A Case of Infectious and Para-infectious Herpes Simplex Virus and Varicella Zoster Virus Radiculomyelitis
Shlok Sarin1, Ibrahim Alkhodair1, Rui Tang1, Sarah Venus1, Michel Boustany1, Alexander Lewis1, Kamal Chemali1, Patrick Fagan1, Komal Sawlani1
1Neurology, University Hospitals Cleveland Medical Center
Objective:
Herpes Simplex Virus (HSV) and Varicella Zoster Virus (VZV) can rarely cause a radiculomyelitis. Here we present a patient with HSV and VZV central nervous system (CNS) co-infection.
Results:
A 77-year-old male with myasthenia gravis (MG) (acetylcholine-receptor antibody positive on pyridostigmine, prednisone, mycophenolate, and monthly intravenous immunoglobulin (IVIg)) presented with three weeks of progressive bilateral lower extremity weakness and paresthesias. Initial examination showed proximal leg weakness worse on the left, sensory loss in a distal to proximal gradient, and lower limb hyporeflexia. Initial cerebrospinal fluid (CSF) analysis showed xanthochromia, protein 273, white blood cell (WBC) 60 (49% neutrophils, 28% lymphocytes), red blood cell (RBC) 36, and positive HSV2 and VZV PCR. MRI showed C5-6 cord hyperintensity, central and dorsal thoracic patchy longitudinally-extensive hyperintensities, and cauda equina enhancement. Skin examination revealed scattered umbilicated crusted papulovesicles, and PCR analysis demonstrated disseminated VZV and genital HSV2. Initial treatment was three weeks of acyclovir and scheduled IVIg, however symptoms progressed to near paraplegia. Hospital course was complicated by encephalopathy, urinary tract infection, and kidney injury. MRI brain two weeks after presentation showed minimal intraventricular hemorrhage. Patient developed signs of myasthenic crisis requiring intubation and five sessions of plasma exchange. Repeat MRI spine showed progression of thoracic spine hyperintensities and continued cauda equina enhancement. Repeat CSF analysis showed xanthochromia, protein 535, WBC 266 (17% neutrophils, 78% lymphocytes), RBC 38,000, and negative HSV2 and VZV PCR. Given concern for para-infectious process, patient was treated with five days of intravenous steroids and IVIg with mild symptom improvement.
Conclusions:
Our patient presented with HSV and VZV radiculomyelitis co-infection and disseminated skin lesions while immunocompromised. This triggered a myasthenic crisis responsive to plasma exchange; however, his lack of improvement suggests an additional para-infectious process. This case highlights the importance of thorough workup and examination, including skin, in immunocompromised patients.
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