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Tada S, Kaito Y, Watanabe A, Sugiyama Y, Nishigaichi A, Miwa T, Watanabe K, Hazama T, Takahashi D. Varicella-Zoster Meningitis and Myelitis After Herpes Zoster Dermatitis Treatment With Amenamevir: A Case Series and Literature Review. Cureus 2024; 16:e54775. [PMID: 38524092 PMCID: PMC10961168 DOI: 10.7759/cureus.54775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 03/26/2024] Open
Abstract
Varicella-zoster virus (VZV), known for causing chickenpox, establishes latent infections in neural tissues. Reactivation of VZV can lead to herpes zoster (HZ) and various neurological complications. In this report, we present four cases of VZV meningitis and myelitis following amenamevir treatment for HZ dermatitis with positive VZV DNA in cerebrospinal fluid (CSF) revealed by polymerase chain reaction (PCR). Three of them were considered immunocompromised hosts given the fact that two of these patients were taking immunosuppressive drugs for rheumatoid arthritis, and one patient had a history of sigmoid colon cancer (four months after resection). After HZ onset, amenamevir, which has poor CSF transfer, was prescribed for all the patients, and all of them developed central nervous complications by VZV (meningitis in three cases and myelitis in one case) confirmed by PCR. All the patients were treated with acyclovir, which has a higher CSF transfer, and fully recovered. We speculate that amenamevir might have failed to prevent VZV infection in the central nervous system (CNS) and think that consideration should be given to administering acyclovir in preference to amenamevir for ΗΖ patients at high risk of CNS VZV infection, such as immunocompromised hosts.
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Affiliation(s)
- Satoru Tada
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, JPN
- Department of Neurology, National Hospital Organization Osaka Minami Medical Center, Osaka, JPN
| | - Yuta Kaito
- Department of Neurology, National Hospital Organization Osaka Minami Medical Center, Osaka, JPN
| | - Akihiro Watanabe
- Department of Neurology, National Hospital Organization Osaka Minami Medical Center, Osaka, JPN
| | - Yukio Sugiyama
- Department of Neurology, National Hospital Organization Osaka Minami Medical Center, Osaka, JPN
| | - Akira Nishigaichi
- Department of Rheumatology, National Hospital Organization Osaka Minami Medical Center, Osaka, JPN
| | - Takashi Miwa
- Department of Neurology, National Hospital Organization Osaka Minami Medical Center, Osaka, JPN
| | - Kotaro Watanabe
- Department of Neurology, National Hospital Organization Osaka Minami Medical Center, Osaka, JPN
| | - Takanori Hazama
- Department of Neurology, National Hospital Organization Osaka Minami Medical Center, Osaka, JPN
| | - Daisuke Takahashi
- Department of Neurology, National Hospital Organization Osaka Minami Medical Center, Osaka, JPN
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Abstract
PURPOSE OF REVIEW The patient who presents with an acute spinal cord syndrome with weakness/paralysis of the limbs presents a diagnostic. Two important syndromes are acute transverse myelitis (ATM) and acute flaccid paralysis (AFP). Both can be caused by a number of infectious and noninfectious causes. Since 2014 there have been outbreaks of acute flaccid myelitis (a subgroup of AFP) in the United States, with a national surveillance program underway. In addition, there have been increasing reports of ATM from new and emerging pathogens, and opportunistic infections in immunocompromised hosts. RECENT FINDINGS Infectious causes of ATM or AFP need to be ruled out first. There may be important clues to an infectious cause from epidemiologic risk factors, immune status, international travel, MRI, and laboratory findings. We summarize key features for the more common pathogens in this review. Advances in laboratory testing have improved the diagnostic yield from cerebrospinal fluid, including real-time polymerase chain reaction, metagenomic next-generation sequencing, and advanced antibody detection techniques. These tests still have limitations and require clinical correlation. SUMMARY We present a syndromic approach to infectious myelopathies, focusing on clinical patterns that help narrow the diagnostic possibilities.
