Varicella zoster virus transverse myelitis without cutaneous rash

[A 73-year-old man with polyradiculopathy and multiple cranial neuropathies emerging separate from the originating dermatome of a varicella zoster skin lesion]

A 73-year-old man developed delayed-onset multiple cranial neuropathies of cranial nerves V, VII and VIII, and segmental paresis in the ipsilateral upper extremity related to the C4 to Th1 segment, after all skin lesions with varicella zoster (VZV) on the left neck of the C3-4 dermatome had dried and crusted over. On admission, cerebrospinal fluid (CSF) revealed pleocytosis (all mononuclear cells, 12/μl). Treatment was started with intravenous acyclovir (10 mg/kg, every 8 h for 14 days) and methylprednisolone (1,000 mg/day for 3 days). Four days after starting treatment, left segmental paresis was improved, but the multiple cranial neuropathies persisted. Oral prednisolone (0.5 mg/kg/day) was administered for 5 days, then tapered off. All neurological symptoms had disappeared by hospital day 23. Of particular interest was the discrepancy between skin regions affected by VZV (C3-4) and the regions of cranial neuropathy (cranial nerves V, VII, and VIII) and muscle weakness innervated by C4-Th1. Although CSF was negative for VZV DNA according to PCR testing, the antibody index for VZV was elevated. This suggests intrathecal synthesis of VZV antibodies and supports the diagnosis of VZV meningitis. Also, all cranial nerves involved in this case were reported to have the cranial nerve ganglia where VZV could have established latency and been reactivated. This suggests concurrent reactivation on each cranial nerve ganglia without cutaneous lesions, as zoster sine herpete. In addition, anastomoses among the upper cervical nerves, which are found in some patients, may have contributed to this condition. These mechanisms underlie various neurological symptoms associated with VZV infection.

Chronic myelitis associated with zoster sine herpete: A case report

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.

The Role of Magnetic Resonance Imaging in Acute Transverse Myelitis

Eighteen adult patients presenting with acute transverse myelitis (ATM) were evaluated using magnetic resonance imaging. Only 7 had abnormal scans showing an area of increased signal intensity within the cord solely on T2 weighted images; Tl weighted images were normal. The MRI abnormality did not correlate with the cause of the transverse myelitis, the extent of maximum neurological deficit, or the prognosis. A scan performed more than 5 days after the onset of disease was most likely to be positive. Even though the prognostic value of MRI in ATM may be limited, it remains a valuable technique for ruling out other causes of noncompressive spinal cord lesions, such as hemmorhage, vascular malformation, or tumor.

[A patient with myelitis of varicella-zoster without skin lesions--diagnostic value of virus antibody index in CSF]

A previously healthy 55-year-old woman developed abnormal sensation on the right occipital region. It expanded for the following three weeks. On admission, examination revealed abnormal and decreased sensation in touch and pinprick at right C2 to C6 dermatome without skin lesion. There was no muscle weakness. Deep tendon reflexes were more active in the right than in the left. MRI demonstrated a lesion of isointensity on T1-weighted, hyperintensity on T2-weighted, which was enhanced with contrast material on gadolinium-enhanced T1-weighted image at the upper cervical spinal cord corresponding to C2. Laboratory studies showed no immunosuppression and autoantibodies. The antibody index to varicella-zoster virus (VZV) was elevated in the cerebrospinal fluid (CSF). This finding prompted us to a diagnosis of myelitis of zoster sine herpete. VZV is thought to be a causative agent in cases of CNS infections of unknown etiology such as myelitis, even in the absence of skin manifestations. Amplification of VZV DNA by PCR in the CSF and the detection of an intrathecal production of anti-VZV antibodies have important diagnostic value, although their presence depends on the timing of the CSF sampling. The percentage of PCR-positive cases drops after seven or ten days, whereas that of specific antibodies-positive cases elevates. Because VZV myelitis are usually protracted, PCR does not always provide an exquisite sensitivity. Thus, the evaluation of antibody index provides the evidence of intrathecal production of anti-VZV antibodies. That is expressed as CSF antibody titer/serum antibody titer/CSF IgG/serum IgG. This quotient superior to 1.5 or 2.0 suggests CNS synthesis. As the sample of our patient was taken relatively late, this value was diagnostic. We would like to emphasize the importance of making precise diagnosis and adequate initial treatment in patients with myelitis of unknown etiology even if there is no skin lesions.

