Aberrant functional and causal connectivity of the amygdala in herpes zoster and post-herpetic neuralgia patients.

OBJECTIVE: Resting-state functional magnetic resonance imaging (rs-fMRI) and Granger causality analysis (GCA) were used to observe the characteristics of amygdala and whole-brain effect connections in patients with herpes zoster (HZ) and post-herpetic neuralgia (PHN) and to determine their relationship with clinical features. METHODS: Rs-fMRI scans were performed on 50 HZ; 50 PHN; and 50 age-, sex- and education-year-matched healthy controls (HCs). Bilateral amygdala subregions were used as seeds for functional connectivity (FC). GCA was used to analyze the effective connection of brain regions that were significantly different among groups. Then, the correlation between FC, and GCA values and clinical indices was investigated. RESULTS: PHN had impaired FC between the amygdala subregion with the putamen, cortex, anterior cingulate cortex (ACC) to HCs and reduced FC of medial amygdala (MeA) with the parieto-occipital lobe and motor cortex to HZ; HZ had reduced FC of the lateral amygdala (LA) with the insula to HCs. GCA values from the bilateral LA to the bilateral ACC, left MeA to the bilateral ACC and left putamen, and right ACC to the bilateral MeA were reduced in PHN patients compared to HCs. Compared with HCs, the GCA values from the left MeA to the left ACC and right putamen were reduced in HZ. The GCA values from the amygdala subregion to the ACC were positively correlated with HAMA or HAMD scores in PHN. CONCLUSION: PHN showed reduced FC between the amygdala subregions and cortico-putamen and decreased effective connectivity from the amygdala subregion to the ACC and putamen. ADVANCES IN KNOWLEDGE: HZ and PHN patients had significant changes in effective connectivity in brain regions, including diverse functional areas emanating from and projecting to the amygdala. The current findings will provide a new perspective for understanding the neuropathophysiological mechanism HZ and PHN.

Greater functional connectivity between the ventral frontal cortex and occipital cortex in herpes zoster patients than post-herpetic neuralgia patients.

OBJECTIVE: This study aimed to compare whole brain network between herpes zoster (HZ) patients and post-herpetic neuralgia (PHN) patients, as well as to investigate the associations between whole brain network changes and pain intensity and the accuracy of classifying between different types of pain. METHODS: PHN patients (n = 50) and HZ patients (n = 50) and healthy controls (HCs) (n = 50) underwent resting-state functional magnetic resonance imaging (rs-fMRI). Functional connectivity and global and local graph theory metrics were calculated by using Dosenbach-160 atlas. The relationship between neuroimaging indicators and clinical scales was evaluated using correlation analysis, and receiver operating characteristic (ROC) curves evaluated the feasibility of classifying PHN and HZ patients using specific neuroimaging indicators. RESULTS: (1) 10 greater average connectivities were found in HZ group among the default mode, frontoparietal, cingulo-opercular, sensorimotor, occipital networks (ONs), and cerebellum (p < 0.001). (2) HZ patients exhibited higher global efficiency than those in the PHN and HCs (t = 2.178, p = 0.038). (3) Multiple linear regression analyses indicated that functional connectivity between the ventral frontal cortex in the cingulo-opercular network and the occipital gyrus in the ON influenced the visual analog score pain scores (ß = 4.273; p = 0.004). CONCLUSION: The variation of functional connectivity between ventral frontal cortex in the cingulo-opercular network and occipital gyrus in the ON may be a robust neuroimaging marker of the transition from HZ to PHN patients. ADVANCES IN KNOWLEDGE: Whole-brain network analysis may be effective in distinguishing HZ and PHN patients and predicting pain intensity.

MR Features of Varicella-zoster Myelitis in an Immunocompetent Patient.

