The varicella zoster virus vasculopathies: clinical, CSF, imaging, and virologic features

Infectious Encephalitis: A Persistent Clinical Challenge

Encephalitis is a serious neurologic condition that frequently results in long-term neurologic complications. Effective management in adults with suspected infectious encephalitis involves testing the cerebrospinal fluid for common pathogens, including herpes simplex virus-1, varicella-zoster virus, enteroviruses, and West Nile virus. Early initiation of high-dose intravenous acyclovir is recommended. Epidemiologic clues and immune status of the host should be considered when attempting to identify the cause of encephalitis. When no cause is identified, next-generation sequencing or a brain biopsy may be warranted. Further research should focus on developing new therapeutic options for this challenging clinical syndrome.

Herpes Zoster Vaccination and Dementia Occurrence

Importance

Recent evidence from a quasi-experiment in Wales showed that herpes zoster (HZ) vaccination appears to prevent or delay dementia. Exploiting a similar quasi-experiment in Australia, this study investigated the effect of HZ vaccination on dementia occurrence in a different population and health system setting.

Objective

To determine the effect of HZ vaccination on the probability of receiving a new diagnosis of dementia.

Design, Setting, and Participants

In Australia, starting November 1, 2016, live attenuated HZ vaccination was provided free to individuals aged 70 to 79 years through primary care clinicians. Thus, individuals whose 80th birthday was just a few weeks before November 1, 2016, never became eligible, whereas those whose 80th birthday was just a few weeks later were eligible. The key strength of this quasi-experiment is that one would not expect that these comparison groups who differ in age only minutely would, on average, differ in any health characteristics and behaviors. Primary health care records were analyzed with week-of-birth information from 65 general practices across Australia, using a regression discontinuity design.

Exposure

Eligibility for HZ vaccination based on date of birth.

Main Outcome

New diagnoses of dementia as recorded in primary care electronic health record data.

Results

In this sample of 101 219 patients, 52.7% were women and mean age was 62.6 years (SD, 9.3 years) as of November 1, 2016. Individuals born just before vs just after the date-of-birth eligibility threshold (November 2, 1936) for HZ vaccination were well balanced in their past preventive health services uptake and past chronic disease diagnoses. There was an abrupt increase of 16.4 percentage points (95% CI, 13.2-19.5; P < .001) in the probability of ever receiving HZ vaccination between patients born shortly before vs shortly after the date-of-birth eligibility threshold. The eligibility rules of the HZ vaccination program thus created comparison groups born just on either side of the date-of-birth eligibility threshold who were likely similar to each other, except for a large difference in their probability of receiving the intervention (HZ vaccination) of interest. This study found that eligibility for HZ vaccination (ie, being born shortly after vs shortly before November 2, 1936) decreased the probability of receiving a new dementia diagnosis during 7.4 years by 1.8 percentage points (95% CI, 0.4-3.3 percentage points; P = .01). Being eligible for HZ vaccination did not affect the probability of taking up other preventive health services (including other vaccinations) or the probability of receiving a diagnosis of common chronic conditions other than dementia.

Conclusions and Relevance

By taking advantage of a quasi-experiment and corroborating findings from Wales in a different population, this study provides evidence of the potential benefits of HZ vaccination for dementia that is more likely to be causal than that of more commonly conducted associational studies.

A natural experiment on the effect of herpes zoster vaccination on dementia

Neurotropic herpesviruses may be implicated in the development of dementia1-5. Moreover, vaccines may have important off-target immunological effects6-9. Here we aim to determine the effect of live-attenuated herpes zoster vaccination on the occurrence of dementia diagnoses. To provide causal as opposed to correlational evidence, we take advantage of the fact that, in Wales, eligibility for the zoster vaccine was determined on the basis of an individual's exact date of birth. Those born before 2 September 1933 were ineligible and remained ineligible for life, whereas those born on or after 2 September 1933 were eligible for at least 1 year to receive the vaccine. Using large-scale electronic health record data, we first show that the percentage of adults who received the vaccine increased from 0.01% among patients who were merely 1 week too old to be eligible, to 47.2% among those who were just 1 week younger. Apart from this large difference in the probability of ever receiving the zoster vaccine, individuals born just 1 week before 2 September 1933 are unlikely to differ systematically from those born 1 week later. Using these comparison groups in a regression discontinuity design, we show that receiving the zoster vaccine reduced the probability of a new dementia diagnosis over a follow-up period of 7 years by 3.5 percentage points (95% confidence interval (CI) = 0.6-7.1, P = 0.019), corresponding to a 20.0% (95% CI = 6.5-33.4) relative reduction. This protective effect was stronger among women than men. We successfully confirm our findings in a different population (England and Wales's combined population), with a different type of data (death certificates) and using an outcome (deaths with dementia as primary cause) that is closely related to dementia, but less reliant on a timely diagnosis of dementia by the healthcare system10. Through the use of a unique natural experiment, this study provides evidence of a dementia-preventing or dementia-delaying effect from zoster vaccination that is less vulnerable to confounding and bias than the existing associational evidence.

Current epidemiology of infectious encephalitis: a narrative review

BACKGROUND

Infectious encephalitis poses a global health challenge with high mortality and severe neurological consequences in survivors. Emerging pathogens and outbreaks are reshaping the patterns of the disease.

OBJECTIVES

The objective of this study is to understand the current epidemiology for improving prevention, diagnosis, and treatment.

SOURCES

Medline/PubMed was searched using 'encephalitis' and related MeSH terms from 2020 to September 2024. Population-based and case-control studies on encephalitis were searched without time restrictions. Other studies known by the authors were also included.

CONTENT

The incidence of infectious encephalitis ranged from 1.4 to 13.8 cases per 100 000 per year with a bimodal peak in infants and older adults. Herpes viruses remain the most common causes of sporadic encephalitis with herpes simplex virus type 1 and varicella zoster virus reported most frequently. In endemic regions, arboviruses such as Japanese encephalitis virus and West Nile virus contribute significantly to the disease burden. Climate change is adding to the spread of these vector-borne viruses thereby both altering the geographical distribution of causative agents and increasing the frequency of outbreaks. Evidence on risk factors associated with encephalitis is scarce and hampered by the absence of population-based case-control studies. The prognosis of infectious encephalitis remains unchanged during recent decades with high case-fatality rates and may vary according to, e.g. aetiology, age, and presence of immunocompromising conditions or other comorbidities. Importantly, a substantial proportion of survivors are left with disabling neurological sequelae.

IMPLICATIONS

The findings underscore the importance of public health surveillance and prevention strategies to address the changing epidemiology of encephalitis. This can be pursued through vaccination programmes and vector control efforts. Future research should focus on identifying risk factors, improving diagnostic tools, optimizing current treatment as well as exploring novel therapies for patients with encephalitis. Timely treatment and specialised post-hospital rehabilitation remain essential for patient management.

The role of atherosclerosis in HIV-associated vasculopathy in young South African stroke patients

BACKGROUND

HIV-associated vasculopathy is known to cause stroke in people living with HIV (PLWH). The role of atherosclerosis is unclear. We assessed the aetiology of vasculopathy in PLWH and tested the utility of markers of subclinical atherosclerosis to distinguish atherosclerotic (AV) from non-atherosclerotic vasculopathy (NAV).

