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Farhat N, Daoud S, Hdiji O, Sakka S, Damak M, Mhiri C. Myelopathy after zoster virus infection in immunocompetent patients: A case series. J Spinal Cord Med 2021; 44:334-338. [PMID: 31013469 PMCID: PMC7952078 DOI: 10.1080/10790268.2019.1607053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
CONTEXT After primary infection, varicella zoster virus (VZV) becomes latent in ganglionic neurons. If immunity declines, VZV is reactivated and can spread to the dermatome depending from this ganglion and in some cases to the spinal cord. Myelopathy is rare and may develop in the absence of skin rash making the diagnosis very difficult. FINDINGS From 1994 to 2014, we collected five observations of clinically and laboratory confirmed zoster myelopathy. The age of our patients ranged from 14 to 78. They did not have any significant past medical history. Four patients had a history of radicular rash. After 3 weeks (4-45 days), patients presented paraparesis, sensory loss, and sphincter dysfunction. Cerebrospinal fluid (CSF) analysis revealed an elevated protein level (5/5cases) and pleocytosis (2/5 cases). Spinal cord magnetic resonance imaging (MRI) demonstrated T2 hyper intense lesions with swelling and contrast enhancement. The diagnosis was supported by laboratory evidence, including the detection of VZV antibodies in the CSF. All patients received intravenous acyclovir and two patients received IV methylprednisolone. A marked improvement was observed in most of the patients within 2 months. CONCLUSION /CLINICAL RELEVANCE Based on our patients and on previous reports, we highlight the possibility of the occurrence of VZV myelopathy in immunocompetent subjects. The diagnosis must be evoked even in the absence of typical skin lesions. In this case, spinal cord MRI and virological tests are useful tools for the diagnosis. We also emphasize on the importance of accurate diagnosis to enable the specific treatment and ameliorate the outcome.
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Affiliation(s)
- Nouha Farhat
- Department of Neurology, Habib Bourguiba University Hospital, Sfax, Tunisia,Neuroscience laboratory “LR-12-SP-19”, Faculty of medicine, Sfax University, Sfax, Tunisia
| | - Sawsan Daoud
- Department of Neurology, Habib Bourguiba University Hospital, Sfax, Tunisia,Neuroscience laboratory “LR-12-SP-19”, Faculty of medicine, Sfax University, Sfax, Tunisia,Correspondence to: Sawsan Daoud, Department of Neurology, Habib Bourguiba University Hospital, CP 3029 – Sfax, Tunisia; Ph: (216) 21 46 46 80.
| | - Olfa Hdiji
- Department of Neurology, Habib Bourguiba University Hospital, Sfax, Tunisia,Neuroscience laboratory “LR-12-SP-19”, Faculty of medicine, Sfax University, Sfax, Tunisia
| | - Salma Sakka
- Department of Neurology, Habib Bourguiba University Hospital, Sfax, Tunisia,Neuroscience laboratory “LR-12-SP-19”, Faculty of medicine, Sfax University, Sfax, Tunisia
| | - Mariem Damak
- Department of Neurology, Habib Bourguiba University Hospital, Sfax, Tunisia,Neuroscience laboratory “LR-12-SP-19”, Faculty of medicine, Sfax University, Sfax, Tunisia
| | - Chokri Mhiri
- Department of Neurology, Habib Bourguiba University Hospital, Sfax, Tunisia,Neuroscience laboratory “LR-12-SP-19”, Faculty of medicine, Sfax University, Sfax, Tunisia
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Abstract
RATIONALE Neurological complications of varicella-zoster virus (VZV) infection include cerebral infarction, meningoencephalitis, segmental sensory disturbance, facial nerve palsy, and myelitis. Chronic myelitis is rarely reported. Diagnosis of VZV infection can be confirmed by elevated anti-VZV immunoglobulin G (IgG) antibody or detection of VZV DNA in the cerebrospinal fluid (CSF), the former reported to be superior. The detection rate of VZV DNA is generally thought to decrease with time after the onset of the condition. The utility of VZV DNA polymerase chain reaction (PCR) is thus thought to be limited to the acute phase of the disease. The presence of skin lesions also helps to render a diagnosis; however, cases of zoster sine herpete (ZSH), the occurrence of segmental symptoms without skin lesions, renders the diagnosis of VZV infection more difficult. Antiviral drugs, such as acyclovir, are the treatment of choice to resolve VZV infections. PATIENT CONCERNS A 65-year-old Japanese man felt heaviness and a throbbing pain on the ulnar side of the right forearm. He was previously diagnosed with cervical spondylosis, and received nonsteroidal anti-inflammatory drugs with little improvement. Contrast cervical magnetic resonance imaging showed a swelling and an increased signal intensity of the spinal cord, and an enhancing lesion, all of which were suggestive of myelitis. DIAGNOSIS We found no evidence for diagnoses of sarcoidosis, Behçet disease, multiple sclerosis, or neuromyelitis optica spectrum disorder. The CSF analysis revealed an elevation of the total protein concentration and that the patient was positive for VZV DNA, while anti-VZV IgG was not elevated. The patient was therefore diagnosed with ZSH myelitis. INTERVENTIONS We administered acyclovir and valaciclovir as the first therapy. At the time of recurrence, we used high-dose acyclovir, vidarabine, and high-dose methylprednisolone pulse therapy. OUTCOMES The patient's dysesthetic pain in the right upper limb improved following the first antiviral therapy. Two months later, he suffered a recurrence, but the second therapy significantly relieved his symptoms. LESSONS VZV infection should be regarded as an important differential diagnosis of chronic myelitis. VZV DNA PCR should be performed even in the chronic phase of the condition to introduce the possibility of antiviral therapy as a treatment option.
