Objective:

To describe a case of Elsberg syndrome associated with HSV-2, highlighting its rarity, the diagnostic and therapeutic challenges, and its potential improvement with antiviral treatment. 

Background:

Elsberg syndrome usually presents as an acute or subacute lumbosacral radiculitis with lower spinal cord myelitis, most commonly cauda equina syndrome. It is typically associated with infections like HSV, VZV, SARS-CoV-2, and West Nile virus. The diagnosis is often overlooked, and a workup is required to rule out other diseases. The use of antivirals is recommended; however, clinical improvement has not been consistently documented.

Design/Methods:

Results:

A 21-year-old male with a recent diagnosis of genital HSV-2 presented with saddle anesthesia and urinary retention one month following the diagnosis. MRI of the neuroaxis showed bilateral sacral nerve root enhancement and a T2 hyperintense cord lesion in the lower spinal cord consistent with sacral myeloradiculitis. Cerebrospinal fluid showed white blood cells of 23 µL, red blood cells of 2 µL, protein of 46 mg/dL, and glucose of 63 mg/dL. HSV PCR in the CSF resulted negative. He was treated with IV acyclovir at 10 mg/kg every 8 hours, which caused dramatic improvement in symptoms. He experienced resolution of urinary retention and about 80 percent return in sensation to the perineal area within 3 days of treatment. On day 5, he was discharged on oral antiviral medication, per patient preference.

Conclusions:

A negative HSV PCR in the CSF does not rule out infectious causes of lumbosacral myeloradiculitis. Clinical history and presentation should be strongly considered, and timely intervention with antiviral medication may result in symptom improvement.