Long-segment transverse myelitis in an immunocompetent patient due to varicella zoster virus reactivation

Varicella-zoster virus infection and autonomic dysfunction

BACKGROUND AND PURPOSE

Autonomic dysfunction has been occasionally described in varicella-zoster virus (VZV) infection, while few systematic reviews are available. We systematically review autonomic dysfunction due to VZV infection.

METHODS

This study followed the PRISMA guideline, and three databases were researched and included cross-sectional studies in full-length publications in the English language using appropriate search keywords.

RESULTS

A total of 102 articles were identified initially; finally 45 studies were used for review, comprising pupillomotor dysfunction in 4, sudomotor dysfunction in 2, cardiovascular dysfunction in 2, gastrointestinal dysfunction in 14, and urogenital dysfunction in 23. They can be summarized as (1) VZV infection rarely produces orthostatic hypotension, which involves diffuse sympathetic dysfunction by polyneuropathy. (2) In contrast, VZV infection produces dysfunction of the bladder and the bowel, which involves segmental parasympathetic or sympathetic dysfunction by dorsal root ganglionopathy.

CONCLUSIONS

Awareness of VZV-related autonomic dysfunction is important, because such patients may first visit a gastroenterology or urology clinic. Close collaboration among neurologists, dermatologists, gastroenterologists, and urologists is important to start early antiviral agents and maximize bowel and bladder care in such patients.

Transverse myelitis caused by varicella-zoster

Transverse myelitis is a rare neurological complication seen with varicella-zoster virus (VZV) infection, which is common among immunocompromised hosts. It can occur during the primary VZV infection or reactivation of latent infection. It is a complication that requires prompt diagnosis and treatment. The present case is that of a 28-year-old immunocompetent man, who presented with fever, rash and acute-onset spastic paraparesis with bladder involvement. Causes such as herpes simplex 1 and 2, cytomegalovirus, enterovirus and Epstein-Barr virus infection were ruled out. On evaluation, he was diagnosed with acute primary disseminated VZV infection with parainfectious transverse myelitis, based on positive cerebrospinal fluid multiplex PCR (PCR) and serum VZV IgM antibodies. He was treated with intravenous acyclovir and steroids, with which he improved significantly.