Sunct and trigeminal neuralgia attributed to meningoencephalitis (pdf) paperity fetal anoxia

See also

SUNCT: a new case with some unusual features SUNCT: a new case with some unusual features

A case of short–lasting unilateral neuralgiform headache with conjunctival … A case of short–lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT). Discussion of clinical features and differential diagnosis

SUNCT and optic nerve hypoplasia SUNCT and optic nerve hypoplasia

SUNCT syndrome or first division trigeminal neuralgia associated with … SUNCT syndrome or first division trigeminal neuralgia associated with cerebellar hypoplasia

Bilateral SUNCT-like headache in a patient with prolactinoma responsive to …

Bilateral SUNCT-like headache in a patient with prolactinoma responsive to lamotrigine

fetal anoxia

Different forms of trigeminal autonomic cephalalgias in the same patient: … Different forms of trigeminal autonomic cephalalgias in the same patient: description of a case

A case of early-onset and monophasic trigeminal autonomic cephalalgia: could it … A case of early-onset and monophasic trigeminal autonomic cephalalgia: could it be a SUNCT?

J headache pain

SUNCT and trigeminal neuralgia attributed to meningoencephalitis

Pablo eguia 0 1

Juan carlos garcia-monco 0 1

Nuria ruiz-lavilla 0 1

Vanesa diaz-konrad 0 1

Fernando monton 0 1

0 J. C. Garcia-monco department of neurology, hospital de galdacano , vizcaya , spain

1 P. Eguia () N. Ruiz-lavilla V. Diaz-konrad F. Monton department of neurology, hospital nuestra sen ̃ora de candelaria , carretera del rosario 145, 38010 santa cruz de tenerife , spain

fetal anoxia

We describe a 46-year-old female with viral meningoencephalitis (likely varicella-zoster virus) who developed a SUNCT syndrome followed a few days later by trigeminal neuralgia. Both disorders resolved in parallel with the resolution of encephalitis, which suggests a causal link. In conclusion, headache attributed to intracranial infection may have the clinical features of SUNCT or TN.

SUNCT; tacs; trigeminal neuralgia; meningoencephalitis; VVZ; varicella-zoster


The IHS classification of headache disorders (ICHD-II) [



Establishes that a headache occurring for the first time in

Close temporal relation to an infection should be coded as a

Secondary headache attributed to the infection.Fetal anoxia

Short-lasting unilateral neuralgiform headache attacks

With conjunctival injection and tearing syndrome (SUNCT)

And trigeminal neuralgia (TN) are occasionally secondary

To space-occupying lesions in the posterior fossa or

Involving the pituitary gland, but its association to viral

Encephalitis has not been reported so far.

We describe a patient with SUNCT syndrome and

Coexistent TN occurring over the course of an acute

A 46-year-old woman presented with 1 week of fever. On

The day of admission she developed somnolence and

Headache. She described right-sided episodes of severe

Retro-orbital burning pain, lasting 30–60 s, associated with

Prominent lacrimation, conjunctival injection, ptosis and

Rhinorrhea. She had up to 10 attacks per hour.Fetal anoxia no triggers

Were identified. Her past medical history revealed episodic

Migraine without aura and smoking.

On examination, she was somnolent, had mild neck

Stiffness and fever of 39 C. Cranial nerve examination,

Including the corneal reflex, was normal. Serum chemistry

Values, CBC and differential were normal. A brain CT scan

Without contrast was normal. Lumbar puncture revealed 40

White cells/mm3 (88% monocytes), 20 red cells/mm3,

Protein of 42 mg/dl, and glucose of 70 mg/dl. CSF gram

Stain was unrevealing and culture came negative.

Intravenous acyclovir was started for presumed herpes simplex

Meningoencephalitis, and was administered for 10 days.

Also, a diagnosis of SUNCT syndrome was made, and

Gabapentine and morphine were initiated.Fetal anoxia the following

Day, EEG demonstrated diffuse slowing without epileptic


On day 2 she developed an additional, different type of

Facial pain, consisting of severe sharp, electric shock-like

Attacks, less than 5 s in duration, over the second division

Of the right trigeminal nerve, without associated autonomic

Features. Attacks occurred spontaneously several times a

Day but were also triggered by eating and touching the nose

Or the upper lip. A diagnosis of TN was made.

On day 3, MRI revealed multiple lesions in both

Cerebral hemispheres located at the cortical-white matter

Junction with increased signal intensity on T2-weighted

Sequences (fig. 1). T1-gadolinium sequences demonstrated

Mild lesion enhancement.Fetal anoxia

On day 5 she developed partial motor seizures and

Valproic acid (1,500 mg daily) was substituted for

Gabapentine. Progressively, fever disappeared, her mental status

Recovered to normal, and there was a gradual decrease in

The frequency and intensity of both types of pain over the

Following days. IgM and igg against VZV were positive in

Serum. VZV serology and PCR in CSF were not performed.

Herpes simplex virus antibodies were negative in serum

And CSF; herpes simplex PCR was not performed. Other

Specific studies for viral, fungal and bacterial agents

Including HIV were negative.

Two weeks after admission, TN had completely

Resolved, and she was discharged on valproic acid. One

Month after admission SUNCT attacks remained at a lower

fetal anoxia

Frequency (3–4/day); they were triggered by bright light.