METHODS

This cross-sectional study recruited PLWH with stroke at a hospital in Johannesburg, South Africa, from 2014 to 2017. Patients with meningitis were excluded. Cerebrospinal fluid (CSF) was tested for multi-viral polymerase chain reaction, including varicella zoster virus (VZV). Once an aetiological category was assigned, carotid intima-media thickness (cIMT) and aortic pulse wave velocity (PWV) were compared in AV and NAV, and to predetermined thresholds for subclinical atherosclerosis (cIMT≥0.70 mm, PWV≥10.00 m/s).

RESULTS

Some 28/85 PLWH (32.9%) vs. 9/109 (8.3%, p < 0.0001) people-without-HIV had vasculopathy on computed tomography angiography. Only four PLWH had AV. Compared with NAV (n = 11), those with AV were older (50.0 ± 4.1 vs. 39.2 ± 9.2 years, p = 0.04) and had more cardiovascular risk factors (median 2.0 [IQR 1.5-2.5] vs. 0.0 [IQR 0.0-1.0], p = 0.02). cIMT in AV was higher than in NAV (1.01 ± 0.07 mm [n = 4] vs. 0.63 ± 0.04 mm [n = 9], p < 0.001). All with AV had cIMT and PWV above the predetermined thresholds, while all except one with NAV were below. We found evidence of VZV in eight PLWH and HIV-associated vasculitis in six.

CONCLUSIONS

Vasculopathy in PLWH in our region appears to be predominantly non-atherosclerotic. cIMT and PWV were useful adjuncts in distinguishing AV from NAV. Despite excluding meningitis, VZV was implicated in a large proportion, emphasizing the likely underdiagnosis of this treatable infection. We thus recommend CSF VZV testing in all PLWH with stroke.

An Autopsy Case of Varicella-zoster Virus Uveitis Progressing to Vasculopathy with Multiple Cerebral Infarctions

We herein report an autopsy case of multiple cerebral infarctions caused by varicella-zoster virus (VZV) vasculopathy. A 60-year-old man, previously diagnosed with VZV uveitis, subsequently developed cerebral infarction with multiple cerebral vessel stenoses. Based on the results of a polymerase chain reaction test of cerebrospinal fluid, the patient was diagnosed with VZV vasculopathy. Despite treatment with acyclovir and prednisolone, the vascular stenosis progressed and became complicated by extensive cerebral infarctions. Upon autopsy, inflammatory cell infiltration was pathologically observed in the vessel walls of the anterior and middle cerebral arteries, consistent with the magnetic resonance imaging findings.

Management of severe acute encephalopathy in the ICU: an expert consensus statement from the french society of intensive care medicine

INTRODUCTION

Acute encephalopathy in the ICU poses significant diagnostic, therapeutic, and prognostic challenges. Standardized expert guidelines on acute encephalopathy are needed to improve diagnostic methods, therapeutic decisions, and prognostication.

METHODS

The experts conducted a review of the literature, analysed it according to the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) methodology and made proposals for guidelines, which were rated by other experts. Only expert opinions with strong agreement were selected.

RESULTS

The synthesis of expert work and the application of the GRADE method resulted in 39 recommendations. Among the 39 formalized recommendations, 1 had a high level of evidence (GRADE 1 +) and 10 had a low level of evidence (GRADE 2 + or 2-). These recommendations describe indication for ICU admission, use of clinical scores and EEG for diagnosis, detection of complications, and prognostication. The remaining 28 recommendations were based on expert consensus. These recomandations describe common indications for blood and CSF studies, neuroimaging, use of neuromonitoring, and provide guidelines for management in the acute phase.

CONCLUSION

This expert consensus statement aims to provide a structured framework to enhance the consistency and quality of care for ICU patients presenting with acute encephalopathy. By integrating high-quality evidence with expert opinion, it offers a pragmatic approach to addressing the complex nature of acute encephalopathy in the ICU, promoting best practices in patient care and facilitating future research in the field.

Inflammatory disorders that affect the cerebral small vessels

ABSTRACT

This comprehensive review synthesizes the latest advancements in understanding inflammatory disorders affecting cerebral small vessels, a distinct yet understudied category within cerebral small vessel diseases (SVD). Unlike classical SVD, these inflammatory conditions exhibit unique clinical presentations, imaging patterns, and pathophysiological mechanisms, posing significant diagnostic and therapeutic challenges. Highlighting their heterogeneity, this review spans primary angiitis of the central nervous system, cerebral amyloid angiopathy-related inflammation, systemic vasculitis, secondary vasculitis, and vasculitis in autoinflammatory diseases. Key discussions focus on emerging insights into immune-mediated processes, neuroimaging characteristics, and histopathological distinctions. Furthermore, this review underscores the importance of standardized diagnostic frameworks, individualized immunomodulation approaches, and novel targeted therapies to address unmet clinical demands.

Varicella zoster vasculopathy causing recurrent ischaemic strokes in an immunocompetent patient

A 66-year-old woman reported 10 days of generalised weakness, falls and memory 'glitches'. She had developed left-sided ophthalmic herpes zoster 3 months before but was otherwise well. MR scan of brain showed acute left-sided ischaemic strokes and CT cerebral angiogram identified marked stenoses of the left anterior and middle cerebral arteries. We suspected varicella-zoster virus vasculopathy, confirmed by cerebrospinal fluid analysis. Initially she had further ischaemic strokes despite intravenous acyclovir, prednisone, aspirin and clopidogrel. However, after prolonged acyclovir and prednisone, there were no new infarcts though imaging of left anterior and middle cerebral artery vessel walls showed persistent inflammation. Varicella zoster vasculopathy can cause recurrent ischaemic strokes, even in immunocompetent people with no cardiovascular risk factors, and despite long-term antiviral therapy.

Post-infectious central nervous system vasculitides in adults: an underdiagnosed and treatable disease : Part I. Overview

INTRODUCTION

The differential diagnosis of Primary Central Nervous System Angiitis (PACNS) is complex and includes several inflammatory and non-inflammatory conditions. Among the first ones, post-infectious CNS vasculitides represent a relevant topic and they are often underdiagnosed.

AIMS

The main aim of this review is to summarize the clinical and neuroimaging features of post-infectious vasculitides, highlighting the diagnostic clues and the need to carefully consider them in the differential diagnosis of PACNS.

FINDINGS

Several infectious agents (viruses, bacteria, fungi and parasites) can be involved in documented post-infectious vasculitides, often with a pathological confirmation. Post-infectious vasculitides involve not only immunocompromised hosts but also immunocompetent people and the diagnosis might be complicated by the lack of close time relationship between infections and neuro-logical symptoms, as in Varicella Zoster Virus (VZV) related vasculopathy in adults. Several complications may occur, ranging from ischemic to hemorrhagic stroke, from arterial to venous thrombosis, from large to small vessel involvement, often simultaneously.

CONCLUSIONS

Post-infectious vasculitides are caused by a broad spectrum of microorganisms and they should be carefully considered in the differential diagnosis of some neurological pictures and neuroradiologicals findings in immunocompetent adults too.

A Case of Multiple Intracranial Hemorrhages Due to Biopsy-Proven Varicella Zoster Virus Vasculopathy Without Rash

Varicella zoster virus (VZV) vasculopathy is a rare complication of VZV infection that can lead to severe neurological manifestations, including multiple intracranial hemorrhages. We report the case of an 80-year-old male patient with a history of Parkinson's disease and hypertension who presented with altered consciousness and motor difficulties. Imaging studies revealed recurrent cortical-subcortical hemorrhages in the right frontal lobe. Laboratory tests showed elevated cerebrospinal fluid (CSF) protein, increased CSF cell count, and a significantly elevated VZV IgG antibody index, while CSF VZV DNA was undetectable. A brain biopsy confirmed the diagnosis, showing vasculitis with VZV DNA positivity via real-time polymerase chain reaction (PCR) and immunohistochemistry. The patient was treated with intravenous acyclovir and corticosteroids, which partially improved clinical outcomes. This case highlights the importance of considering VZV vasculopathy as a differential diagnosis in unexplained intracranial hemorrhages, even in the absence of typical skin lesions. Comprehensive diagnostic evaluation, including CSF antibody testing and brain biopsy, is essential for accurate diagnosis and management.