BACKGROUND: Varicella-zoster virus (VZV) is a latent virus that can remain in the central nervous system. Reactivation of the virus can cause some neurologic manifestations, and myelitis is one of the rarest of them. In this report, we aimed to present the MRI features of long-segment cervical myelitis after VZV infection, which is rarely reported in the literature. CASE PRESENTATION: A 69-year-old patient, who was diagnosed with varicella-zoster two months ago and treated with valacyclovir, was admitted to our clinic with worsening of his complaints and weakness in the right upper extremity. Neurological examination was normal in the left upper and bilateral lower extremities, but the muscle strength in the right upper extremity was evaluated as 4/5 grade. While rare leukocytes (10 leukocytes/mm³, 50 erythrocytes/mm³, high protein level (46 mg/dl, ref.15- 40 mg/dl)) were seen in the cerebrospinal fluid (CSF) analysis, no microorganisms were seen, and no growth was observed in the culture. VZV antibody-immunoglobulin G (Ab-IgG) was positive in CSF, while polymerase chain reaction [PCR] for VZV was negative. On cervical MRI, lesions showing T2 hyperintensity were observed from the C3-4 level to the C7-T1 level, eccentrically located in the right paramedian spinal cord. On post-contrast images, patchy heterogeneous contrast enhancement was noted in these regions of the spinal cord. When the patient's history, CSF features and MRI examinations were evaluated together, the lesions were consistent with VZV myelitis. The patient was started on valacyclovir treatment, and during the follow-up, the patient's complaints decreased, while no progress was observed in neurologic symptoms. CONCLUSION: As a result, we aimed to report the MRI features of this rare complication of varicellazoster and emphasize the necessity of keeping this in mind in the etiology of myelitis, especially in cases with patchy enhancement, to achieve early diagnosis and treatment.

Cervical Root Enlargement in Segmental Zoster Paresis: A Study with Magnetic Resonance Imaging and Nerve Ultrasound.

A 72-year-old woman presented with acute-progressive muscle weakness after a rash in the left upper limb. Muscle weakness was restricted to the left C5 innervated muscles. Short inversion time inversion recovery magnetic resonance imaging (MRI) showed a high-intensity signal in the left C5 nerve root, and nerve ultrasound showed its enlargement. She was diagnosed with segmental zoster paralysis (SZP) and treated with acyclovir and methylprednisolone. Her muscle strength gradually recovered, and the abnormal signal and enlargement in the left C5 nerve root improved. This is the first SZP case of confirmed improvement of abnormal findings on MRI and nerve ultrasound in association with muscle power recovery.

Abnormal within- and cross-networks functional connectivity in different outcomes of herpes zoster patients.

Neuroimaging studies have displayed aberrant brain activities in individual sensory- and emotional-linked regions in postherpetic neuralgia (PHN) patients. However, multi-dimensional dysfunction in chronic pain may rely on the interplay between networks. Little is known about the changes in the functional architecture of resting state networks (RSNs) in PHN. In this cross-sectional study, we recruited 31 PHN patients, 33 RHZ patients and 34 HCs; all participants underwent resting-state functional magnetic resonance imaging scans. We investigated the differences of within- and cross-network connectivities between different outcomes of HZ patients [including PHN and recuperation from herpes zoster (RHZ)] and healthy controls (HCs) so as to extract a characteristic network pattern of PHN. The abnormal network connectivities were then correlated with clinical variables in respective groups. PHN and RHZ patients could be similarly characterized by abnormal within-default mode network (DMN), DMN-salience network (SN) and SN-basal ganglia network (BGN) connectivity relative to HCs. Of note, compared with RHZ patients, PHN patients could be characterized by abnormal DMN-BGN and within-BGN connectivity. Furthermore, the within-DMN connectivity was associated with pain-induced emotional scores among PHN patients. Our study presented that network-level imbalance could account for the pain-related dysfunctions in different outcomes of herpes zoster patients. These insights are potentially useful for understanding neuromechanism of PHN and providing central therapeutic targets for PHN.

Unusual Presentation of Herpes Zoster Infection Mimicking Soft Tissue Metastases of Breast Cancer on 18F-FDG PET/CT Imaging.

