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Myelitis and Radiculitis Complicating Varicella-Zoster Virus Reactivation

A 44-year-old man presented with small painful vesicular rash on his left shoulder and arm. After three days, the patient progressively lost motor strength and sensitivity in his left upper limb. Magnetic resonance imaging (MRI) showed a hyperintense signal in the left gray matter columns of the cervical spinal cord at the level of C3 to C5 based on T2-weighted and short tau inversion recovery (STIR) images, with slight contrast-enhancement. MRI also demonstrated contrast-enhancement in the left C5 nerve root and the adjacent homolateral paravertebral muscles, and this was associated with edema (Figure 1A-E). Analysis of cerebrospinal fluid (CSF) demonstrated elevated white blood cell counts with 100% mononuclear cells and a positive polymerase chain reaction for varicella-zoster virus (VZV). The patient was treated with intravenous acyclovir and a pulse of intravenous methylprednisolone.

FIGURE 1:
The reactivation of varicella zoster virus is complicated by myelitis and radiculitis. Cervical spine MRI showing hyperintense signal in the left gray matter columns of the spinal cord at C3 to C5 based on axial T2-weighted imaging (arrow in A) and sagittal STIR (arrow in B), and with contrast enhancement (arrow in C). Contrast enhancement was also detected in the left C5 spinal nerve root and the nerve (arrows in D and E), suggesting myelorradiculitis. The edema and contrast-enhancement in the corresponding homolateral paravertebral muscles (arrowheads) are of additional note.

Primary infection with VZV in susceptible individuals causes varicella, which usually is harmless in healthy patients. The virus subsequently enters a phase of latency in ganglionic neurons. On reactivation, which is usually triggered by a decline in specific cell-mediated immunity, the virus often spreads peripherally causing herpes zoster. However, it can also spread centrally to cause neurological complications, including myelitis11. Goyal T, Zaheer M, Goyal A, Khan Z. Long-segment transverse myelitis in an immunocompetent patient due to varicella zoster virus reactivation. J Neurovirol. 2020;26(1):127-9. doi: 10.1007/s13365-019-00786-3.
https://doi.org/10.1007/s13365-019-00786...
,22. Nagel MA, Gilden D. Neurological complications of varicella zoster virus reactivation. Curr Opin Neurol. 2014;27(3):356-60. doi: 10.1097/WCO.0000000000000092.
https://doi.org/10.1097/WCO.000000000000...
. The pathogenesis of VZV-related myelitis is postulated to be related to direct viral invasion. Vascular and autoimmune mechanisms have also been proposed in its pathophysiology33. Abbas SA, El Helou J, Chalah MA, Hilal H, Saliba G, Abboud H, et al. Longitudinal Extensive Transverse Myelitis in an Immunocompetent Older Individual-A Rare Complication of Varicella-Zoster Virus Reactivation. Medicina (Kaunas). 2019;55(5):E201. doi: 10.3390/medicina55050201.
https://doi.org/10.3390/medicina55050201...
.

Although not specific, the unilateral involvement of gray matter in the spinal cord is one form in which VZV myelitis presents. It might also present itself as transverse myelitis or Brown-Séquard syndrome. Thus, VZV myelitis is diagnosed through clinical suspicion and subsequent virologic confirmation11. Goyal T, Zaheer M, Goyal A, Khan Z. Long-segment transverse myelitis in an immunocompetent patient due to varicella zoster virus reactivation. J Neurovirol. 2020;26(1):127-9. doi: 10.1007/s13365-019-00786-3.
https://doi.org/10.1007/s13365-019-00786...
,22. Nagel MA, Gilden D. Neurological complications of varicella zoster virus reactivation. Curr Opin Neurol. 2014;27(3):356-60. doi: 10.1097/WCO.0000000000000092.
https://doi.org/10.1097/WCO.000000000000...
.

ACKNOWLEDGMENTS

We thank Marco Yukio Tsuno, Clínica de Dagnóstico por Imagem and Laboratório Exame for his technical support for the development of this study.

REFERENCES

  • 1
    Goyal T, Zaheer M, Goyal A, Khan Z. Long-segment transverse myelitis in an immunocompetent patient due to varicella zoster virus reactivation. J Neurovirol. 2020;26(1):127-9. doi: 10.1007/s13365-019-00786-3.
    » https://doi.org/10.1007/s13365-019-00786-3
  • 2
    Nagel MA, Gilden D. Neurological complications of varicella zoster virus reactivation. Curr Opin Neurol. 2014;27(3):356-60. doi: 10.1097/WCO.0000000000000092.
    » https://doi.org/10.1097/WCO.0000000000000092
  • 3
    Abbas SA, El Helou J, Chalah MA, Hilal H, Saliba G, Abboud H, et al. Longitudinal Extensive Transverse Myelitis in an Immunocompetent Older Individual-A Rare Complication of Varicella-Zoster Virus Reactivation. Medicina (Kaunas). 2019;55(5):E201. doi: 10.3390/medicina55050201.
    » https://doi.org/10.3390/medicina55050201

Publication Dates

  • Publication in this collection
    13 Nov 2020
  • Date of issue
    2021

History

  • Received
    29 May 2020
  • Accepted
    03 July 2020
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