Clinical spectrum and possible pathogenesis of progressive outer retinal necrosis

OBJECTIVE

Progressive outer retinal necrosis (PORN) is an alphaherpesvirus-caused panuveitis with devastating consequences for the eye. Our study aims to describe new findings in the clinical spectrum and propose a mechanism for the pathogenesis of PORN.

METHODS

Observational, consecutive case series. Seven eyes from five patients diagnosed with PORN were enrolled. Detailed case histories, ocular examination findings and multimodal images of retina were collected. Optic nerve and brain imaging were obtained by MRI.

RESULTS

All eyes were confirmed human alphaherpesviruses positive in ocular fluid by qPCR. Optic nerve oedema was observed on MRI in all eyes. A relative afferent pupillary defect was recorded in the affected eye for the unilateral cases. Two patients with unilateral involvement had a history of viral encephalitis and focal encephalomalacia found in the temporal lobe on brain MRI. The affected eyes were characterised by sensory retinal necrosis sparing retinal pigment epithelium, starting at the end of the retinal nerve fibre (horizontal raphe or peripheral area of the retina) and progressing rapidly along the nerve fibre. The wall of the retinal artery and vein was destroyed, resulting in blood flow interruption on fluorescein angiography and retinal haemorrhages along the large vessels.

CONCLUSIONS

Combination the neurotropic characteristics of alphaherpesviruses and the signs of PORN, we hypothesised that the reactivated PORN virus originated from the lateral geniculate nucleus, then propagated along the optic nerve and was released at the terminals, causing necrosis of the entire sensory retina rather than just affecting the outer segment.

Post-infectious central nervous system vasculitides in adults: an underdiagnosed and treatable disease part II. Neuroimaging of selected etiologies : Part II. Neuroimaging of selected etiologies

INTRODUCTION

As detailed in the first part of this review, post-infectious vasculitides are a wide and complex category, including several clinical, microbiological and neuroradiological patterns. In order to raise the suspicion for diagnosis, the knowledge of two different neuroradiological issues is needed, i.e. the knowledge of neuroimaging pattern of infections and the one of neuroimaging pattern of vasculitis.

AIMS

The main aim of this second part is to summarize the neuroradiological features of post-infectious vasculitides focusing on imaging of vessels and consequences of vessel involvement, continuing the discussion proposed in the first part about neuroimaging of infections. In some cases, the two neuroradiological issues are both simultaneously present in the same patient, but in other cases only the second one can be depicted due to the latency between infection and vasculitis.

FINDINGS

Beyond general features of cerebral vascular involvement in post-infectious vasculitides, some well-studied and homogenous diseases, as treponemal vasculitis, Varicella Zoster Virus (VZV) arteriopathy, neuroborreliosis, SARS-CoV2-related endotheliopathy are described in detail, being not rare and sometimes underdiagnosed. The main clinical and neuroradiological features of these conditions are deeply addressed, providing diagnostic clues and pictorial examples.

CONCLUSIONS

Although some general features are common in clinical presentation and neuroimaging of post-infectious vasculitides, there are few neuroimaging clues pointing out a specific microbial agent as causative. The main step is to raise the diagnostic suspicion in order to start the dedicated investigation pathway and treatment.

Decoding the Nexus: Cellular and Molecular Mechanisms Linking Stroke and Neurotoxic Microenvironments in Brain Cancer Patients

Stroke is an often underrecognized albeit significant complication in patients with brain cancer, arising from the intricate interplay between cancer biology and cerebrovascular health. This review delves into the multifactorial pathophysiological framework linking brain cancer to elevated stroke risk, with particular emphasis on the crucial role of the neurotoxic microenvironment (NTME). The NTME, characterized by oxidative stress, neuroinflammation, and blood-brain barrier (BBB) disruption, creates a milieu that promotes and sustains vascular and neuronal injury. Key pathogenic factors driving brain cancer-related stroke include cancer-related hypercoagulability, inflammatory and immunological mechanisms, and other tumor-associated processes, including direct tumor compression, infection-related sequelae, and treatment-related complications. Recent advances in genomic and proteomic profiling present promising opportunities for personalized medicine, enabling the identification of biomarkers-such as oncogenes and tumor suppressor genes-that predict stroke susceptibility and inform individualized therapeutic strategies. Targeting the NTME through antioxidants to alleviate oxidative stress, anti-inflammatory agents to mitigate neuroinflammation, and therapies aimed at reinforcing the BBB could pave the way for more effective stroke prevention and management strategies. This integrative approach holds the potential to reduce both the incidence and severity of stroke, ultimately improving clinical outcomes and quality of life for brain cancer patients. Further research and well-designed clinical trials are essential to validate these strategies and integrate them into routine clinical practice, thereby redefining the management of stroke risk in brain cancer patients.

Steno-occlusive Intracranial Large Vessel Arteriopathies in Childhood: A Pattern Oriented Approach to Neuroimaging Diagnosis

Intracranial steno-occlusive large vessel arteriopathies refer to abnormalities of the arterial wall that typically express luminal stenosis. Notably, some entities that can find themselves within this category may also express luminal dilation, and/or aneurysm formation as an alternative phenotype. Intracranial steno-occlusive large vessel arteriopathies are a leading cause of arterial ischemic stroke (AIS) in children, often progress, and can predispose to recurrent brain infarction. Intracranial arterial dissections account for a subset of cases expressing the focal cerebral arteriopathy (FCA) phenotype because the affected arterial segment, clinical presentation, and AIS patterns are very similar to the inflammatory subtype of FCA.

A Case of Varicella Zoster Virus Encephalitis with Advanced Human Immunodeficiency Virus Disease Diagnosed by Brain Biopsy

A 40-year-old Japanese man with human immunodeficiency virus presented with disturbance of consciousness 2 years after dropping out. He was emaciated without any zoster skin lesions, and his CD4+ lymphocyte count was 4 cells/μL. Disseminated Mycobacterium avium infection and pneumocystis pneumonia were diagnosed, and a brain biopsy revealed varicella zoster virus (VZV) encephalitis with multiple real-time polymerase chain reaction tests and immunochemistry. Antiretroviral therapy and intravenous acyclovir were administered, and the patient survived with neurological sequelae. VZV encephalitis is rare, particularly among people with AIDS, but it is a significant disease with a poor prognosis.

Varicella-Zoster Disease of the Central Nervous System in Immunocompetent Children: Case Series and a Scoping Review

BACKGROUND

Varicella-Zoster Virus (VZV) is characterized by its ability to enter a dormant state within the body. When the wild or vaccine virus reactivates, it can lead to herpes zoster (HZ), which infrequently manifests as a neuroinfection.

OBJECTIVES

The aim of the study was to analyze the clinical manifestations and outcomes associated with VZV reactivation in the CNS in immunocompetent children.