Neurological disease produced by varicella zoster virus reactivation without rash

Reactivation of varicella zoster virus (VZV) from latently infected human ganglia usually produces herpes zoster (shingles), characterized by dermatomal distribution pain and rash. Zoster is often followed by chronic pain (postherpetic neuralgia or PHN) as well as meningitis or meningoencephalitis, cerebellitis, isolated cranial nerve palsies that produce ophthalmoplegia or the Ramsay Hunt syndrome, multiple cranial nerve palsies (polyneuritis cranialis), vasculopathy, myelopathy, and various inflammatory disorders of the eye. Importantly, VZV reactivation can produce chronic radicular pain without rash (zoster sine herpete), as well as all the neurological disorders listed above without rash. The protean neurological and ocular disorders produced by VZV in the absence of rash are a challenge to the practicing clinician. The presentation of these conditions varies from acute to subacute to chronic. Virological confirmation requires the demonstration of amplifiable VZV DNA in cerebrospinal fluid (CSF) or in blood mononuclear cells, or the presence of anti-VZV IgG antibody in CSF or of anti-VZV IgM antibody in CSF or serum.

Recommendations for the management of herpes zoster

The objective of this article is to provide evidence-based recommendations for the management of patients with herpes zoster (HZ) that take into account clinical efficacy, adverse effects, impact on quality of life, and costs of treatment. Systematic literature reviews, published randomized clinical trials, existing guidelines, and the authors' clinical and research experience relevant to the management of patients with HZ were reviewed at a consensus meeting. The results of controlled trials and the clinical experience of the authors support the use of acyclovir, brivudin (where available), famciclovir, and valacyclovir as first-line antiviral therapy for the treatment of patients with HZ. Specific recommendations for the use of these medications are provided. In addition, suggestions are made for treatments that, when used in combination with antiviral therapy, may further reduce pain and other complications of HZ.

Mielorradiculopatia esquistossomótica

A mielorradiculopatia esquistossomótica é a forma ectópica mais grave e incapacitante da infecção pelo Schistosoma mansoni. A sua prevalência em área endêmica tem sido subestimada. O diagnóstico baseia-se na presença de sintomas neurológicos decorrentes de lesões da medula espinhal em nível torácico baixo e/ou lombar alto, na demonstração da infecção esquistossomótica por técnicas microscópicas ou sorológicas e na exclusão de outras causas de mielite transversa. O tratamento precoce, com esquistossomicidas e corticoesteróides, mostra-se eficaz na maioria dos casos e os pacientes não tratados não se recuperam ou morrem. Não há consenso sobre doses e duração do tratamento, mas estudo recente sugere que os corticoesteróides devam ser usados por pelo menos seis meses. Como o diagnóstico é presuntivo e o tratamento essencialmente clínico, há que se manter alerta para a presença da doença, aperfeiçoar a propedêutica e, dessa forma, evitar-se a laminectomia rotineira. Com o advento da ressonância magnética da medula espinhal houve grande avanço no diagnóstico da esquistossomose medular. Como conseqüência, o número de casos de mielopatia esquistossomótica relatados tem aumentado rapidamente.

Multiple cerebral infarcts due to varicella-zoster virus large-vessel vasculopathy in an immunocompetent adult without skin involvement

We report the case of a 52-year-old immunocompetent man with varicella-zoster virus large-vessel vasculopathy and multiple bilateral cerebral infarcts who had no history of skin involvement. Etiologic diagnosis was made by isolation of varicella-zoster virus from a cerebrospinal fluid specimen. The patient had marked improvement in mental status after acyclovir therapy was initiated.