ABSTRACT: Herpes zoster infection caused by reactivation of dormant varicella zoster virus results in painful vesicular rash in corresponding dermatome. We report a case of a 56-year-old woman with breast cancer who was referred to PET/CT scan for adjuvant chemotherapy response assessment. Her scan showed multiple FDG-avid skin lesions. Blinded to the patient's clinical information, these skin lesions initially looked suspicious for soft tissue metastases. However, the patient history revealed that she had been experiencing herpes zoster infection during the scan, and these lesions with FDG uptake were eventually confirmed to be caused by herpes zoster infection by physical examination.

Disrupted default mode network dynamics in recuperative patients of herpes zoster pain.

INTRODUCTION: Previous studies of herpes zoster (HZ) have focused on acute patient manifestations and the most common sequela, postherpetic neuralgia (PHN), both serving to disrupt brain dynamics. Although the majority of such patients gradually recover, without lingering severe pain, little is known about life situations of those who recuperate or the brain dynamics. Our goal was to determine whether default mode network (DMN) dynamics of the recuperative population normalize to the level of healthy individuals. METHODS: For this purpose, we conducted resting-state functional magnetic resonance imaging (fMRI) studies in 30 patients recuperating from HZ (RHZ group) and 30 healthy controls (HC group). Independent component analysis (ICA) was initially undertaken in both groups to extract DMN components. DMN spatial maps and within-DMN functional connectivity were then compared by group and then correlated with clinical variables. RESULTS: Relative to controls, DMN spatial maps of recuperating patients showed higher connectivity in middle frontal gyrus (MFG), right/left medial temporal regions of cortex (RMTC/LMTC), right parietal lobe, and parahippocampal gyrus. The RHZ (vs HC) group also demonstrated significant augmentation of within-DMN connectivity, including that of LMTC-MFG and LMTC-posterior cingulate cortex (PCC). Furthermore, the intensity of LMTC-MFG connectivity correlated significantly with scoring of pain-induced emotions and life quality. CONCLUSION: Findings of this preliminary study indicate that a disrupted dissociative pattern of DMN persists in patients recuperating from HZ, relative to healthy controls. We have thus provisionally established the brain mechanisms accounting for major outcomes of HZ, offering heuristic cues for future research on HZ transition states.

Early Treatment with Temporary Spinal Cord Stimulation Effectively Prevents Development of Postherpetic Neuralgia.

BACKGROUND: Some 7.7% of the Chinese population suffer from herpes zoster each year, with 29.8% proceeding on to develop postherpetic neuralgia (PHN). This amounts to over 32 million people per year. PHN is preceded by 2 phases of pain: acute herpetic neuralgia (AHN), and subacute herpetic neuralgia (SHN). Considering the large individual and economic burden, preventing the transition of AHN/SHN to PHN is crucial. However, to date this has been difficult. OBJECTIVES: To evaluate the efficacy of temporary spinal cord stimulation (tSCS) treatment and prevention of PHN. STUDY DESIGN: A retrospective, observational study. SETTING: Department of Pain Medicine. METHODS: From 2013 to 2017, 99 patients with AHN (n = 42), SHN (n = 34), and PHN (n = 23) underwent tSCS treatment (7-14 days) after failed pharmacologic and interventional therapies. Visual analog scale (VAS), Pittsburgh Sleep Quality Index (PSQI), and analgesic consumption were recorded at baseline, post-tSCS, and 1, 3, 6, and 12 months after tSCS treatment. RESULTS: Pooled results demonstrated statistically significant decreases in VAS scores and PSQI post-tSCS and at 1, 3, 6, and 12 months follow-up (P < 0.001). When compared with the PHN group, both AHN and SHN groups were clinically and statistically improved in VAS scores and PSQI (P < 0.001). Analgesic consumption decreased in all 3 groups after tSCS treatment, and downward linear gradient of medication in the AHN group was more significant than that in the SHN and PHN groups. At 12 months follow-up, 2.5% (1/40) patients in the AHN group, 16.0% (4/25) in the SHN group, and 62.5% (10/16) in the PHN group had ongoing pain >= 3/10 VAS score requiring analgesia. Expressed differently, at 12 months, 97.5% of the AHN group and 84% of the SHN group had pain of 2/10 VAS score or less versus only 37.5% of the PHN group. LIMITATIONS: This was a single-center, retrospective study, which made it difficult to collect complete data for all variables. The therapeutic effect of tSCS could not be studied independently. CONCLUSIONS: This retrospective analyses of 99 patients treated with tSCS (7-14 days) suggests that tSCS may be effective for treating and preventing PHN. Early treatment within 4 to 8 weeks was more likely to result in pain <= 2/10 VAS score, improvement in sleep, and no requirement for analgesia at 12 months. Early tSCS may be a promising prevention strategy against the development of chronic neuropathic pain following herpes zoster infection. Further research is justified. KEY WORDS: Herpes zoster, zoster-related pain, postherpetic neuralgia, temporary spinal cord stimulation.