METHODS

We searched medical databases for case reports using the keywords "zoster", "meningitis", "encephalitis", and "immunocompetent". The inclusion criteria were age below 18 years, any gender, race, and ethnicity, no features or history of immunodeficiency, and confirmation of VZV reactivation through the detection of VZV DNA in the CSF. Patients were categorized into two groups: children experiencing the reactivation of the wild virus and children with the vaccine strain virus.

RESULTS

The cohort included six children hospitalized in our hospital and 49 children reported in the literature. In 37 (67%), a wild-type virus was detected, while in 18 (33%), an infection was caused by the vaccine strain. There were no differences in the clinical presentation between the two groups. A typical rash was observed in 32 (58%) children. Approximately 41 of the 55 children (75%) received antiviral treatment. Four patients experienced complications.

CONCLUSIONS

Neither a history of VZV immunization nor the absence of a skin rash can definitively exclude VZV meningitis. It is important to note that any seemingly healthy child, regardless of recognized risk factors, could develop HZ meningitis.

"Bloomy rind sign" in varicella-zoster virus brainstem meningoencephalitis

The bloomy rind sign, characterized by band-like abnormalities along the surface of the brainstem on magnetic resonance imaging without contrast enhancement, has been considered a specific imaging marker for leptomeningeal metastasis from lung adenocarcinoma. In this study, we describe the case of an 85-year-old male with a 3-week history of headache, fever, and progressive cognitive impairment. The patient was diagnosed with varicella-zoster virus brainstem meningoencephalitis and magnetic resonance imaging revealed hyperintensities along the brainstem surface on fluid-attenuated inversion recovery and diffusion-weighted imaging that mimicked a bloomy rind sign. However, the patient showed no signs of lung cancer or meningeal carcinomatosis. This case suggests that the bloomy rind sign is not exclusive to leptomeningeal metastasis but can also be observed in other conditions, such as central nervous system infections.

Percutaneous Cerebral Angioplasty for Refractory Middle Cerebral Artery Stenosis Due to Varicella-Zoster Virus-Related Vasculopathy: A Case Report

An 81-year-old man was admitted to our hospital with left hemiplegia after treatment for herpes zoster of the first branch of the right trigeminal nerve. CSF examination revealed an elevated varicella-zoster virus (VZV) antibody index. Brain MRI showed cerebral infarction in the right middle cerebral artery (MCA) territory and vessel wall thickening and enhancing effects at the ipsilateral MCA. Despite the standard treatment, the MCA stenosis progressed with recurrent infarcts. Percutaneous cerebral angioplasty was performed to the distal portion of the right MCA without deterioration. This case can provide a treatment option for refractory progressive VZV vasculopathy.

[A case of a young woman with bilateral medial medullary infarcts caused by varicella-zoster virus vasculopathy without skin rash]

The patient, a 36-year-old female, had no previous history of shingles. She was admitted to the hospital due to nausea and lightheadedness. Upon admission, she was diagnosed with bilateral medial medullary infarcts. She received treatment with intravenous edaravone and argatroban, as well as antiplatelet therapy with aspirin and clopidogrel. However, her dysphagia, dysarthria, and paraplegia worsened. Due to changes in the lesion of the basilar artery on brain ‍MRA, we suspected the possibility of basilar artery dissection, and discontinued antiplatelet therapy. Subsequent imaging studies suggested vasculitis. After examining the cerebrospinal fluid, we diagnosed varicella-zoster virus (VZV) vasculopathy. Based on this diagnosis, we administered steroid pulse therapy for three days, started intravenous acyclovir, and resumed antithrombotic therapy with clopidogrel. Prednisone was administered for five days. Biochemical tests revealed an elevated D-dimer level. Due to the presence of lower extremity venous thrombus, clopidogrel was replaced with apixaban. The acyclovir infusion was discontinued due to observed acyclovir-induced neutropenia. These treatments improved neurological symptoms, circumflex thickening of the basilar artery, and contrast effects in the same area. On the 70th day, the patient was transferred to the hospital for rehabilitation. It is important to consider VZV angiopathy as a potential cause of juvenile cerebral infarction accompanying progressive basilar artery stenosis, regardless of the presence or absence of a skin rash.

The effect of herpes zoster vaccination at different stages of the disease course of dementia: Two quasi-randomized studies

The varicella zoster virus, a neurotropic herpesvirus, has been hypothesized to play a role in the pathophysiology of dementia, such as through neuroinflammatory processes or intracerebral vasculopathy. Using unique natural experiments, our group has previously found that live-attenuated herpes zoster (HZ) vaccination reduced the incidence of new diagnoses of dementia in both Wales and Australia. To inform further research and ultimately clinical care, it is crucial to understand at which stage of the disease course of dementia the HZ vaccine has its effect. Representing the two opposing ends of the dementia disease course as it can be ascertained from electronic health record data, the aims of this study were twofold: to determine the effect of HZ vaccination on i) new diagnoses of mild cognitive impairment (MCI) among individuals without any record of cognitive impairment, and ii) deaths due to dementia among individuals living with dementia. Our approach took advantage of the fact that at the time of the start date (September 1 2013) of the HZ vaccination program in Wales, individuals who had their eightieth birthday just after this date were eligible for HZ vaccination for one year whereas those who had their eightieth birthday just before were ineligible and remained ineligible for life. This eligibility rule created comparison groups just on either side of the September 2 1933 date-of-birth eligibility threshold who differed in their age by merely a week but had a large difference in their probability of receiving HZ vaccination. The key strength of our study is that these comparison groups should be similar in their health characteristics and behaviors except for a minute difference in age. We used regression discontinuity analysis to estimate the difference in our outcomes between individuals born just on either side of the date-of-birth eligibility threshold for HZ vaccination. Our dataset consisted of detailed country-wide electronic health record data from primary care in Wales, linked to hospital records and death certificates. We restricted our dataset to individuals born between September 1 1925 and September 1 1942. Among our study cohort of 282,557 without any record of cognitive impairment at baseline, HZ vaccination eligibility and receipt reduced the incidence of a new MCI diagnosis by 1.5 (95% CI: 0.5 - 2.9, p=0.006) and 3.1 (95% CI: 1.0 - 6.2, p=0.007) percentage points over nine years, respectively. Similarly, among our study cohort of 14,350 individuals who were living with dementia at baseline, being eligible for and receiving HZ vaccination reduced deaths due to dementia by 8.5 (95% CI: 0.6 - 18.5, p=0.036) and 29.5 (95% CI: 0.6 - 62.9, p=0.046) percentage points over nine years, respectively. Except for dementia, HZ vaccination did not have an effect on any of the ten most common causes of morbidity and mortality among adults aged 70 years and older in Wales in either of our two study cohorts. The protective effects of HZ vaccination for both MCI and deaths due to dementia were larger among women than men. Our findings suggest that the live-attenuated HZ vaccine has benefits for the dementia disease process at both ends of the disease course of dementia.

Giant cell arteritis and therapeutic response: a dual facet of immunotherapy in metastatic clear cell renal carcinoma

Immune checkpoint inhibitors have emerged as a promising cancer treatment, allowing significant and long-term therapeutic responses. Nivolumab, an anti-programmed cell death protein-1, is one of the molecules of this therapeutic class with known and manageable side effects. Giant cell arteritis is a rare immune-related adverse event most often manifested by headaches poorly released by common antalgics and can result in visual loss. We report its occurrence in an 80-year-old patient on maintenance nivolumab for metastatic clear cell renal carcinoma. Prompt diagnosis and initiation of glucocorticoid therapy led to symptom improvement and visual recovery.