Two months later, SUNCT attacks had resolved except for

The dysautonomic features. She continued to experience 3

Or 4 daily episodes, of lacrimation with conjunctival

Injection and rhinorrhea that occurred at the same time of

The day, particularly upon morning awakening. The

Episodes were painless, and rather, she described a right eye

Discomfort, like a foreign body. They occurred with a

Highly variable frequency, between 1 and 4 days a week

And 1–3 times a day, and lasted up to 15 min. An

Ophthalmological evaluation was unremarkable. Valproic acid

Was tapered off and stopped. Six months later the

Autonomic signs and symptoms completely resolved.Fetal anoxia the

Episodic ocular discomfort remained, and was still present

15 months later.

Fig. 1 axial fluid-attenuated

Inversion recovery image (a)

Shows two hyperintense lesions

(arrows) located at the

Corticalwhite matter junction. Axial

T1gadolinium sequence (b)

Demonstrates mild enhancement

(arrow) of an occipital lobe



This report describes the unusual association of SUNCT

Syndrome with TN over the course of a viral

Meningoencephalitis. The temporal relationship between the onset and

Resolution of meningoencephalitis and pain attacks

Suggests that these events were linked. Furthermore, the



] indicates that a new headache in close

Temporal relation to an infection should be coded as a

Secondary headache attributed to the infection.Fetal anoxia although

Pain characteristics may mimic those of primary

Headaches, headaches associated with infection are not well

Characterized, and this chapter of the ICHD-II remains

Controversial [


]. It is of interest that this patient’s past

Medical history revealed episodic migraine without aura,

But the infection did not elicit migraine attacks.

The association of TN with SUNCT has been reported

Before. Bouhassira et al. [


] and sesso [


] described

Patients with SUNCT syndrome evolving from V1 TN,

Raising the question of whether these two entities are

Pathogenetically distinct conditions or ends of the same


Leone et al. [


] suggested that a disturbance of

Hypothalamic neurotransmitter regulation might result in

fetal anoxia

Variable activation patterns of the trigeminal system,

Explaining some of the different clinical characteristics of

The short-lasting unilateral headaches, such as their varying

Duration and accompanying autonomic symptoms. It could

Be argued that this patient had secondary forms of

Headache mimicking the primary syndromes due to the

Encephalitic injury of structures involved in the

Pathogenesis of these syndromes, perhaps on a background of

Individual susceptibility. Alternatively, viral infection

Could have resulted in irritation/inflammation of the

Trigeminal root, thus triggering pain attacks. It should be

Noted that this patient did not develop any facial herpetic

Rash, and that pain characteristics were atypical for an

fetal anoxia

Herpetic neuralgia.

The persistence of circadian dysautonomic features in

The absence of pain for several weeks in our patient

Suggests a hypothalamic abnormality with subsequent

Trigemino-vascular and cranial autonomic activation, and is

Consistent with the proposed pathophysiology of SUNCT



]. This dissociation between pain and autonomic features

Has been reported before in one patient with SUNCT [



And in patients with cluster headache (CH) [



The residual feeling of a foreign body in the eye with

Normal ophthalmological evaluation is also interesting.

Some patients with hemicrania continua (HC) describe a

Sensation of ocular discomfort, similar to that of a foreign

Body or ‘‘sand’’ in the eye [


fetal anoxia

], and in a series of 43 SUNCT

Patients one of them referred an ipsilateral gritty eye [



HC and SUNCT share posterior hypothalamus activation

And dysautonomic features [


]. Hence, residual ‘‘foreign

Body in the eye’’ feeling could reflect a dysfunction of the

Trigeminal-autonomic system.

Meningoencephalitis in this patient was likely caused by

VZV, as the serology suggested, and is usually the result of

Viral reactivation [

10, 11

]. VZV meningoencephalitis

Without an accompanying rash, like in our patient, has been

Described before [

12, 13

], but we have only found two case

Reports on the association of acute onset TN or tacs with

Varicella-zoster. A physician reported his own case of

Acute-onset TN associated with a significant rising in VZV

fetal anoxia

Antibodies [


]. Giacovazzo et al. [


] reported a case of

Chronic paroxysmal hemicrania (CPH) related to an

Ophthalmic herpes-zoster infection.

SUNCT syndrome is often refractory to medical therapy

And lamotrigine may be considered the first choice [



Therapy in this patient, however, was influenced by the

Underlying process and the presence of motor seizures.

Valproic acid is not a first-line drug for SUNCT or TN.

Thus, it is likely that the headaches ceased spontaneously

After meningoencephalitis resolved, which again supports a

Causal link.

In summary, headache attributed to encephalitis may

Mimic primary syndromes like SUNCT and TN. The

Hypothetical role of neurotropic viruses, such as VZV, in

The pathogenesis of tacs remains to be clarified.Fetal anoxia

Acknowledgments the authors are grateful to dr. Vicente martin,

From the radiology department of our institution, for providing us

With the MR images.

Conflicts of interest none.

1. Headache classification committee of the international headache society ( 2004 ) the international classification of headache disorders, 2nd edn . Cephalalgia 2004 ; 24 ( suppl 1 ): 1 – 160

2. Marchioni E , tavazzi E , bono G , minoli L , bastianello S , sinforiani E , sances G , tinelli C , nappi G ( 2006 ) headache attributed to infection: observations on the IHS classification (ICHD-II) . Cephalalgia 26 : 1427 – 1433

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fetal anoxia

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