Pseudohernia abdominal como complicación infrecuente de herpes zóster cutáneo: reporte de un caso / Abdominal pseudohernia as a complication infrequent cutaneous herpes zoster: report of a case

Una de las infecciones virales más comunes -sobretodo en personas de mayor edad- es el Herpes Zóster (HZ). Su característica clínica, hace sospechar al médico de forma temprana, para otorgar un tratamiento adecuado y oportuno. Dentro de las complicaciones más frecuentes se encuentran las sensitivas, como la neuralgia postherpética.1 Sin embargo, existen un grupo de complicaciones motoras de menor incidencia, como lo es la Pseudohernia abdominal. Ésta corresponde a una paresia segmentaria, que se manifiesta como una protrusión de la pared abdominal sin un defecto real, que aumenta con maniobras de valsalva.1 Generalmente se puede presentar en hombres, mayores de 60 años, inmunosuprimidos o con neoplasias hematológicas.1,2,3 El diagnóstico es clínico, aunque se puede confirmar con estudio imagenológico, que evidencie una musculatura de la pared abdominal adelgazada con respecto a la contralateral y que descarta un orificio herniario por un defecto estructural. 2 La electromiografía también puede jugar un rol al evidenciar anormalidades en la conducción nerviosa. 2 La pseudohernia por HZ tiene un buen pronóstico en la mayoría de los pacientes con recuperación completa: entre 2-18 meses. 3 Su principal riesgo es la pseudobstrucción intestinal, que se puede manifestar como constipación.2,4 En el siguiente reporte de caso, se analiza a la pseudohernia abdominal como complicación motora infrecuente del HZ y sus características.

One of the most common viral infections -especially in elderly- is Herpes Zoster (HZ). Its clinical characteristic makes the doctor suspect early, to grant adequate and timely treatment. Among the most frequent complications are the sensitive ones, such as postherpetic neuralgia1 . However, there is a group of motor complications of lower incidence, such as abdominal pseudohernia. This corresponds to a segmental paresis, which manifests as a protrusion of the abdominal wall without a real defect that increases with valsalva maneuvers1 . It can generally present in men, older than 60 years, immunosuppressed or with hematological neoplasms1,2,3, The diagnosis is clinical, although it can be confirmed with an imaging study, which shows a thinner abdominal wall musculature with regard to the contralateral wall, and which rules out a hernial orifice due to a structural defect2 . Electromyography can also play a role in show abnormalities in nerve conduction2 . HZ pseudohernia has a good prognosis in most patients with complete recovery: between 2-18 months.3 Its main risk is intestinal pseudoobstruction, which can manifest as constipation2,4. In the following case report, abdominal pseudohernia is analyzed as a rare motor complication of HZ and its characteristics.

Infectious causes and outcomes in patients presenting with cerebral spinal fluid pleocytosis.