Herpes zoster vaccination and new diagnoses of dementia: A quasi-randomized study in Australia

Increasing evidence suggests that neurotropic herpesviruses could play a role in the development of dementia, possibly through a neuroinflammatory process. Herpes zoster (HZ) vaccination has been reported to lead to a reduced probability of being diagnosed with dementia in several correlational studies and in a prior analysis by our team in Wales. This present study constitutes the first investigation to use a quasi-randomized study design in an electronic health record dataset from a large and diverse nation (Australia) to aim to determine the effect of HZ vaccination on dementia. In Australia, starting on November 1 2016, live-attenuated HZ vaccination was provided for free to individuals aged 70 to 79 years of age through primary care providers. Thus, those whose 80th birthday was just a few days prior to November 1 2016 never became eligible, whereas those whose 80th birthday was just a few days later were eligible. The key advantage of our approach is that one would not expect that these population groups who differ in their age by only a minute degree would, on average, differ in any of their health characteristics and behaviors. We used detailed primary healthcare records with week-of-birth information from 65 general practices across Australia. We analyzed our data using a regression discontinuity approach. Our sample consisted of 101,219 patients. As expected, patients born just before versus shortly after the date-of-birth eligibility threshold (November 2 1936) for HZ vaccination were well-balanced in their past preventive health services uptake and chronic disease diagnoses. There was an abrupt increase of 15.7 (95% CI: [12.2 - 19.3], p < 0.001) percentage points in the probability of ever receiving HZ vaccination between patients born shortly before versus shortly after the eligibility threshold. The eligibility rules of the HZ vaccination program, thus, created comparison groups just on either side of the date-of-birth eligibility threshold who were similar to each other, except for a large difference in their probability of receiving the intervention (HZ vaccination) of interest. Eligibility for HZ vaccination (i.e., being born shortly before versus shortly after November 2 1936) decreased the probability of receiving a new dementia diagnosis over 7.4 years by 2.0 percentage points (95% CI: [0.3 - 3.7], p = 0.021). Being eligible for HZ vaccination did not affect the probability of taking up other preventive health services (including other vaccinations), nor the probability of being diagnosed with other common chronic conditions than dementia. This study provides important evidence on the potential benefits of HZ vaccination for dementia because its quasi-randomized design allows for conclusions that are more likely to be causal than those of the existing associational evidence.

Exploring the Link between Varicella-Zoster Virus, Autoimmune Diseases, and the Role of Recombinant Zoster Vaccine

The varicella-zoster virus (VZV) is a human neurotropic herpes virus responsible for varicella and herpes zoster (HZ). Following primary infection in childhood, VZV manifests as varicella (chickenpox) and enters a period of latency within the dorsal root ganglion. A compromised cellular immune response due to aging or immunosuppression triggers viral reactivation and the development of HZ (shingles). Patients with autoimmune diseases have a higher risk of developing HZ owing to the immunodeficiency associated with the disease itself and/or the use of immunosuppressive agents. The introduction of new immunosuppressive agents with unique mechanisms has expanded the treatment options for autoimmune diseases but has also increased the risk of HZ. Specifically, Janus kinase (JAK) inhibitors and anifrolumab have raised concerns regarding HZ. Despite treatment advances, a substantial number of patients suffer from complications such as postherpetic neuralgia for prolonged periods. The adjuvanted recombinant zoster vaccine (RZV) is considered safe and effective even in immunocompromised patients. The widespread adoption of RZV may reduce the health and socioeconomic burdens of HZ patients. This review covers the link between VZV and autoimmune diseases, assesses the risk of HZ associated with immunosuppressant use, and discusses the benefits and risks of using RZV in patients with autoimmune diseases.

Varicella Zoster Virus Vasculopathy: An Under-Recognized Entity

Varicella zoster virus (VZV) vasculopathy is a rare yet potentially severe neurological manifestation resulting from VZV reactivation, primarily affecting immunocompromised individuals. We present a case report of a 61-year-old male with VZV vasculopathy who initially presented with herpes zoster ophthalmicus, subsequently complicated by meningoencephalitis and an acute infarct in the territory of the left middle cerebral artery (MCA). Imaging revealed acute and chronic infarcts in the capsuloganglionic regions, accompanied by thickening and enhancement of the left MCA wall. Treatment involved a 14-day course of intravenous acyclovir, supplemented with oral prednisolone, resulting in modest clinical improvement. VZV vasculopathy represents an infrequently acknowledged neurological syndrome, particularly prevalent among immunocompromised individuals. Early recognition and appropriate intervention offer promise in ameliorating outcomes for affected patients. This case emphasizes the importance of including VZV vasculopathy in the differential diagnosis of neurological deficits, especially within high-risk populations.

Characteristics and long-term prognosis of Danish residents with a positive intrathecal antibody index test for herpes simplex virus or varicella-zoster virus compared with individuals with a positive cerebrospinal fluid PCR: a nationwide cohort study

OBJECTIVES

We compared characteristics and outcomes of individuals who in the cerebrospinal fluid (CSF) were positive for herpes simplex virus (HSV) or varicella-zoster virus (VZV)-intrathecal antibody index test ([AI]-positive) vs. individuals who were PCR-positive for HSV type 1 (HSV1), type 2 (HSV2), and for VZV.

METHODS

Nationwide cohort study of all Danish residents with positive CSF-AI or -PCR for HSV or VZV (1995-2021). We calculated short- and long-term risks as age-, sex-, and comorbidity-adjusted odds ratios (aOR), adjusted hazard ratios (aHR), and absolute risk differences with 95% CIs.

RESULTS

Compared with individuals with positive PCR for HSV1 (n = 321), HSV2 (n = 497), and VZV (n = 1054), individuals with a positive AI for HSV (n = 177) and VZV (n = 219) had CSF pleocytosis less frequently (leucocyte count >10/μL: HSV-AI: 39%, VZV-AI: 52%, HSV1-PCR: 81%, HSV2-PCR: 92%, VZV-PCR: 83%), and were less frequently diagnosed with central nervous system infection ([aOR {95%CI}]: HSV-AI vs. HSV1-PCR: [0.1 {0.1, 0.2}], HSV-AI vs. HSV2-PCR: [0.1 {0.0, 0.1}], VZV-AI vs. VZV-PCR: [0.2 {0.2, 0.3}]). Individuals with a positive HSV-AI or VZV-AI had increased risk of demyelinating disease ([aOR {95%CI}; aHR {95%CI}]: HSV-AI vs. HSV1-PCR: [4.6 {0.9, 24.5}; aHR not applicable], HSV-AI vs. HSV2-PCR: [10.4 {2.3, 45.9}; 12.4 {2.3, 66.0}], VZV-AI vs. VZV-PCR: [aOR not applicable; 10.3 {1.8, 58.8}]). Disability pension was less frequent among HSV-AI than HSV1-PCR cohort members (5-year risk difference: -23.6%, 95%CI: -35.2, -11.8), and more frequent among VZV-AI than VZV-PCR cohort members (5-year risk difference: 16.8%, 95%CI: 5.0, 28.7).

DISCUSSION

AI-positive individuals differ from PCR-positive individuals in several aspects. AI appears unspecific for current central nervous system infections.

