“Trigeminal Tract Sign” in Patients With Herpes Zoster Ophthalmicus: A Case Series of a Novel Imaging Finding
Bibliographic record
Abstract
Objective Herein, we report three patients presenting with zoster ophthalmicus caused by varicella zoster virus (VZV) with unexpected and novel cervico-medullary findings on magnetic resonance imaging (MRI). Background Zoster opthalmicus involves reactivation of latent VZV in the ophthalmic division of the trigeminal nerve producing a dermatomal rash. In a minority of patients this leads to ophthalmic findings and damage to surrounding peripheral nerves through perineural/intraneural inflammation. MRI findings in zoster opthalmicus are often nondescript or normal leading to misdiagnosis and delays in treatment. Design/Methods This was a case-series describing patients in Calgary, Alberta who presented with zoster opthalmicus, and who were noted incidentally to have similar appearing lesions in the ipsilateral cervico-medullary region on brain MRI. Standard MRI imaging of the brain and selected high-resolution images of the orbits and globes were reviewed by neuroradiology (CW). Results Three patients, with varying phenotypes of zoster opthalmicus, are described: a 70-yo male with ipsilateral decreased visual acuity and oculomotor/abducens palsy; a 75-yo female with ipsilateral oculomotor/facial nerve palsies; and a 35-yo immunocompromised female with ipsilateral blepharoconjunctivitis and optic neuritis. In all 3 cases, MRI revealed profound T2 and fluid-attenuated inversion recovery (FLAIR) hyperintensity along the spinotrigeminal tract of the clinically affected side, extending from the posterolateral pons and medulla into the cervical region. Conclusions To our knowledge, hyperintensity within the medulla and spinal trigeminal tract in zoster opthalmicus is a rare imaging finding. We have coined this radiologic finding the “trigeminal tract sign” due to the anatomic structure affected. A thorough radiologic/laboratory workup should be considered in patients with similar presentations; however, a high index of suspicion for zoster opthalmicus should be considered in cases with the aforementioned imaging findings. Whether this radiological finding predicts disease severity or the likelihood of multiple cranial nerve involvement (as was seen in all patients in this series) requires further study.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.002 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.000 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.002 | 0.001 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".