To evaluate the infectious etiologies, clinical features, and outcomes of patients with CNS infections at a tertiary care center. Patients that present with a pleocytosis in the cerebral spinal fluid (CSF), defined as a CSF WBC count > 5 cells/mm3, from July 2015 to June 2016 at a tertiary care hospital were analyzed for this report. Data from patients with confirmed (n = 43) and presumed (n = 51) CNS infections were analyzed. CNS infection was the leading known cause of CSF pleocytosis (n = 43, 18% of all patients with a pleocytosis in the CSF), and HSV-2 was identified as the leading causative pathogen (n = 10) followed by varicella zoster virus (n = 5). Fifty-three percent of patients with a pleocytosis in the CSF did not receive a diagnosis. In the patients that did not receive a diagnosis, CNS infection was presumed to be the cause in 51 patients (21% of patients with CSF pleocytosis). The mean time to diagnosis for patients with confirmed CNS infection was 16 days, but time to diagnosis was highly variable depending on the causative pathogen. There was a significant overlap in CSF parameters and peripheral white blood cell counts in patients diagnosed with a viral, bacterial, or fungal infection. Neuroimaging changes were present in only 44% of CNS infections. The overall mortality was 7% for CNS infections, and 17% of patients with a CNS infection had a severe neurologic deficit at presentation while only 3% had a severe deficit at the last neurologic assessment. This study provides new insights into the infectious causes of disease in a cohort of patients with pleocytosis in the CSF. The study provides new insights into the time to diagnosis and outcomes in patients that present with pleocytosis in the CSF.

A retrospective case series of segmental zoster paresis of limbs: clinical, electrophysiological and imaging characteristics.

BACKGROUND: Segmental zoster paresis (SZP) of limbs, characterized by focal weakness of extremity, is recognized as a rare complication of herpes zoster (HZ). The following study analyzes the clinical characteristics and data from electromyography and MRI scans in patients with motor weakness after zoster infection. METHODS: One thousand three hundred ninety-three patients from our database (Shandong Provincial Qianfoshan Hospital) suffering from HZ were retrospectively reviewed from June 2015 to July 2017. Patients who fulfilled the diagnostic criteria for SZP were included in the analysis. The clinical characteristics, as well as electromyography findings and MRI scans were analyzed. RESULTS: SZP was present in 0.57% of patients with HZ (8/1393). The average age of symptom onset in 8 SZP patients was 69 years old (SD: 13, range 47-87). The severity of muscle weakness ranged from mild to severe. The electrophysiological testing revealed the characteristics of axonopathy. Radiculopathy (2/8), plexopathy (2/8), radiculoplexopathy (3/8) and combined radiculopathy and mononeuropathy (1/8) were also identified. MRI revealed hyperintensity of the affected spinal dorsal horns, nerve roots or peripheral nerves. CONCLUSIONS: SZP is associated with obvious limb weakness, nerve axons lesions and localization to nerve roots, plexus or peripheral nerves.

[Trigeminal Herpes Zoster Presenting with High-intensity Signals for the Spinal Trigeminal Nucleus and Tract on Diffusion-weighted Image: A Case Report of Stroke Mimic].

A 50-year-old woman was admitted to our hospital with dysesthesia on the right upper portion of her face and a headache. Diffusion-weighted brain magnetic resonance imaging (MRI) revealed high-intensity signals in the dorsolateral portion of the medulla oblongata. She was diagnosed with lateral medullary infarction and was intravenously treated with sodium ozagrel. On the second day of hospitalization, she had nausea and vomiting and showed nystagmus to all directions, suggesting damage to the vestibular nucleus. These manifestations coincided with partial symptoms of lateral medullary syndrome. On the third day of hospitalization, a rash appeared on the region of skin innervated by the first and second branches of the right trigeminal nerve. A reevaluation of the MRI findings indicated the presence of a lesion of the right spinal trigeminal nucleus and tract. She was treated with acyclovir for 14 days, and was discharged without any residual symptoms. Varicella zoster virus-DNA was detected in her cerebrospinal fluid. This disease mimics the presentation of a stroke and is important for differential diagnosis. (Received August 1, 2017; Accepted September 14, 2017; Published February 1, 2018).