Encephalitis in HIV-negative immunodeficient patients: a prospective multicentre study, France, 2016 to 2019

BackgroundData on infectious encephalitis in immunodeficient (ID) individuals are scarce. This population may present with atypical clinical symptoms, be infected by uncommon pathogens and develop poor outcomes.AimWe aimed to describe the epidemiology of infectious encephalitis among HIV-negative ID patients.MethodsPatients from the ENCEIF (Etude Nationale de Cohorte des Encéphalites Infectieuses en France) prospective cohort meeting criteria for infectious encephalitis between January 2016 and December 2019 were included. We compared clinical presentation, magnetic resonance imaging (MRI) results, biological results, infection causes and outcome of ID patients with immunocompetent (IC) patients using Pearson's chi-squared test and Student's t-test. We carried out logistic regression to assess the role of immunodeficiency as risk factor for poor outcome.ResultsID patients (n = 58) were older (mean 72 vs 59 years), had higher prevalence of diabetes (26% vs 12%), pre-existing neurological disorders (12% vs 5%) and higher case-fatality rate (23.6% vs 5.6%) compared to IC patients (n = 436). Varicella zoster virus was the primary cause of encephalitis in ID patients (this aetiology was more frequent in ID (25.9%) than in IC patients (11.5%)), with herpes simplex virus second (22.4% in ID patients vs 27.3% in IC patients). Immunodeficiency was an independent risk factor for death or major sequelae (odds ratio: 3.41, 95%CI: 1.70-6.85).ConclusionsVaricella zoster virus is the most frequent cause of infectious encephalitis in ID patients. Immunodeficiency is a major risk factor for poor outcome. ID encephalitis patients should benefit from stringent investigation of cause and early empiric treatment.

Pathology of Primary Angiitis of the Central Nervous System

Primary angiitis of the central nervous system (PACNS) is a rare and potentially severe form of vasculitis that is limited to the brain, spinal cord, and meninges. Despite extensive research, the etiology and underlying immunologic mechanisms of PACNS remain largely unknown. PACNS presents with a variety of clinical, radiological, and pathologic features, but it is generally characterized by inflammation and destruction of the walls of blood vessels in the CNS, which can lead to tissue ischemia and/or hemorrhage. Three main histopathologic patterns have been identified, namely granulomatous, lymphocytic, and necrotizing vasculitis.

Diagnostic Methods and Management Strategies of Herpes Simplex and Herpes Zoster Infections

Herpesviruses are medium-sized double-stranded DNA viruses. Of more than 80 herpesviruses identified, only 9 human herpesviruses have been found to cause infection in humans. These include herpes simplex viruses 1 and 2 (HSV-1 and HSV-2), varicella-zoster virus (VZV), human cyto-megalovirus (HCMV), Epstein-Barr virus (EBV), and human herpesvirus (HHV-6A, HHV-6B, HHV-7, HHV-8). HSV-1, HSV-2, and VZV can be problematic given their characteristic neurotropism which is the ability to invade via fusion of its plasma membrane and reside within neural tissue. HSV and VZV primarily infect mucocutaneous surfaces and remain latent in the dorsal root ganglia for a host's entire life. Reactivation causes either asymptomatic shedding of virus or clinical manifestation of vesicular lesions. The clinical presentation is influenced by the portal of entry, the immune status of the host, and whether the infection is primary or recurrent. Affecting 60% to 95% of adults, herpesvirus-associated infections include gingivostomatitis, orofacial and genital herpes,and primary varicella and herpes zoster. Symptomatology, treatment, and potential complications vary based on primary and recurrent infections as well as the patient's immune status.

The association of stroke with herpes zoster ophthalmicus

BACKGROUND/OBJECTIVES

Studies have reported an association between herpes zoster ophthalmicus (HZO) and stroke. We sought to validate this association with rigorous controls for both medical comorbidities and social factors using a nationwide U.S. administrative medical claims database.

SUBJECTS/METHODS

A two-step approach was taken: first a retrospective case-control study was performed, followed by a self-controlled case series (SCCS). For the case control study, cox proportional hazard regression with inverse proportional treatment weighting assessed the hazard for stroke. In the SCCS, incidence of stroke was compared prior to and after the diagnosis of HZO.

RESULTS

For the case-control study, 25,720 cases and 75,924 controls met our eligibility criteria. 1712 (6.7%) and 4544 (6.0%) strokes occurred in the case and control groups respectively, conferring an 18% increased risk of stroke in the observed 1-year post-HZO period (HR = 1.18, 95% CI: 1.12-1.25, p < 0.001). SCCS analysis showed the risk for stroke was highest in the month immediately after HZO episode compared to any other time range (1-30 days after, relative risk 1.58, p < 0.001) and even higher when assessing time more distal time points prior to the HZO diagnosis (days 1-30 after HZO diagnosis had RR = 1.69 (95% CI: 1.38-2.07) and RR = 1.93 (95% CI: 1.55-2.39) compared with days -120 to -91 and -150 to -121 prior to index, respectively (p < 0.001).

CONCLUSIONS

After accounting for stroke risk factors, our analysis confirms the association between HZO and stroke, with highest risk in the immediate month after an episode.

Identifying CNS infections in transplantation and immunomodulatory therapy

Opportunistic central nervous system (CNS) infections are a significant cause of morbidity and mortality in immunocompromized patients, including those undergoing transplantation and receiving immunomodulatory therapy. Particularly in these individuals, the clinical presentation of these infections may have atypical patterns, emphasizing the need to consider various diagnostic possibilities, including noninfectious conditions. Quick and accurate identification, along with prompt treatment, is crucial for improving patient outcomes. Therefore, understanding which pathogens are likely to cause infection based on factors such as timing post-transplantation, specific organ transplant, and the mechanism of action of immunomodulatory medications is essential. This review will provide a detailed description of the types of infections that may arise in the context of transplantation and immunomodulatory therapy.

Case Report and Literature Review: Isolated Trochlear Nerve Palsy due to Herpes Zoster Infection

Introduction

Trochlear nerve palsy (TNP) is a common cause of vertical diplopia resulting from superior oblique muscle weakness. While herpes zoster is a well-documented cause of cranial neuropathies, reports of TNP associated with herpes zoster infection remain limited.

Case Presentation

We report a case of a 65-year-old patient with typical herpes zoster ophthalmicus on the left side of his face with subsequent corneal endotheliitis and isolated TNP. The MRI revealed a faint enhancement at the cavernous sinus on the same side as the TNP. Cerebrospinal fluid detected human herpesvirus 3, confirming the diagnosis. An intravenous antiviral was administered for 14 days with prolonged maintenance to prevent recurrence. Oral corticosteroids were also used as an adjuvant to reduce inflammation. After treatment, the uveitis subsided, and the vertical diplopia recovered partially. TNP from herpes zoster is a rare presentation. The underlying pathogenic mechanisms, including potential direct viral invasion, inflammatory responses, and possible vasculopathy affecting the trochlear nerve, are explored.

Conclusion

TNP can be a rare neuro-ophthalmic complication of herpes zoster infection. Clinicians should maintain a high index of suspicion when assessing patients with cranial neuropathies in the context of herpes zoster. Prompt antiviral therapy and supportive measures can aid in the resolution of symptoms and alleviate potential long-term sequelae.