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Lee JE, Lee S, Kim KH, Jang HR, Park YJ, Kang JS, Han SY, Lee SH. A Case of Transverse Myelitis Caused by Varicella Zoster Virus in an Immunocompetent Older Patient. Infect Chemother 2016; 48:334-337. [PMID: 27883372 PMCID: PMC5204014 DOI: 10.3947/ic.2016.48.4.334] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 04/07/2016] [Indexed: 12/24/2022] Open
Abstract
Varicella zoster virus (VZV) is a human neurotropic alphaherpesvirus that causes chickenpox (varicella) in children. VZV reactivation may lead to neurological complications, including transverse myelitis. However, transverse myelitis caused by VZV reactivation is rare in immunocompetent patients. Herein, we report a case of transverse myelitis caused by VZV in an immunocompetent older patient, and confirmed this case by polymerase chain reaction. A 79-year-old woman visited our service with complaints of weakness in the right lower leg, generalized vesicular eruptions, and throbbing pain in the right flank for ten days. Spine MRI showed transverse myelitis in the thoracic spine at level T4-T11. The patient was treated with acyclovir and her neurological functions improved, except for sensory impairment below level T10. For older patients, early and aggressive antiviral treatment against VZV may be necessary even though these patients are immunocompetent.
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Affiliation(s)
- Jeong Eun Lee
- Deparment of Internal Medicine, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Shinwon Lee
- Deparment of Internal Medicine, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Kye Hyung Kim
- Deparment of Internal Medicine, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Hee Ryeong Jang
- Deparment of Internal Medicine, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Young Joo Park
- Deparment of Internal Medicine, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jin Suk Kang
- Deparment of Internal Medicine, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Sung Yong Han
- Deparment of Internal Medicine, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Sun Hee Lee
- Deparment of Internal Medicine, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea.
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Lee MH, Song JH, Lee DI, Ahn HS, Park JW, Cha YD. Newly developed urinary retention and motor weakness of lower extremities in a postherpetic neuralgia patient. Korean J Pain 2013; 26:76-9. [PMID: 23342213 PMCID: PMC3546216 DOI: 10.3344/kjp.2013.26.1.76] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 09/24/2012] [Accepted: 09/25/2012] [Indexed: 12/28/2022] Open
Abstract
During the early stage of postherpetic neuralgia, an epidural block on the affected segment is helpful in controlling pain and preventing progression to a chronic state. The main neurologic complication following an epidural block is cord compression symptom due to an epidural hematoma. When neurologic complications arise from an epidural block for the treatment of postherpetic neuralgia, it is important to determine whether the complications are due to the procedure or due to the herpes zoster itself. We report a case of a patient who was diagnosed with herpes zoster myelitis during treatment for postherpetic neuralgia. The patient complained of motor weakness in the lower extremities after receiving a thoracic epidural block six times. Although initially, we believed that the complications were due to the epidural block, it was ultimately determined to be from the herpes zoster myelitis.
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Affiliation(s)
- Mi Hyun Lee
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Seoul, Korea
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Lee CC, Wu JC, Huang WC, Shih YH, Cheng H. Herpes zoster cervical myelitis in a young adult. J Chin Med Assoc 2010; 73:605-10. [PMID: 21093831 DOI: 10.1016/s1726-4901(10)70132-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Accepted: 05/14/2010] [Indexed: 12/11/2022] Open
Abstract
Varicella zoster virus infection, which causes chickenpox and herpes zoster (HZ), is not uncommon in the general population. Varicella zoster virus can be latent in cranial nerve or dorsal root ganglia, and reactivate several decades later to produce vesicles with post-herpetic neuralgia. HZ myelitis usually occurs in elderly or immunocompromised patients. We report here a case of HZ myelitis of the cervical spinal cord in a 35-year-old woman who was immunocompetent. Cervical myelitis developed 1 month after the eruption of vesicles. Pure sensation loss was limited initially from the C2 to T1 dermatomes, but later progressed to lower limb sensory loss and sphincter function impairment. The patient's motor function was also mildly affected. Despite the initial rapid neurological deterioration, the symptoms dramatically improved after 5 days of parenteral acyclovir and steroid administration with rehabilitation. We therefore propose that early medical intervention is necessary for better and earlier recovery.