Varicella-zoster virus: a re-emerging infection

Varicella-zoster virus (VZV) causes chickenpox (varicella), becomes latent in cranial nerve and dorsal root ganglia, and can reactivate many years later to produce shingles (zoster) and postherpetic neuralgia (PHN). Elderly and immunocompromised individuals are also at risk for complications of VZV reactivation involving the central nervous system (CNS), including myelitis, large-vessel encephalitis/granulomatous arteritis, small-vessel encephalitis, meningoencephalitis, and ventriculitis. Peripheral nervous system (PNS) complications range from zoster and postherpetic neuralgia to postinfectious polyneuritis (Guillain-Barre syndrome, GBS). These complications can occur with or without cutaneous manifestations. An increase in elderly and immunocompromised individuals will likely result in a higher prevalence of these conditions; therefore, VZV can be seen as a "re-emerging" infection of the early twenty-first century. In this review, we summarize our experience and the existing literature on CNS and PNS complications of VZV reactivation. Special attention is paid to reports of complications without rash, as these entities are more difficult to diagnose.

Myelitis

Acute transverse myelitis (ATM) with moderate symptomatology and smaller multiple magnetic resonance imaging lesions is often caused by multiple sclerosis. Severe ATM with extensive magnetic resonance imaging lesions with or without associated meningitis often has a viral cause, particularly in the younger age groups, whereas vascular disorders may prevail among older patients. Previously, one had to rely on indirect evidence such as viral serology or viral identification in throat washings to confirm a diagnosis of myelitis. Thus, mycoplasma myelitis may occur coincident with a mycoplasma pneumonia. Viral myelitis is now often diagnosed by specific polymerase chain reaction of the cerebrospinal fluid, for echovirus, Coxsackie virus, mumps virus, herpes simplex virus or varicella-zoster virus, but an autoimmune component may still be important. An anterior horn syndrome may be produced by the tick-borne encephalomyelitis virus. Severe ATM may also be a postinfectious or postvaccinal disorder [i.e. a partial acute disseminated encephalomyelitis (ADEM)]. Neuromyelitis optica, a combination of severe myelitis and optic neuritis, is often a manifestation of ADEM or systemic lupus erythematosus. Many of these disorders are potentially treatable with specific antiviral agents or immunosuppression. 'Idiopathic' ATM is probably a consequence of inadequate examination and follow up. The differential diagnoses-viral myelitis, multiple sclerosis, ADEM, neuromyelitis optica, spinal arteriovenous malformation and arteritis-should be considered and are usually identified by a rapid diagnostic work-up, leaving few ATM cases undiagnosed.

Current pharmacological approaches to the therapy of varicella zoster virus infections: a guide to treatment

Varicella zoster virus (VZV), a member of the herpesvirus family, is responsible for both primary (varicella, chickenpox) as well as reactivation (zoster, shingles) infections. In immunocompetent patients, the course of varicella is generally benign. For varicella zoster, post-herpetic neuralgia is the most common complication. In immunocompromised patients (particularly those with AIDS), transplant recipients and cancer patients, VZV infections can be life-threatening. For these patients and also for immunocompetent patients at risk such as pregnant women or premature infants, the current treatment of choice is based on either intravenous or oral aciclovir (acyclovir). The low oral bioavailability of aciclovir, as well as the emergence of drug-resistant virus strains, have stimulated efforts towards the development of new compounds for the treatment of individuals with VZV infections. Among these new compounds, penciclovir, its oral prodrug form famciclovir and the oral pro-drug form of aciclovir (valaciclovir), rank among the most promising. As with aciclovir itself, all of these drugs are dependent on the virus-encoded thymidine kinase (TK) for their intracellular activation (phosphorylation), and, upon conversion to their triphosphate form, they act as inhibitors/alternative substrate of the viral DNA polymerase. Therefore, cross-resistance to these drugs may be expected for those virus mutants that are TK-deficient and thus resistant to aciclovir. Other classes of nucleoside analogues dependent for their phosphorylation on the viral TK that have been pursued for the treatment of VZV infections include sorivudine, brivudine, fialuridine, fiacitabine and netivudine. Among oxetanocins, which are partially dependent on viral TK, lobucavir is now under clinical evaluation. Foscarnet, which does not require any previous metabolism to interact with the viral DNA polymerase, is used in the clinic when TK-deficient VZV mutants emerge during aciclovir treatment. TK-deficient mutants are also sensitive to the acyclic nucleoside phosphonates (i.e. [s]-1-[3-hydroxy-2-phosphonylmethoxypropyl]cytosine; HPMPC); these agents do not depend on the virus-encoded TK for their phosphorylation but depend on cellular enzymes for conversion to their diphosphoryl derivatives which then inhibit viral DNA synthesis. Vaccination for VZV has now come of age. It is recommended for healthy children, patients with leukaemia, and patients receiving immunosuppressive therapy or those with chronic diseases. The protection induced by the vaccine seems, to some extent, to include zoster and associated neuralgia. Passive immuniatin based on specific immunoglobulins does not effectively prevent VZV infection and is therefore restricted to high risk individuals (i.e. immunocompromised children and pregnant women).