Infectious leukoencephalopathies

Leukoencephalopathy from infectious agents may have a rapid course, such as human simplex virus encephalitis; however, in many diseases, it may take months or years before diagnosis, such as in subacute sclerosing panencephalitis or Whipple disease. There are wide geographic distributions and susceptible populations, including both immunocompetent and immunodeficient patients. Many infections have high mortality rates, such as John Cunningham virus and subacute sclerosing panencephalitis, although others have effective treatments if suspected and treated early, such as herpes simplex encephalitis. This chapter will describe viral, bacterial, and protozoal infections, which predominantly cause leukoencephalopathy. We focus on the clinical presentation of these infectious agents briefly covering epidemiology and subtypes of infections. Next, we detail current pathophysiologic mechanisms causing white matter injury. Diagnostic and confirmatory tests are discussed. We cover predominantly MRI imaging features of leukoencephalopathies, and in addition, summarize the common imaging features. Additionally, we detail how imaging features may be used to narrow the differential of a leukoencephalopathy clinical presentation. Lastly, we present an outline of common treatment approaches where available.

Varicella-zoster virus vasculopathy in a patient with multiple sclerosis receiving natalizumab

We present a case of a woman in her 30s with relapsing-remitting multiple sclerosis, treated with natalizumab, who developed ophthalmic varicella zoster virus (VZV) infection, with subsequent vasculopathy causing cerebral ischaemic lesions. She was treated with acyclovir, prednisolone and acetylsalicylic acid and fully recovered. VZV vasculopathy is associated with stroke and immunomodulating treatments may increase the risks of these adverse events. To date, nine VZV-related vasculopathy cases in patients treated with natalizumab have been reported in English literature and are summarised in this paper. Although rare, VZV intracerebral vasculopathy is an important differential diagnosis in patients with unexplained new-onset neurological symptoms after a herpes zoster infection. Treatment guidelines for VZV vasculopathy and for continuing treatment of multiple sclerosis after such an event are currently not established.

SARS-CoV-2 and Brain Health: New Challenges in the Era of the Pandemic

Respiratory viral infections have been found to have a negative impact on neurological functions, potentially leading to significant neurological impairment. The SARS-CoV-2 virus has precipitated a worldwide pandemic, posing a substantial threat to human lives. Growing evidence suggests that SARS-CoV-2 may severely affect the CNS and respiratory system. The current prevalence of clinical neurological issues associated with SARS-CoV-2 has raised significant concerns. However, there needs to be a more comprehensive understanding of the specific pathways by which SARS-CoV-2 enters the nervous system. Based on the available evidence, this review focuses on the clinical neurological manifestations of SARS-CoV-2 and the possible mechanisms by which SARS-CoV-2 invades the brain.

PRIMARY ANGIITIS OF THE CENTRAL NERVOUS SYSTEM - A DIAGNOSTIC CHALLENGE

Primary angiitis of the central nervous system (PACNS) is a rare and severe disease confined to the central nervous system, i.e., the brain and spinal cord. The etiology, pathogenesis and immune mechanism of PACNS have not yet been completely elucidated. The diagnosis is challenging; it is based upon constellation of clinical picture, cerebrospinal fluid analysis, imaging methods or tissue biopsy as the gold standard. In differential diagnosis of PACNS, it is necessary to rule out infectious, malignant or systemic inflammatory diseases, as well as reversible cerebral vasoconstriction syndrome. Immunosuppressants are cornerstone therapy for PACNS, although evidence-based strategies for the management are lacking so far. PACNS is an entity with considerable morbidity and mortality. Awareness of this rare and heterogeneous disease is crucial for establishing early diagnosis and treatment initiation.

Central Nervous System Vasculitis: Primary Angiitis of the Central Nervous System and Central Nervous System Manifestations of Systemic Vasculitis

Central nervous system vasculitis (CNSV) is a group of disorders leading to inflammatory vasculopathy within the brain, spinal cord, and leptomeninges. CNSV is divided into primary angiitis of the central nervous system (PACNS) and secondary CNSV based on the underlying etiology. PACNS is a rare inflammatory disorder with poorly understood pathophysiology and heterogeneous and highly variable clinical features. The diagnosis depends on a combination of clinical and laboratory variables, multimodal imaging, and histopathological examination as well as exclusion of mimics. Several systemic vasculitides, infectious etiologies and connective tissue disorders have been shown to cause secondary CNSV and require prompt recognition.

Stroke risk after varicella-zoster virus infection: a systematic review and meta-analysis

Varicella-zoster virus (VZV) infection may cause vascular inflammatory changes leading to an increased risk of stroke. Previous studies have focused on the risk of stroke and less on changes in stroke risk and prognosis. We aimed to explore the changing patterns of stroke risk and stroke prognosis after VZV infection. This study is a systematic review and meta-analysis. We searched PubMed, Embase, and the Cochrane Library for studies on stroke after VZV infection between January 1, 2000, and October 5, 2022. Relative risks were combined for the same study subgroups using a fixed-effects model and pooled across studies using a random-effects model. 27 studies met the requirements, including 17 herpes zoster (HZ) studies and ten chickenpox studies. There was an increased risk of stroke after HZ, and this risk decreased over time: relative risk 1.80 (95% CI 1.42-2.29) within 14 days, 1.61 (95% CI 1.43-1.81) within 30 days, 1.45 (95% CI 1.33-1.58) within 90 days, 1.32 (95% CI 1.25-1.39) within 180 days, 1.27 (95% CI 1.15-1.40) at one year and 1.19 (95% CI 0.90-1.59) after one year, with the same trend in the stroke subtype. The risk of stroke after herpes zoster ophthalmicus was higher, with a maximum relative risk of 2.26 (95% CI 1.35-3.78). The risk of stroke after HZ was higher in patients aged around 40 years: relative risk 2.53 (95% CI 1.59-4.02), and similar in men and women. Also, after pooling studies of post-chickenpox stroke, we found that the middle cerebral artery and its branches were most frequently involved (78.2%), with a better prognosis in most patients (83.1%) and less frequent vascular persistence progression (8.9%). In conclusion, the risk of stroke increases after VZV infection, decreasing over time. Post-infection vascular inflammatory changes often occur in the middle cerebral artery and its branches, with a better prognosis in most patients and less frequent persistent progression.

Increased human immunodeficiency virus viral load with cerebral infarction due to varicella zoster virus vasculopathy on treatment with bictegravir/emtricitabine/tenofovir alafenamide suspension: a case report and literature review

BACKGROUND

Varicella-Zoster virus (VZV) vasculopathy occasionally occurs in immunocompromised patients and is difficult to treat. The risk factor and optimal therapy remain unclear. Patients with human immunodeficiency virus (HIV) and dysphagia or difficulty in oral intake receive antiretroviral therapy (ART) suspension. However, there remains little evidence regarding ART suspension.

CASE PRESENTATION

We experienced a case of a 55-year-old man diagnosed with HIV and severe multiple cerebral infarctions due to VZV vasculopathy. We started on bictegravir/tenofovir alafenamide/emtricitabine (BIC/TAF/FTC) and acyclovir (ACV), and prednisone. He was started on BIC/TAF/FTC suspension because of deteriorated swallowing. The HIV viral load was increased; however, no drug-resistance genes were detected. We successfully treated him with doltegravir/abacavir/lamibudine suspension. We performed two literature reviews of the administration of BIC/TAF/3TC suspension and VZV vasculopathy in patients with HIV. Three cases of BIC/TAF/3TC suspension were considered treatment failures. Recent history of VZV infection and a CD4 count under 200 μL may be risk factors for VZV vasculopathy. The effective treatment may be using steroid and ACV; however, treatment duration could differ.

CONCLUSIONS

BIC/TAF/FTC suspension administration may be unstable, and treating ACV and steroid may be optimal therapy for VZV vasculopathy; however, the evidence level is low.