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Shikova E, Kumanova A, Tournev I, Zhelyazkova S, Vassileva E, Ivanov I, Pishmisheva M. Varicella zoster virus infection in neurological patients in Bulgaria. J Neurovirol 2021; 27:272-278. [PMID: 33661458 DOI: 10.1007/s13365-021-00952-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/09/2021] [Accepted: 01/20/2021] [Indexed: 11/29/2022]
Abstract
The clinical manifestations of neurological complications associated with varicella zoster virus (VZV) are non-specific and indistinguishable from those of other viral infections. Therefore, the definite diagnosis requires evidence of VZV infection in cerebrospinal fluid (CSF). The aim of this study was to determine the frequency of VZV DNA detection in CSF of patients with neurological diseases in order to obtain information concerning involvement of VZV infection in neuropathology in the country. This study is a retrospective survey of test results obtained from January 2015 to October 2019. During this period, 411 CSF specimens were tested for the presence of VZV DNA by nested PCR. Fisher's exact test was used to test for statistically significant difference in the frequency of VZV DNA positivity of CSF specimens from different groups. Of all 411 tested CSF samples, 11.2% were positive for VZV DNA. The highest VZV prevalence was detected in CFS from patients with meningitis-18.2%, followed by patients with cranial neuritis (15.4%), encephalitis (12.2%), Guillain-Barré syndrome (11.1%), myelitis (10%), and with other neurological syndromes (8.2%). The difference of VZV prevalence in CSF of patients according to the gender and age was not statistically significant. Our results indicated that VZV is a frequent causative agent of neurological diseases, suggesting an important role of VZV infection for neuropathology in the country. Therefore, efforts for wider application of VZV identification in CSF to facilitate faster onset of antiviral treatment and further strategies concerning varicella zoster virus vaccines in the country are needed.
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Affiliation(s)
- Evelina Shikova
- National Center of Infectious and Parasitic Diseases, Sofia, Bulgaria. .,Central Microbiology Laboratory, University Hospital "Alexandrovska", Sofia, Bulgaria.
| | - Antoniya Kumanova
- National Center of Infectious and Parasitic Diseases, Sofia, Bulgaria
| | - Ivailo Tournev
- Clinic of Neurology, University Hospital "Alexandrovska", Sofia, Bulgaria
| | - Sashka Zhelyazkova
- Clinic of Neurology, University Hospital "Alexandrovska", Sofia, Bulgaria
| | - Evgenia Vassileva
- Clinic of Neurology, University Hospital "Tsaritsa Yoanna - ISUL", Sofia, Bulgaria
| | - Ivan Ivanov
- Department of Pediatrics, Faculty of Medicine, St. George University Hospital, Medical University - Plovdiv, Plovdiv, Bulgaria
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Choudhary A, Bhargava A, Khichar S, Pradhan S. Etiological spectrum, clinico-radiological profile and treatment outcomes of longitudinally extensive transverse myelitis - A prospective study from Northwest India. J Neuroimmunol 2020; 351:577456. [PMID: 33341581 DOI: 10.1016/j.jneuroim.2020.577456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 10/24/2020] [Accepted: 12/06/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To study etiological, clinical and radiological profile and treatment outcomes in patients of longitudinally extensive transverse myelitis (LETM). METHODS This was a prospective study conducted at Dr. S.N. medical college, Jodhpur, India, of patients presenting with LETM between March 2018 to March 2020. RESULTS Our study included 32 patients (median age 32 years, female to male ratio of 2.5: 1). Neuromyelitis optica spectrum disorders (NMOsd) was the most common diagnosis affecting 14 patients followed by 5 patients of idiopathic myelitis, 4 patients of para-infectious myelitis, 3 patients of multiple sclerosis (MS), 3 patients of acute demyelinating encephalomyelitis (ADEM) and 1 patient each of myelin oligodendrocyte glycoprotein (MOG) antibody disease, sarcoidosis and mixed connective tissue disorder (MCTD). All the patients of NMOsd were positive for aquaporin 4 (AQP4) antibody. Spinal MRI showed central pattern of involvement in NMOsd and eccentric pattern of involvement in MS. All the patients of para-infectious myelitis were varicella myelitis. Twenty-eight (87.5%) patients had good clinical recovery at 6 months. CONCLUSION Although, LETM is classically associated with NMOsd, it can have multiple etiologies. Identifying the etiology is important for long term treatment and prognosis which varies according to the disease. Patients in our study presented with relapses and severe disease but had good clinical recovery with treatment.
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Affiliation(s)
| | - Amita Bhargava
- Department of neurology, Dr S N medical college, Jodhpur, India
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Goyal T, Zaheer M, Goyal A, Khan Z. Long-segment transverse myelitis in an immunocompetent patient due to varicella zoster virus reactivation. J Neurovirol 2019; 26:127-129. [PMID: 31376078 DOI: 10.1007/s13365-019-00786-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 06/03/2019] [Accepted: 07/18/2019] [Indexed: 12/30/2022]
Abstract
Transverse myelitis is a segmental, full-thickness inflammation of the spinal cord with various etiologies including varicella zoster virus infection. Symptoms can manifest as sensory deficits, severe lower back pain radiating down the legs, bowel/bladder incontinence, and extremity weakness. This case report is unique in that it highlights a patient who developed long-segment transverse myelitis after a varicella zoster virus infection which has not been previously reported in the literature.
