Polyradiculoneuropathy Associated to Human Herpesvirus 2 in an HIV-1-Infected Patient (Elsberg Syndrome): Case Report and Literature Review

Elsberg Syndrome With Albuminocytologic Dissociation - A Guillain-Barré Syndrome Mimic or Guillain-Barré Syndrome Variant?

Introduction

Elsberg Syndrome is a presumed infectious lumbosacral radiculitis, with or without accompanying lumbar myelitis, that is often attributed to herpes simplex virus type 2 (HSV-2).

Case

A 58-year-old man presented with lower extremity anesthesia, ataxic gait, radiological evidence of radiculitis, and CSF albuminocytologic dissociation. Polymerase chain reaction testing of CSF confirmed HSV-2 infection.

Conclusion

A variety of presentations are reported within the scope of Elsberg Syndrome, potentially with distinct disease mechanisms. Delayed onset of neurological symptoms after resolution of rash and absence of pleocytosis raises the possibility that some patients meeting criteria for Elsberg Syndrome have a post-infectious immune-mediated neuropathy. We advise a lower threshold for PCR testing of herpes viruses in patients with acute neuropathy and albuminocytologic dissociation, particularly in cases with early sacral involvement.

Elsberg Syndrome with Mixed Presentation as Meningitis Retention Syndrome: A Pediatric Case Report and Comprehensive Review of the Literature

Elsberg syndrome is a typically infectious syndrome that may cause acute or subacute bilateral lumbosacral radiculitis and sometimes lower spinal cord myelitis. Patients often present with various neurological symptoms involving the lower extremities, including numbness, weakness, and urinary disturbances such as retention. A 9-year-old girl with no significant past medical history presented with altered mental status, fever, urinary retention, and anuria and was found to have encephalomyelitis. An extensive diagnostic workup led to ruling out possible etiologies until identifying Elsberg syndrome. In this report, we describe a case of Elsberg syndrome caused by West Nile virus (WNV). To the best of our knowledge, this is the first reported case of its kind in the pediatric population. Utilizing PubMed and Web of Science databases, we reviewed the literature to describe the neurogenic control of the urinary system in correlation to a multitude of neurologic pathologies.

Cauda equina syndrome due to herpes simplex virus type 2-associated meningoradiculitis (Elsberg syndrome) after posterior lumbar spinal fusion surgery: Case report and review of literature

Elsberg syndrome is a rare but well-defined clinical condition, including acute or subacute lumbosacral meningoradiculitis, which might be accompanied by myelitis and is often associated with herpes simplex virus type 2 (HSV-2) infection. We report the case of an immunocompetent 24-year-old man who presented with perineal pain, saddle hypoesthesia, and urinary retention associated with Elsberg syndrome due to HSV-2 infection 20-day after the posterior lumbar spinal fusion surgery. Lumbar magnetic resonance imaging (MRI) with gadolinium enhancement showed mildly enhanced and swollen right sacral nerve roots. One week after the admission, electromyography and nerve conduction studies (EMG-NCS) demonstrated severe axonal damage and radiculopathy at right S3 and S4 roots. Cerebrospinal fluid (CSF) analysis revealed lymphocytic pleocytosis, elevated protein, positive HSV-2 IgG index, and positive HSV-2 polymerase chain reaction (PCR). The patient was treated with intravenous acyclovir for 14 days and showed a gradual improvement in anal sphincter control and urination. Therefore, according to our findings, surgery might have an immunosuppressing role, and in cases with symptoms of cauda equina syndrome (CES) and systemic infection, in the postoperative setting, viral meningoradiculitis should be considered.

Infectious Myelopathies

Infectious diseases are an important cause of spinal cord dysfunction. Infectious myelopathies are of growing concern given increasing global travel and migration and expanding prevention and treatment with vaccinations, antibiotics, and antiretrovirals. Clinicians must recognize these pathologies because outcomes can dramatically improve with prompt diagnosis and management. We provide a complete review of the most frequent infectious agents that can affect the spinal cord. For each pathogen we describe epidemiology, pathophysiology, anatomic location, characteristic clinical syndromes, diagnostic approach, treatment, and prognosis. The review includes spinal imaging from selected cases.