A Rare Case of Varicella-Zoster Virus Encephalitis Presenting With Lost Ability to Play the Piano in an Immunocompetent Pediatric Patient

Varicella-zoster virus (VZV) is a member of the alpha-herpesvirus family, which can occasionally cause severe neurological complications such as encephalitis. In this case report, we discuss a rare finding of VZV encephalitis in which an immunocompetent pediatric patient, vaccinated against varicella, presented with altered mental status and no vesicular rash. A 15-year-old male presented to the Emergency Department with progressively worsening altered mental status over the past three days. The patient's mother stated that he was exhibiting frequent memory lapses as well as the sudden loss of the ability to play the piano. After admission to the pediatric general floor, lumbar puncture was performed and cerebrospinal fluid analysis returned positive for VZV, confirmed by polymerase chain reaction. The patient was then started on intravenous (IV) acyclovir at a dose of 650 mg every 8 hours to treat VZV-induced encephalitis. While the patient continued to have intermittent episodes of confusion and headaches, his overall condition improved, and by day 4, he was able to resume playing the piano and ukulele. The patient was discharged on day 8 with no home medications, and a follow-up with this primary care physician was scheduled. This patient is one of only four recorded cases of VZV encephalitis in immunocompetent children. It is extremely rare to encounter pediatric patients with this diagnosis and, as such, can elude physicians when developing differential diagnoses. If VZV is suspected, a lumbar puncture should be performed promptly, and, if confirmed, IV acyclovir should be started. Furthermore, this case highlights the need for future research with regard to VZV and potential predisposing factors in immunocompetent patients.

Zoster Polyneuritis Cranialis and Intracranial Vasculopathy

A case report of varicella zoster virus (VZV) producing cranial polyneuropathy with intracranial vasculopathy afflicting the internal carotid artery, in a 45-year lady is presented. The clinical features included appearance of zosteriform rash in the left external auditory canal and concha, affliction of ophthalmic and maxillary divisions of V, VI, VII, VIII, IX and X cranial nerves. Contrast MRI brain demonstrated attenuated flow void in the left internal carotid artery. The diagnosis was confirmed with raised level of IgG VZV antibody in serum and detection of VZV IgG antibody in CSF, although PCR for VZV DNA in CSF was negative. The significance lies in atypical presentation, the diagnostic dilemma it poses, poor prognosis of cranial nerve function and the need for multidisciplinary approach to patient management and rehabilitation.

Intracranial vessel wall magnetic resonance imaging features of infectious vasculitis

Vasculitis is a complication of several infectious diseases affecting the central nervous system, which may result in ischemic and/or hemorrhagic stroke, transient ischemic attack, and aneurysm formation. The infectious agent may directly infect the endothelium, causing vasculitis, or indirectly affect the vessel wall through an immunological mechanism. The clinical manifestations of these complications usually overlap with those of non-infectious vascular diseases, making diagnosis challenging. Intracranial vessel wall magnetic resonance imaging (VWI) enables the evaluation of the vessel wall and the diseases that affect it, providing diagnostic data beyond luminal changes and enabling the identification of inflammatory changes in cerebral vasculitis. This technique demonstrates concentric vessel wall thickening and gadolinium enhancement, associated or not with adjacent brain parenchymal enhancement, in patients with vasculitis of any origin. It permits the detection of early alterations, even before a stenosis occurs. In this article, we review the intracranial vessel wall imaging features of infectious vasculitis of bacterial, viral, and fungal etiologies.

Zoster-Associated Prothrombotic Plasma Exosomes and Increased Stroke Risk

Herpes zoster (HZ; shingles) caused by varicella zoster virus reactivation increases stroke risk for up to 1 year after HZ. The underlying mechanisms are unclear, however, the development of stroke distant from the site of zoster (eg, thoracic, lumbar, sacral) that can occur months after resolution of rash points to a long-lasting, virus-induced soluble factor (or factors) that can trigger thrombosis and/or vasculitis. Herein, we investigated the content and contributions of circulating plasma exosomes from HZ and non-HZ patient samples. Compared with non-HZ exosomes, HZ exosomes (1) contained proteins conferring a prothrombotic state to recipient cells and (2) activated platelets leading to the formation of platelet-leukocyte aggregates. Exosomes 3 months after HZ yielded similar results and also triggered cerebrovascular cells to secrete the proinflammatory cytokines, interleukin 6 and 8. These results can potentially change clinical practice through addition of antiplatelet agents for HZ and initiatives to increase HZ vaccine uptake to decrease stroke risk.

Rash, Facial Droop, and Multifocal Intracranial Stenosis Due to Varicella Zoster Virus Vasculitis

Background: This is a case of multifocal intracranial stenosis in a 74 year old male ultimately discovered to be due to Varicella Zoster Virus infection. Purpose: We highlight the importance of a broad differential diagnosis, even when the most likely etiology of intracranial stenosis is atherosclerosis. Our paper reviews the differential diagnosis as well as "red flags" for intracranial vasculopathy. Even though intracranial atherosclerotic disease is the most common cause of vasculopathy, infectious or inflammatory vasculitis should be considered on the differential. Conclusions: Before considering bypass surgery or other invasive neurosurgical procedures, ensure reversible causes of vasculopathy have been ruled out. The presence of cranial neuropathies, rash, and/or elevated inflammatory markers should be red flags for vasculitis in patients presenting with stroke.

Hemorrhagic Stroke Due to Varicella Zoster Virus Vasculopathy

Varicella-zoster virus (VZV) vasculopathy is a granulomatous vasculitis that has a wide variety of clinical presentations. It is most common in patients with HIV not on anti-retroviral therapy (ART) with low cluster of differentiation (CD)4 cell counts. This disease affects the central nervous system and can cause small intracranial bleeds. Our patient presented with stroke-like symptoms in the setting of recent VZV reactivation in the ophthalmic distribution with HIV on ART. Her MRI scan showed a small punctate bleed and the CSF workup was consistent with VZV vasculitis. She was treated with 14 days of acyclovir and five days of high-dose steroids with clinical improvement to baseline.

Immune changes and their relationship with prognosis in patients with varicella-zoster virus encephalitis/meningitis

OBJECTIVES

This study aimed to investigate the immune changes in patients with varicella-zoster virus (VZV) encephalitis/meningitis and explored their relationships with prognosis.

METHODS

A total of 129 patients with herpes zoster (HZ), 32 patients with VZV encephalitis/meningitis and 31 non-HZ and non-VZV people as healthy controls were included into the present study. The numbers of peripheral T lymphocytes and the serum levels of complements 3 (C3), complements 4 (C4) and immunoglobulin A (IgA), immunoglobulin G (IgG), and immunoglobulin M (IgM) were detected and compared among groups. In 32 patients with VZV encephalitis/meningitis, the immune related variables were compared between the favorable and the unfavorable prognosis group and their relationships with prognosis were further evaluated.

RESULTS

There were marked differences in the peripheral CD3+, CD4+ and CD8+ cells and CD4+/CD8+ ratio in the three groups (P<0.05). As compared with HZ and control groups, the peripheral CD3+ and CD4+ cells were reduced dramatically in patients with VZV encephalitis/meningitis (P<0.05). In 32 patients with VZV encephalitis/meningitis, the absolute CD3+ and CD4+ cells in patients with favorable prognosis were significantly higher than in patients with unfavorable prognosis (P<0.05), and they were positively related to the prognosis of these patients (r=0.3852, P=0.0295; r=0.3719, P=0.0361).

CONCLUSION

These immune changes were compromised in VZV encephalitis/meningitis. The peripheral CD3+ and CD4+ levels may be employed to predict prognosis.