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Affiliation(s)
- Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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Gilden D, Nagel MA, Ransohoff RM, Cohrs RJ, Mahalingam R, Tanabe JL. Recurrent varicella zoster virus myelopathy. J Neurol Sci 2008; 276:196-8. [PMID: 18945446 DOI: 10.1016/j.jns.2008.09.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2008] [Revised: 09/12/2008] [Accepted: 09/16/2008] [Indexed: 12/29/2022]
Abstract
Myelopathy is an uncommon complication of VZV infection and may develop in the absence of rash. We report the rare recurrence of myelopathy in an immunocompetent adult who initially developed myelopathy after ophthalmic-distribution zoster. Recurrent myelopathy two years later caused by VZV was verified by the presence of new-onset clinical symptoms and signs consistent with myelopathy, new lesions in the spinal cord detected by MRI, and evidence of intrathecal synthesis of anti-VZV IgG antibody in CSF. After virological verification and antiviral therapy, myelopathy did not recur and anti-VZV IgG antibody could not be detected in CSF. In contrast to earlier cases of recurrent VZV myelopathy in immunocompetent adults that developed weeks to months after the first episode of myelopathy, this is the first instance of recurrence years later.
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Affiliation(s)
- Don Gilden
- Department of Neurology, University of Colorado Denver, School of Medicine, Denver, CO, USA.
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Kleinschmidt-DeMasters BK, Gilden DH. The expanding spectrum of herpesvirus infections of the nervous system. Brain Pathol 2006; 11:440-51. [PMID: 11556690 PMCID: PMC8098551 DOI: 10.1111/j.1750-3639.2001.tb00413.x] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Herpesviruses cause various acute, subacute, and chronic disorders of the central (CNS) and peripheral (PNS) nervous systems in adults and children. Both immunocompetent and immunocompromised individuals may be affected. Zoster (shingles), a result of reactivation of varicella zoster virus (VZV), is the most frequent neurologic complication. Other neurological complications include encephalitis produced by type I herpes simplex virus (HSV-1), and less frequently HSV-2, as well as by VZV and cytomegalovirus (CMV). Acute meningitis is seen with VZV and HSV-2, and benign recurrent meningitis with HSV-2. Combinations of meningitis/ encephalitis and myelitis/radiculitis are associated with Epstein Barr Virus (EBV); myelitis with VZV, CMV, EBV, and HSV-2; and ventriculitis/encephalitis with VZV and CMV. Brainstem encephalitis due to HSV and VZV, and polymyeloradiculitis due to CMV are well documented. HHV-6 produces childhood exanthem subitum (roseola) and febrile convulsions. Immunocompetent and immunocompromised hosts manifest different incidences and patterns of herpesvirus infections. For example, stroke due to VZV-mediated large vessel disease (herpes zoster ophthalmicus) occurs predominantly in immunocompetent hosts, while small vessel disease (leukoencephalitis) and ventriculitis develop almost exclusively in immunocompromised patients. EBV-associated primary CNS lymphomas also are restricted to immunosuppressed individuals. Recent large CSF PCR studies have shown that VZV, EBV, and CMV more frequently produce meningitis, encephalitis, or encephalopathy in immunocompetent hosts than was formerly realized. We review herpesvirus infections of the nervous system and illustrate the expanding spectrum of disease by including examples of a 75-year-old male on steroid treatment for chronic lung disease with fatal HSV-2 meningitis and an 81-year-old male with myasthenia gravis, long-term azathioprine use, and an EBV-associated primary CNS lymphoma.
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MESH Headings
- Adolescent
- Adult
- Aged
- Child
- Child, Preschool
- Cytomegalovirus/genetics
- Cytomegalovirus/immunology
- Cytomegalovirus/pathogenicity
- Female
- Herpesviridae Infections/classification
- Herpesviridae Infections/pathology
- Herpesviridae Infections/physiopathology
- Herpesvirus 1, Human/genetics
- Herpesvirus 1, Human/immunology
- Herpesvirus 1, Human/pathogenicity
- Herpesvirus 2, Human/genetics
- Herpesvirus 2, Human/immunology
- Herpesvirus 2, Human/pathogenicity
- Herpesvirus 3, Human/genetics
- Herpesvirus 3, Human/immunology
- Herpesvirus 3, Human/pathogenicity
- Herpesvirus 4, Human/genetics
- Herpesvirus 4, Human/immunology
- Herpesvirus 4, Human/pathogenicity
- Herpesvirus 6, Human/genetics
- Herpesvirus 6, Human/immunology
- Herpesvirus 6, Human/pathogenicity
- Humans
- Infant
- Infant, Newborn
- Male
- Middle Aged
- Nervous System/pathology
- Nervous System/physiopathology
- Nervous System/virology
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