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Affiliation(s)
- Tanvi Goyal
- Department of Internal Medicine, University of Toledo College of Medicine, 3000 Arlington Avenue, Toledo, OH, 43614, USA.
| | - Muhammad Zaheer
- Department of Rheumatology, Immunology and Allergy, University of Oklahoma, 800 Stanton L. Young Blvd, Oklahoma City, OK, 73126-0901, USA
| | - Anirudh Goyal
- Department of Internal Medicine, Rutgers New Jersey Medical School, 185 South Orange Avenue, Newark, NJ, 07103, USA
| | - Zubair Khan
- Department of Internal Medicine, University of Toledo College of Medicine, 3000 Arlington Avenue, Toledo, OH, 43614, USA
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Arenaza-Basterrechea N, González Fernández J, Al Kassam Martínez D. Parainfectious longitudinally extensive transverse myelitis associated with varicella-zoster virus. NEUROLOGÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.nrleng.2016.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Arenaza-Basterrechea N, González Fernández J, Al Kassam Martínez D. Mielitis transversa longitudinal extensa parainfecciosa asociada a virus varicela zóster. Neurologia 2018; 33:342-343. [DOI: 10.1016/j.nrl.2016.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 03/09/2016] [Accepted: 03/12/2016] [Indexed: 10/21/2022] Open
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Savoldi F, Kaufmann TJ, Flanagan EP, Toledano M, Weinshenker BG. Elsberg syndrome: A rarely recognized cause of cauda equina syndrome and lower thoracic myelitis. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2017; 4:e355. [PMID: 28534040 PMCID: PMC5427668 DOI: 10.1212/nxi.0000000000000355] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 04/05/2017] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Filippo Savoldi
- Departments of Neurology (F.S., E.P.F., M.T., B.G.W.), and Neuroradiology (T.J.K.), Mayo Clinic, Rochester, MN; and Neuroimaging Research Unit (F.S.), Department of Neurology, San Raffaele Scientific Institute and University, Milan, Italy
| | - Timothy J Kaufmann
- Departments of Neurology (F.S., E.P.F., M.T., B.G.W.), and Neuroradiology (T.J.K.), Mayo Clinic, Rochester, MN; and Neuroimaging Research Unit (F.S.), Department of Neurology, San Raffaele Scientific Institute and University, Milan, Italy
| | - Eoin P Flanagan
- Departments of Neurology (F.S., E.P.F., M.T., B.G.W.), and Neuroradiology (T.J.K.), Mayo Clinic, Rochester, MN; and Neuroimaging Research Unit (F.S.), Department of Neurology, San Raffaele Scientific Institute and University, Milan, Italy
| | - Michel Toledano
- Departments of Neurology (F.S., E.P.F., M.T., B.G.W.), and Neuroradiology (T.J.K.), Mayo Clinic, Rochester, MN; and Neuroimaging Research Unit (F.S.), Department of Neurology, San Raffaele Scientific Institute and University, Milan, Italy
| | - Brian G Weinshenker
- Departments of Neurology (F.S., E.P.F., M.T., B.G.W.), and Neuroradiology (T.J.K.), Mayo Clinic, Rochester, MN; and Neuroimaging Research Unit (F.S.), Department of Neurology, San Raffaele Scientific Institute and University, Milan, Italy
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Chen LK, Arai H, Chen LY, Chou MY, Djauzi S, Dong B, Kojima T, Kwon KT, Leong HN, Leung EMF, Liang CK, Liu X, Mathai D, Pan JY, Peng LN, Poblete ERS, Poi PJH, Reid S, Tantawichien T, Won CW. Looking back to move forward: a twenty-year audit of herpes zoster in Asia-Pacific. BMC Infect Dis 2017; 17:213. [PMID: 28298208 PMCID: PMC5353949 DOI: 10.1186/s12879-017-2198-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 01/09/2017] [Indexed: 02/05/2023] Open
Abstract
Background Herpes zoster (HZ) is a prevalent viral disease that inflicts substantial morbidity and associated healthcare and socioeconomic burdens. Current treatments are not fully effective, especially among the most vulnerable patients. Although widely recommended, vaccination against HZ is not routine; barriers in Asia-Pacific include long-standing neglect of adult immunisation and sparse local data. To address knowledge gaps, raise awareness, and disseminate best practice, we reviewed recent data and guidelines on HZ from the Asia-Pacific region. Methods We searched PubMed, Scopus, and World Health Organization databases for articles about HZ published from 1994 to 2014 by authors from Australia, China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, New Zealand, the Philippines, Singapore, Taiwan, Thailand, and Vietnam. We selected articles about epidemiology, burden, complications, comorbidities, management, prevention, and recommendations/guidelines. Internet searches retrieved additional