragme etait normale le jour precedant I 'irruption cutan.::e.Le laps de remps asscL court et !'absence cl 'autrcs etiologies lai ssent pcnscr que le zo na est vraisemblablcment rcspons able de la paralysie du diaphragme.La paralysie du di aphragmc suivant un zo na est probablcment sous-tl iagnostiquee ct !'association entre les deu x conditions pcut t'acilcmenl passer inaper~ue , en particulier si l' intcrv alle de temps cntrt• la lktec tion du 1.ona L't eclle tie la paralysic est long .and po lymya lg ia rheuma1ica (for which she was taking predni so nc).She was dyspneic on walking one block anti had some assoc iated orthopnea.The chest pa in was of the ' pressure • type, usua lly brought on by exercise and relieved by ni trog lycerin.Coro nary ischemia with heart failure was considered ini tially.Ho we ve r. on physical exam ination.there was no ev idence of heart failure.examination of the chest was unre markable and an e lecrrocardiogram showed no acute cha nges .A ches t radiograph on day 2 was normal (Figure 1 ).day (day 3), she was found to ha ve local e rythema and a few bli s ters.which were initially attributed to a burn from the hot pad.However.when more blisters appeared and were loc alized to the left cervical and upper thoracic derma to mes, a diagnosis of herpes zoster was made.T he rash progressed to crusting over a few days.

On
In re trospec t, the shoulder and neck pain was probably due to herpes zoster.The chest pain at presentation was probably cardiac in origin, although z.oste r of the upper left chest may have been contributory.The cause of the d ys pnL•a at presentation was not definitely established.hut it could have been due to heart failure.whi c h was not clinically manifes t at rest.
A few days af'tcr the rash appeared .she noticed worsening of dyspnea .espec ially on lying down.A re peat chest radiograph (day 20) showed that the left he midi a phrag m was elevated with no lung parenchymal or mcdi as tinal abnormality (Figure 2).Fluoroscopy showed parado xical move ment of the le ft hemidiaphrag m and a positive •sniff' tes t, confirming hemidiaphragma tic paralysis.Spiromctry s ho wed forced vital capacity (FVC) to be 79% of predicted and forced expiratory volume in I s (FEY 1) to be 88 % of predicted.Lung volumes could not be measured due to dyspnea.Pulse o ximetry showed no hypoxcmia in the sitting or supine po sitions .T he maximal inspiratory airway pressure (Plmax) was found to be low at 28 cm I-'20, evc.n for a woman of her age ( I ).
The patient was advised to s leep in a propped-up positi on to minimi ze dyspnea.At discharge (day 32).there was no improve ment in Plmax.though the.patient reported some subjective improvement in shortness of breath.Three months after it was first detected, the le ft hemidiaphragm was still elevated on chest radiography.

DISCUSSION
The diaphragmatic pa ra lysi s was believed to be due to phrenic nerve involvement by cerv ical herpes zoste r for the fo llowing reasons: the d iaphragm was racl iogra phically normal the day be fore the ras h appe ared and the paralysis followed withi n just a few days; the a oc ia tion is anatomically correc t. the nerve sup ply to the diaphragm being from the lllrd .IVth and Vth ce rvical roots: and there was no evidence to indicate other e ti o log ies .
C ase reports of diaphrag matic paralysis following cnvical zostc r a rc rare.The great majority of' these repo rts are to be found in Eng li sh lang uage publications (2-15) .In these repo rts there was e ither no prior radiogra phy show ing a normal diaphragm , or the inte rv a l bet ween radiogra phs s ho wing a nonna l and later paral yzed diaphrag m was long (seve n weeks to I I years).As we ll, in several re ports .the paral yzed diaphragm was di scovered mo nths to years afte r th e rash.Thus, g iven the many causc.so f diaphragmatic paral ysis ( I 6), its discove ry after cerv ica l he rpes zoster could ha ve been coi nc idental.
