Central nervous system varicella zoster vasculopathy in an immunocompromised patient

Ischemic stroke as the initial presentation in acute myeloid leukemia vs. myelodysplastic syndrome: a case report and literature review with pathophysiological and clinical exploration

BACKGROUND

Myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) present intricate challenges due to their diverse clinical manifestations and thrombotic complications. Thromboembolism (TE) incidence in newly diagnosed AML patients is noteworthy, with arterial TE linked to poorer overall survival. Ischemic strokes, although relatively low in prevalence, carry significant clinical implications.

CASE DESCRIPTION

We report the case of an 84-year-old male with Type 2 Diabetes, Hypertension, and Chronic Kidney Disease, presenting with seizures, focal neurological deficits, and pancytopenia. An unexpected diagnosis of AML or MDS emerged during the investigation. Despite interventions, the patient's condition deteriorated, leading to a fatal outcome weeks later.

CONCLUSION

This case underscores the intricate relationship between hematologic malignancies and ischemic stroke. The rarity of this complication emphasizes the importance of understanding the multifaceted mechanisms at play, including hyperleukocytosis, pro-inflammatory cytokine release, coagulation cascade activation, and direct interactions with endothelial cells. In our literature review, analysis of 15 cases, including ours, revealed a wide age range (3-87 years) and a gender bias towards females. AML diagnosis was predominant, with uniformly low platelet counts. Cortical infarctions, especially in the anterior circulation, were common. Hyperleukocytosis, disseminated intravascular coagulation (DIC), and fatal outcomes were observed in a subset of cases. Despite the grim statistics and often poor prognosis, the identification of specific risk factors, such as thrombocytopenia and cytogenetic abnormalities, offers avenues for targeted prevention and management.

Acute Viral Encephalitis Mimicking Idiopathic Intracranial Hypertension in an Immunocompetent Obese Adolescent Girl

Varicella zoster virus (VZV) is common worldwide and one of the main causes of infectious encephalitis. We report the case of a 13-year-old girl who presented to the emergency department with complaints of recurrent episodes of vague headaches associated with photophobia multiple times within three days before hospitalization. The patient had a history of morbid obesity without other metabolic complications as well as a history of chicken pox in childhood. Doctors subsequently diagnosed her with increased intracranial pressure owing to suspected VZV encephalitis. A lumbar puncture confirmed the presence of VZV in the cerebrospinal fluid. After admitting the diagnosis of VZV encephalitis, doctors treated the patient with intravenous acyclovir and discharged her with oral acyclovir. This case highlights the importance of considering VZV encephalitis in the differential diagnosis for patients presenting with headaches, especially in the presence of typical vesicular skin rashes. The case has an unusual complication associated with shingles, which doctors diagnosed early and treated appropriately.

Varicella-Zoster Virus: A Case of Encephalitis

Infection with the varicella-zoster virus (VZV) is very common worldwide and is one of the main causes of infectious encephalitis. Immunosuppressed patients are at increased risk of severe disease and central nervous system (CNS) involvement. We report the case of a 43-year-old man with HIV infection and poor adherence to antiretroviral therapy who presented to the emergency department (ER) with complaints of diplopia and a frontal headache, referring to having a child with chickenpox. Brain magnetic resonance imaging revealed three hyperintense T2-weighted lesions surrounded by edema in the right sublenticular, left occipital and left parietal regions, and VZV DNA was detected in the cerebrospinal fluid (CSF). After admitting the diagnosis of VZV encephalitis, the patient was treated with intravenous acyclovir, with clinical improvement and a favorable outcome.

Severe Thrombocytopenia with Acute Cerebral Infarction: A Case Report and Literature Review

Common causes of thrombocytopenia include pseudo-thrombocytopenia, splenomegaly, decreased bone marrow production, and increased platelet destruction or depletion. The main clinical manifestation is bleeding, and thrombosis-related complications are rare. This article reports an 87-year-old woman with severe thrombocytopenia for more than 7 years. On day 6 in the hospital, the patient suddenly fell into a coma, and emergency head computed tomography (CT) displayed acute cerebral infarction of the left cerebellar hemisphere, brainstem, and left thalamus. Although thrombocytopenia is often associated with bleeding, there is still a need for vigilance against ischemic diseases. We analyzed the possible causes of acute cerebral infarction with thrombocytopenia and reviewed the literature. Our case is different from the causes of cerebral infarction reported in previous articles, so the relationship between thrombocytopenia and acute cerebral infarction needs further study. The patient, in this case, was not given anticoagulant or antiplatelet therapy but recovered well. It shows that individualized treatment is effective.

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.

Ischemic Optic Neuropathy Secondary to Varicella-Zoster Vasculitis Mimicking Giant Cell Arteritis: Case Report

Differentiating GCA from its many mimickers remains a challenge in the daily clinical practice, especially in patients presenting with unspecific manifestations. We present the case of an 82-year-old woman who presented with a 3-week history of left eye vision loss secondary to bilateral edema and hemorrhage of the optic discs. Despite negative bilateral temporal artery biopsies, the elevation of the inflammatory markers and brain MRA findings suggestive of temporal arteritis as well as stenosis of the basilar artery led us to initiate treatment with high-dose steroids. Inflammatory markers remained elevated despite high-dose steroids which prompted additional work leading to a diagnosis of varicella-zoster encephalitis. Steroid treatment was quickly tapered off and treatment with acyclovir resulted in the normalization of the acute phase reactants. The persistence of elevated inflammatory markers despite high-dose steroids should prompt additional work up for the search of an alternative diagnosis of GCA mimickers.

Herpesvirus-Associated Encephalitis: an Update

Purpose of Review

Recent Findings

Summary

Cellular Immune Signal Exchange From Ischemic Stroke to Intestinal Lesions Through Brain-Gut Axis

As a vital pivot for the human circulatory system, the brain-gut axis is now being considered as an important channel for many of the small immune molecules’ transductions, including interleukins, interferons, neurotransmitters, peptides, and the chemokines penetrating the mesentery and blood brain barrier (BBB) during the development of an ischemic stroke (IS). Hypoxia-ischemia contributes to pituitary and neurofunctional disorders by interfering with the molecular signal release and communication then providing feedback to the gut. Suffering from such a disease on a long-term basis may cause the peripheral system’s homeostasis to become imbalanced, and it can also lead to multiple intestinal complications such as gut microbiota dysbiosis (GMD), inflammatory bowel disease (IBD), necrotizing enterocolitis (NEC), and even the tumorigenesis of colorectal carcinoma (CRC). Correspondingly, these complications will deteriorate the cerebral infarctions and, in patients suffering with IS, it can even ruin the brain’s immune system. This review summarized recent studies on abnormal immunological signal exchange mediated polarization subtype changes, in both macrophages and microglial cells as well as T-lymphocytes. How gut complications modulate the immune signal transduction from the brain are also elucidated and analyzed. The conclusions drawn in this review could provide guidance and novel strategies to benefit remedies for both IS and relative gut lesions from immune-prophylaxis and immunotherapy aspects.