HZ immunisation guidelines. Results From 4007 retrieved articles, we screened-out 1501 duplicates and excluded 1264 extraneous articles, leaving 1242 unique articles. We found guidelines on adult immunisation from Australia, India, Indonesia, Malaysia, New Zealand, the Philippines, South Korea, and Thailand. HZ epidemiology in Asia-Pacific is similar to elsewhere; incidence rises with age and peaks at around 70 years – lifetime risk is approximately one-third. Average incidence of 3–10/1000 person-years is rising at around 5% per year. The principal risk factors are immunosenescence and immunosuppression. HZ almost always causes pain, and post-herpetic neuralgia is its most common complication. Half or more of hospitalised HZ patients have post-herpetic neuralgia, secondary infections, or inflammatory sequelae that are occasionally fatal. These disease burdens severely diminish patients’ quality of life and incur heavy healthcare utilisation. Conclusions Several countries have abundant data on HZ, but others, especially in South-East Asia, very few. However, Asia-Pacific countries generally lack data on HZ vaccine safety, efficacy and cost-effectiveness. Physicians treating HZ and its complications in Asia-Pacific face familiar challenges but, with a vast aged population, Asia bears a unique and growing burden of disease. Given the strong rationale for prevention, most adult immunisation guidelines include HZ vaccine, yet it remains underused. We urge all stakeholders to give higher priority to adult immunisation in general and HZ in particular. Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2198-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Liang-Kung Chen
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Rd., Taipei, 11217, Taiwan. .,Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan.
| | - Hidenori Arai
- National Center for Geriatrics and Gerontology, 7-340 Morioka-cho, Obu, Aichi, 474-8511, Japan
| | - Liang-Yu Chen
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Rd., Taipei, 11217, Taiwan
| | - Ming-Yueh Chou
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan.,Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, No. 386 Ta-Chun 1st Rd., Kaohsiung, 81362, Taiwan
| | - Samsuridjal Djauzi
- Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Salemba Raya No. 6, Jakarta, 10430, Indonesia
| | - Birong Dong
- The Center of Gerontology and Geriatrics, West China Medical School/West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Renmin Nan Lu, Chengdu, Sichuan, 610041, China
| | - Taro Kojima
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Jongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Ki Tae Kwon
- Division of Infectious Diseases, Daegu Fatima Hospital, 99 Ayang-ro, Dong-gu, Daegu, 710-600, Korea
| | - Hoe Nam Leong
- Rophi Clinic, 38 Irrawaddy Rd. #07-54/55, Mount Elizabeth Novena Specialist Centre, Singapore, 329563, Singapore
| | - Edward M F Leung
- Geriatric Medicine Centre (Healthy Ageing), Hong Kong Sanatorium and Hospital, 2 Village Rd. Happy Valley, Hong Kong S.A.R., China
| | - Chih-Kuang Liang
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan.,Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, No. 386 Ta-Chun 1st Rd., Kaohsiung, 81362, Taiwan.,Division of Neurology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Xiaohong Liu
- Division of Geriatrics, Department of Internal Medicine, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Dilip Mathai
- Apollo Institute of Medical Sciences and Research, Apollo Health City Campus, Jubilee Hills, Hyderabad, 500096, India
| | - Jiun Yit Pan
- National Skin Centre, 1 Mandalay Rd., Singapore, 308205, Singapore
| | - Li-Ning Peng
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Rd., Taipei, 11217, Taiwan.,Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan
| | - Eduardo Rommel S Poblete
- Geriatric Center, St. Luke's Medical Center, 279 E. Rodriguez Sr. Ave., Quezon City, 1102, Philippines
| | - Philip J H Poi
- Division of Geriatrics, Department of Medicine, University Malaya Medical Centre, Lembah Pantai, 59100, Kuala Lumpur, Malaysia
| | - Stewart Reid
- Ropata Medical Centre, Lower Hutt, 5010, New Zealand
| | - Terapong Tantawichien
- Division of Infectious Diseases, Department of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Chang Won Won
- Department of Family Medicine, College of Medicine, Kyung Hee University, 1 Hoigi-dong, Dongdaemun-gu, Seoul, 130-720, Korea
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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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