Pain caused by herpes zoster infection

Postherpetic neuralgia (PHN) is a neuropathic pain disorder that occurs most often in the elderly. This painful condition is uniquely suited for clinical research, resulting in an emerging understanding of the pathophysiology of the persistent pain. Until recently, only the tricyclic antidepressants proved effective for PHN. Controlled trials of a wide variety of therapeutic strategies are in progress or have been recently completed.

Rapid recovery from transverse myelopathy in children treated with methylprednisolone

Acute transverse myelopathy is an uncommon disease that manifests with gradually developing weakness of the lower extremities associated with bladder or bowel dysfunction, sensory deficits, and pain localized in the back, legs, or abdomen. There are controversies in the literature regarding the role of steroids in the treatment of acute transverse myelopathy. Recently, a pilot open study of five children with acute transverse myelopathy treated with high-dose methylprednisolone demonstrated significant shortening of motor recovery when compared with an historic control group receiving either no treatment or low-dose steroids. The authors add their experience of 10 children with acute transverse myelopathy treated with high-dose methylprednisolone as soon as the diagnosis was confirmed. The median time of motor recovery in the present series was 5.5 compared with 23 days in the other study. No significant side effects were observed after treatment. This study provides further support that this treatment modality is safe and efficient and should be suggested for all children with acute transverse myelopathy after establishing the diagnosis.

Acute transverse myelitis in childhood: nine cases and review of the literature

Acute transverse myelitis (ATM) is a rare disease in childhood and adolescence. It is characterized by paraplegia with or without sensory symptoms and bladder dysfunction, and typically manifests itself over a period of hours to 1 week. This is a report of nine patients who were treated between 1993 and 1996. To exclude treatable conditions, spinal and cranial MRI with and without contrast medium, electrophysiologic tests, and CSF examinations are performed as soon as possible after onset. At present post- or parainfectious inflammation is thought to be the most frequent cause of ATM. Some causes of ATM can be proved only by follow-up examination. The most important differential diagnoses are multiple sclerosis and Guillain-Barré syndrome with its variants. After exclusion of spinal cord compression, and if specific antibiotic treatment is not possible, a 3-day high-dose i.v. steroid pulse therapy is the most promising treatment. Prognosis is variable and residual symptoms are common. A controlled multicenter study is suggested to assess epidemiology, etiology, and prognosis of ATM.

Case report: varicella-zoster virus myelitis--serial MR findings

The authors describe a 32-year-old male in whom herpes zoster of the left upper extremity was complicated by the development of cervical myelitis. Contrast enhancement and abnormal signal intensity on T1 and T2 weighted images was seen at C1-C6 levels in the spinal cord and medulla. There was also slight enlargement of the cord at these levels. On serial MR imaging the degree of enhancement changed from marked to none with corresponding clinical improvement.

A case of varicella-zoster myelopathy

INTRODUCTION

Early diagnosis of neurological complications of varicella-zoster virus (VZV) is important because of its treatability. We performed polymerase chain reaction (PCR) to detect VZV-DNA from the cerebrospinal fluid (CSF) of a patient with myelopathy.

PATIENT & METHODS

A 69-year-old man developed sensory disturbances in the lower extremities and bladder-bowel disturbances, followed by cutaneous zoster on his left arm. Polymerase chain reaction was applied to identify the viral DNA in CSF.

RESULTS

The increased antibody index of VZV and herpes simplex virus (HSV) in the CSF suggested intrathecal synthesis of IgG antibodies to these viruses. VZV-DNA was detected in the CSF by nested PCR, but neither HSV-1 nor HSV-2 DNA was detected in CSF. He was successfully treated with acyclovir and prednisolone.

CONCLUSION

PCR may be a useful tool for the diagnosis of VZV myelopathy.

