Alyssa Bowlsby1, Michael Smith2, Ayushi Chugh1, Michael Robers1
1Barrow Neurological Institute, 2Creighton University School of Medicine
Objective:
To report a case of Elsberg syndrome caused by herpes simplex virus type 2 (HSV-2), manifesting as cauda equina syndrome.
Background:
Elsberg syndrome is characterized by urinary retention and spinal cord dysfunction, but its presentation varies. Patients may experience prodromal symptoms such as headache, malaise, and fatigue. The condition is often associated with HSV-2, but has been reported with West Nile Virus, VZV, CMV, EBV, and HIV.
Design/Methods:
Not applicable.
Results:
A 38-year-old female presented with bilateral lower extremity numbness and weakness. She had developed back and leg pain over a few weeks. Imaging revealed an arachnoid web that surgery removed with no improvement. She returned weeks later with 4/5 proximal and 3/5 distal lower extremity weakness. Imaging demonstrated cauda equina enhancement and lumbar puncture found neutrophilic pleocytosis (58 WBCs, 63% neutrophils) and increased protein (126.2 mg/dL). She was treated with steroids for possible CIDP and discharged to acute rehabilitation with monthly IVIG. CSF HSV-2 IgG later returned positive. She returned months later with loss of sensation and 0/5 strength in the lower extremities. Imaging demonstrated new abnormal signal in the distal thoracic cord and conus in addition to increased cauda equina enhancement. Lumbar puncture found lymphocytic pleocytosis (73 WBCs, 63% lymphocytes) and increased protein (82.6 mg/dL) with PCR positivity for HSV-2. She was diagnosed with Elsberg syndrome and was treated with acyclovir and methylprednisolone. She was discharged to acute rehabilitation and has had improvement in her weakness to 1/5 and some return of sensation.
Conclusions:
Elsberg syndrome is an overlooked cause of cauda equina syndrome. Diagnosis is based on clinical features and spinal cord imaging and confirmed by CSF analysis for causal viruses. Treatment includes acyclovir combined with corticosteroids. The prognosis varies, but many patients improve with treatment, highlighting the need for timely diagnosis.
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