Hemi-Diaphragmatic Paralysis And Herpes Zoster Infection In A Renal Transplant Recipient; A Case Report

Herpes zoster or shingles is a common condition caused by the varicella zoster virus (VZV). Although it may cause numerous complications, diaphragmatic paralysis is an extremely uncommon event. It usually occurs after involvement of the C3, 4 and 5 dermatomes which give rise to the phrenic nerve. No case has ever been reported in renal transplant recipients. We report a case of 60-year-old-female patient from Punjab, Pakistan, who was a renal transplant recipient on immune suppressant therapy. She presented with worsening shortness of breath 3 weeks after the onset of a painful vesicular rash involving her neck, shoulder and axilla. Serial chest radiographs revealed a persistently elevated right hemi-diaphragrn. Suspecting diaphragmatic paralysis, an ultrasound sniff test was performed which revealed absent contractions of the right hemi diaphragm clinching the diagnosis. She was started on anti-viral therapy and managed conservatively. Six months later a repeat ultrasound sniff test revealed normal contractions and movements of the paralyzed diaphragmatic muscle. Herpes zoster may cause diaphragmatic paralysis in renal transplant recipients. It should be considered in patients with respiratory distress and a typical vesicular rash involving the C3, 4 and 5 dermatomes. Diagnosis is supported by chest radiography and may be confirmed with ultrasonography. Treatment is usually supportive and acyclovir may be of benefit.