title: Infections in the differential diagnosis of Bell's palsy: a plea for performing CSF analysis.
abstract: OBJECTIVE
  Peripheral facial nerve palsy (FP) is the most common single nerve affection. Most cases are idiopathic, but a relevant fraction is caused by potentially treatable aetiologies including infections. Not all current diagnosis and treatment guidelines recommend routine cerebrospinal fluid (CSF) analysis in the diagnostic workup of this symptom. In this study, we evaluated frequency of aetiologies and relevance of CSF analysis in an interdisciplinary cohort.
  
  
  METHODS
  We retrospectively analysed all cases of newly diagnosed FP treated at a German university medical centre in a 3-year period. Diagnostic certainty was classified for infectious aetiologies according to clinical and CSF parameters.
  
  
  RESULTS
  380 patients with FP were identified, 63 children and 317 adults. Idiopathic Bell´s palsy was predominant in 61 %. 25 % of FP was attributed to infections, and other causes were identified in 14 %. Clinical presentation alone was not conclusive for infectious aetiology, in almost half of patients with infection-attributed FP the reported symptoms or clinical signs did not differ from common symptoms of idiopathic Bell`s palsy. Determination of C-reactive protein or white blood cell count was not helpful in the identification of infectious causes, and radiological imaging was performed in a high proportion of adult patients without conclusive results. Nuchal rigidity was found only in 7 % of patients with CSF pleocytosis. The predominant infectious agents were Borrelia burgdorferi, VZV and HSV, and in most of these cases diagnosis relied on the findings of CSF analysis.
  
  
  CONCLUSIONS
  This study outlines the importance of careful differential diagnosis to identify infectious causes of facial nerve palsy. The high incidence and frequent unspecific clinical presentation of infectious FP underlines the importance of including CSF analysis in the diagnostic routine workup of FP.
authors.affiliation: Departments of Neurology, University Medical Centre Göttingen (UMG), Robert-Koch-Straße 40, 37075, Göttingen, Germany.|Department of Neurology, Asklepios Kliniken Schildautal, Karl-Herold-Str.1, 38723, Seesen, Germany.
authors.forename: Katrin
authors.initials: K
authors.lastname: Henkel
authors.affiliation: Departments of Neurology, University Medical Centre Göttingen (UMG), Robert-Koch-Straße 40, 37075, Göttingen, Germany.
authors.forename: Peter
authors.initials: P
authors.lastname: Lange
authors.affiliation: Departments of Medical Microbiology, University Medical Centre Göttingen (UMG), Robert-Koch-Straße 40, 37075, Göttingen, Germany.
authors.forename: Helmut
authors.initials: H
authors.lastname: Eiffert
authors.affiliation: Departments of Neuropathology, University Medical Centre Göttingen (UMG), Robert-Koch-Straße 40, 37075, Göttingen, Germany.|Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, An der Lutter 24, 37075, Göttingen, Germany.
authors.forename: Roland
authors.initials: R
authors.lastname: Nau
authors.affiliation: Departments of Neurology, University Medical Centre Göttingen (UMG), Robert-Koch-Straße 40, 37075, Göttingen, Germany. annette.spreer@unimedizin-mainz.de.|Department of Neurology, University Medical Centre, Johannes Gutenberg University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany. annette.spreer@unimedizin-mainz.de.
authors.forename: Annette
authors.initials: A
authors.lastname: Spreer
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D020330:Bell Palsy / Q000175:diagnosis* / Q000453:epidemiology / Q000209:etiology*; D002494:Central Nervous System Infections / Q000150:complications* / Q000175:diagnosis* / Q000453:epidemiology; D002555:Cerebrospinal Fluid / Q000382:microbiology*; D002648:Child; D003937:Diagnosis, Differential; D005858:Germany / Q000453:epidemiology; D006801:Humans; D012189:Retrospective Studies
keywords: Bell’s palsy; Cerebrospinal fluid; Facial nerve paralysis; HSV; Neuroborreliosis; VZV