The present repo rt doc uments the complete seq uence of events -norma l diaphragm, rash of zoste r and paraly/L'd di a phrag m -within IX days.The sho rt time frame and lack of t•vi de nce to indicate uther etiolog ies mal-.escause :ind effect more like ly .
Di a phragm atic paralysis following cervical he rpes 1ostcr is probably unde1Tecog ni zed because thc.paralysis may be asymptomati c ( 17) and ma y therefore not be looked for.and th e association may be missed if the interval b,' tween appearance of rash and d e tection of paralysis is lon g.This monograph on neonatal lung disease and therapy is really the compilation of the in fo rmation for three distinct domains of perin atal pulmonary disorders that are only linked by the age g roup involved .T he format of the chapters is especially useful in that having other di sciples of the subject comment and cri tique a leading authority ' s observations on a subject allows rapid and concise identi fication of areas of agreement and discrepancy in a limited space.I found the overall prese ntation and discourse brief.de lightful.complete with pithy yet in sightful comments, and I think that this format of monograph is to be encouraged .
T he first secti o n of the monograph is related to 'Surfactant and its u •age ' .T his section of approximately 100 pages.coordinated by Dr A Jobe. covers structure.function , metaholism of surfactant.as well as it s L•linical usage in respiratory distress syndrome and othe r neonatal diseases.
T he second section of the monograph on mechanical vent ilation is more ex tensi ve and occasionally repetitive.In part, this repetition was because the area of discussion was contentious.with more exte nsive commentary upon the narrative, and. in part, because the sec tion encompasse all aspects of mecha nical ventilation Crom phys io logy to diffe rent modalities.It is an extremely well-written, balanced approach to a common l'linical problem but fails to emphasize that the new extreme vcntilatory suppo rt measures are only necessary to a small proportion o r patients.
Howev er.th e sec tions on the lllLXhanics or breathing.pulmona ry gas exchange and advances in co nventional mecha11ical ventil a tion a re excell ent syno ptic distillates or the rnrrent state of knowledge for the neonat e. Moreover.the commentary is partirnlarly apt in hig hlighting the areas of controversy for eac h chapter.I do hclieve that these sections should be required reading for all medica l personnd involved in the care or neonates and young Can Respir J Vol 2 No 2 Summer 1995 infants.The latter sections on the more esoteric techniques or ventilat ion again are excellent distillates of the current state or knowledge.leavened by the insightful, practical commt•nts about the use and limitations of these techniques.
The fin al three chapters on alte rnative me thods of ventilation (negative pressure.continuous i'low and liquid ventilation) constitute a summary of the current and probahlc future directions of research in this area.As summaries of the present state of knowledge, especially as applied to the newborn, these chapte rs are invaluable.There is ex tensive commentary throughout this section, hig hlighting the areas of controversy (and just plain lack or knowled ge) with the overall impression summed up in the statement by Dr C he rnick that "A lot of work will be required, but l. like the authors.remain cautiously optimistic ahuut the new therapy.'' The final section of the monograph is limited to two specific therapies -extracorporeal membrane oxyge nation (ECMOi and nitric oxide.The chapter on the phys iology of EC MO is a succinct ex planation of the physiology and th e different types or support available, many of which art~ only suitable for adult patien ts.The clinical chapter on the use and misuse or ECMO is well done.with extens ive comme ntary leadi ng to a very balanced view and attempts to integrate the place of this therapy in light of the new treatment modalities discussed in the last chapter.It is unfortunate th at the section on nitric oxide physiology in the lung does not reflect the general excellence of the rest of the tex t: undoubtedly this is a function of a review in a fa st-developing area of medicine with new information available on a monthly basis.
In summary l found this compilation to be a well-balanced.well-written summary of the present state of knowledge.The format with the commentators is pa rticularly valuable in delineating the areas of controversy while adding a degree of leavening to the tex t to render the material readable.