[Transverse myelitis as initial symptom of disseminated non-Hodgkin lymphoma and HIV-associated vacuolar myelopathy: case report]

Non-Hodgkin lymphoma is frequently seen in AIDS patients usually affecting the central nervous system (CNS), especially the leptomeninges and the cerebral hemispheres. The epidural involvement is rarely described, ranging from 3.5% to 8.3% among the CNS sites. The authors present a case of disseminated non Hodgkin lymphoma associated to vacuolar myelopathy in a 27 years-old male patient with AIDS emphasizing the importance of this differential diagnosis in the myelopathies of AIDS.

Severe pneumonia in pregnancy three months after resolution of cutaneous zoster

A 22 weeks pregnant women was affected by a life-threatening pneumonia and a paresis of the proximal muscles with cerebrospinal fluid pleocytosis. Her past medical history had been unremarkable except for recurrent episodes of paraumbilical herpes zoster. The clinical findings suggested a dissemination of varicella-zoster virus without skin lesions. Acyclovir was added to the therapy, and the clinical picture began to improve. Varicella-zoster virus DNA was detected in placental tissue by DNA-hybridisation analysis.

Meningoradiculoneuritis due to acyclovir-resistant varicella zoster virus in an acquired immune deficiency syndrome patient

Varicella zoster virus (VZV) is recognized as one of the major viral pathogens reactivated in patients with the acquired immune deficiency syndrome (AIDS). We report the case of meningoradiculoneuritis in an AIDS patient,associated with the isolation in the cerebrospinal fluid (CSF) of a thymidine kinase (TK)-deficient, acyclovir (ACV)-resistant strain of VZV. Although the virus was sensitive in vitro to phosphonoformate (PFA), the patient did not improve during PFA therapy and finally died. Several VZV strains isolated from this patient (including two isolates from the patient's CSF) were analyzed for their TK activity and subsequently the viral TK gene was sequenced showing a major deletion leading to a truncated protein. Their susceptibility to several antiviral agents including ACV, PFA, (E)-5-(2-bromovinyl)-2'-deoxyuridine (BVDU), 9-beta-D-arabinofuranosyladenine (vidarabine), (S)-1-(3-hydroxy-2-phosphonylmethoxypropyl) cytosine (HPMPC), and (S)-9-(3-hydroxy-2-phosphonyl-methoxypropyl)adenine (HPMPA) was evaluated. All the virus strains isolated from this patient remained sensitive to HPMPA and HPMPC, pointing to the potential usefulness of these acyclic nucleoside phosphonates for the treatment of ACV-resistant VZV infections in immunocompromised patients.

Detection of varicella-zoster virus DNA using the polymerase chain reaction in an immunocompromised patient with transverse myelitis secondary to herpes zoster

A case of herpes zoster transverse myelitis is described in which the clinical diagnosis was confirmed by demonstrating the presence of varicella-zoster virus (VZV) DNA in the cerebrospinal fluid (CSF) by amplification using the polymerase chain reaction. This case illustrates the potential role of the selective amplification of VZV DNA from CSF in contributing to the diagnosis of neurological complications associated with VZV infection.

Detection of varicella-zoster virus DNA by polymerase chain reaction in the cerebrospinal fluid of patients suffering from neurological complications associated with chicken pox or herpes zoster

The polymerase chain reaction (PCR) was used to detect varicella-zoster virus (VZV) DNA in the cerebrospinal fluid of patients with VZV infection associated with neurological symptoms. Positive results were obtained in three of five children with post-chicken pox cerebellitis and in seven of seven herpes zoster patients with neurological symptoms. The PCR thus provides a useful tool for the early diagnosis of VZV-associated neurological disease.

Fatal varicella-zoster virus meningoradiculitis without skin involvement

A 77-year-old man with T-cell lymphoma developed an acute fatal meningoradiculitis of cranial nerve roots and cauda equina, pathologically and virologically confirmed to be caused by varicella-zoster virus. This is the first report of fatal varicella-zoster virus-induced neurological disease in the absence of skin lesions. Varicella-zoster virus should be included in the differential diagnosis of acute radiculoneuropathy in the immunocompromised patient, particularly because antiviral treatment for varicella-zoster virus exists.