Herpes Simplex Virus Type 2 Radiculomyelitis Disguised as Conversion Disorder

Herpes simplex virus type 2 (HSV-2) is the most common cause of genital herpes with a seroprevalence of 20-30% in developed countries and 80% worldwide. In addition to neonatal encephalitis and meningitis, HSV-2 is associated with radiculomyelitis marked by pain, paresis, sphincter disturbances, sensory loss, or ascending necrotizing myelitis. We report the case of a patient with a lengthy psychiatric history who presented with lower extremity pain and weakness. Cervical, thoracic, and lumbar MRI scans with and without gadolinium contrast revealed no significant stenosis, neural compression, or other abnormal findings, and the brain MRI with and without gadolinium contrast was normal. The initial diagnosis was conversion disorder due to myriad psychological stressors. Polymerase chain reaction (PCR) of CSF detected HSV-2 and a lymphocytic pleocytosis, and the diagnosis of radiculomyelitis was confirmed. She was treated with i.v. acyclovir for 3 weeks followed by valacyclovir. The patient attained no improvement of her symptoms within 8 months; however, she reported decreased pain and improved strength of the lower extremities by 17 months. Neurologists should be aware of the association between HSV-2 and radiculomyelitis, particularly in the setting of a patient with psychiatric comorbidities. Recognition of HSV-2 through PCR of CSF and prompt treatment with acyclovir may prevent devastating neurological sequelae.

HIV and spinal cord disease

The epidemiology of spinal cord disease in human immunodeficiency virus (HIV) infection is largely unknown due to a paucity of data since combination antiretroviral therapy (cART). HIV mediates spinal cord injury indirectly, by immune modulation, degeneration, or associated infections and neoplasms. The pathologies vary and range from cytotoxic necrosis to demyelination and vasculitis. Control of HIV determines the differential for all neurologic presentations in infected individuals. Primary HIV-associated acute transverse myelitis, an acute inflammatory condition with pathologic similarities to HIV encephalitis, arises in early infection and at seroconversion. In contrast, HIV vacuolar myelopathy and opportunistic infections predominate in uncontrolled disease. There is systemic immune dysregulation as early as primary infection due to initial depletion of gut-associated lymphoid tissue CD4 cells and allowance of microbial translocation across the gut that never fully recovers throughout the course of HIV infection, regardless of how well controlled. The subsequent proinflammatory state may contribute to spinal cord diseases observed even after cART initiation. This chapter will highlight an array of spinal cord pathologies classified by stage of HIV infection and immune status.

Elsberg syndrome: A rarely recognized cause of cauda equina syndrome and lower thoracic myelitis

Objective:

Elsberg syndrome (ES) is an established but often unrecognized cause of acute lumbosacral radiculitis with myelitis related to recent herpes virus infection. We defined ES, determined its frequency in patients with cauda equina syndrome (CES) with myelitis, and evaluated its clinical, radiologic, and microbiologic features and outcomes.

Methods:

We searched the Mayo Clinic medical records for ES and subsequently for combinations of index terms to identify patients with suspected CES and myelitis.

Results:

Our search yielded 30 patients, 2 diagnosed with ES and an additional 28 with clinical or radiologic evidence of CES retrospectively suspected of having ES. We classified patients in 5 groups according to diagnostic certainty. MRI and EMG confirmed that 2 had only myelitis, 5 only radiculitis, and 16 both. Two had preceding sacral herpes infection and 1 oral herpes simplex. Spinal cord lesions were commonly multiple, discontinuous, not expansile, and centrally or ventrally positioned. Lesions generally spared the distal conus. Nerve root enhancement was occasionally prominent and was smooth rather than nodular. Lymphocytic CSF pleocytosis was common. Thirteen patients (43%) had viral isolation studies, which were commonly delayed; the delay may have accounted for the low rate of viral detection. Acyclovir was administered to 6 patients. Most patients recovered with sequelae; 1 patient experienced encephalomyelitis and died.

Conclusion:

ES is a definable condition likely responsible for 10% of patients with combined CES and myelitis. Radiologic findings are not entirely specific but may help in differentiating ES from some competing diagnostic considerations. We propose criteria to facilitate diagnosis.

Imaging in Neurologic Infections II: Fungal and Viral Diseases

Infections of the nervous system have a significant impact on global mortality and morbidity. These infections are medical emergencies that are frequently diagnostically challenging. Incorporation of neuroimaging can be essential for early diagnosis and initiation of proper treatment. In this second part of this two-part review, we focus on diagnostic imaging features of selected fungal and viral nervous system infections.

Rectal ulcer in a patient with VZV sacral meningoradiculitis (Elsberg syndrome)

This report describes the case of a 55-year-old woman with varicella-zoster virus (VZV) sacral meningoradiculitis (Elsberg syndrome) who presented with herpes zoster in the left S2 dermatome area, urinary retention, and constipation. Lumbar magnetic resonance imaging showed the left sacral nerve root swelling with enhancement. Thereafter, she suddenly showed massive hematochezia and hemorrhagic shock because of a rectal ulcer. To elucidate the relation between Elsberg syndrome and rectal ulcer, accumulation of similar cases is necessary. To avoid severe complications, attention must be devoted to the possibility of rectal bleeding in the early stage of Elsberg syndrome.