Diskogenic Reactivation of Herpes Zoster.

Varicella zoster virus remains dormant in the dorsal root ganglia after childhood exposure to chickenpox. Its reactivation results in herpes zoster, otherwise known as shingles, which is a painful vesicular rash in a dermatomal distribution. We present a case of foraminal disk extrusion that resulted in radicular pain in a dermatomal distribution. The resultant inflammatory response around the dorsal root ganglion triggered an episode of shingles, which elegantly highlights the pathophysiology of this condition at a gross anatomic level.

Local Brain Activity Differences Between Herpes Zoster and Postherpetic Neuralgia Patients: A Resting-State Functional MRI Study.

BACKGROUND: Herpes zoster (HZ) can develop into postherpetic neuralgia (PHN), both of which are painful diseases. PHN patients suffer chronic pain and emotional disorders. Previous studies showed that the PHN brain displayed abnormal activity and structural change, but the difference in brain activity between HZ and PHN is still not known. OBJECTIVES: To identify regional brain activity changes in HZ and PHN brains with resting-state functional magnetic resonance imaging (rs-fMRI) technique, and to observe the differences between HZ and PHN patients. STUDY DESIGN: Observational study. SETTING: University hospital. METHODS: Regional homogeneity (ReHo) and fractional aptitude of low-frequency fluctuation (fALFF) methods were employed to analysis resting-state brain activity. Seventy-three age and gender matched patients (50 HZ, 23 PHN) and 55 healthy controls were enrolled. ReHo and fALFF changes were analyzed to detect the functional abnormality in HZ and PHN brains. RESULTS: Compared with healthy controls, HZ and PHN patients exhibited abnormal ReHo and fALFF values in classic pain-related brain regions (such as the frontal lobe, thalamus, insular, and cerebellum) as well as the brainstem, limbic lobe, and temporal lobe. When HZ developed to PHN, the activity in the vast area of the cerebellum significantly increased while that of some regions in the occipital lobe, temporal lobe, parietal lobe, and limbic lobe showed an apparent decrease. LIMITATIONS: (a) Relatively short pain duration (mean 12.2 months) and small sample size (n = 23) for PHN group. (b) Comparisons at different time points (with paired t-tests) for each patient may minimize individual differences. CONCLUSIONS: HZ and PHN induced local brain activity changed in the pain matrix, brainstem, and limbic system. HZ chronification induced functional change in the cerebellum, occipital lobe, temporal lobe, parietal lobe, and limbic lobe. These brain activity changes may be correlated with HZ-PHN transition. KEY WORDS: Herpes zoster, postherpetic neuralgia, resting-state fMRI (rs-fMRI), regional homogeneity (ReHo), fractional aptitude of low-frequency fluctuation (fALFF).

A case of anti aquapolin-4 antibody positive myelitis with hyperhidrosis, following herpes zoster.

We report an acute myelitis in a 53-year-old woman that occurred in 7 days after the diagnosis of Th5-6 herpes zoster. Clinical examination revealed hyperhidrosis of left side of her face, neck, arm and upper chest. She also had muscle weakness of her left leg and sensory impairment for light touch and temperature in her chest and legs. Spinal cord MRI demonstrated a longitudinal T2-hyperintense lesion extending from Th1 to 7. In the axial imaging, the lesion dominantly located in the left side gray matter. Hyperhidrosis, weakness and sensory impairment were improved after intravenous therapy with acyclovir and methylprednisolone. VZV (varicella zoster virus) IgG index of the cerebrospinal fluid was high and serological anti aquaporin-4 antibodies were positive at the time of the admission. This case had both characteristics of VZV myelitis and neuromyelitis optica spectrum disorder. Myelitis relapsed 19 months after the first attack. We believe that sympathetic hyper reactivity due to thoracic spinal cord lesion was responsible for the hyperhidrosis in our patient.

Varicella Reinfection with Unilateral Varicella Pneumonia.

Varicella zoster virus (VZV) infection does not always provide lifelong immunity. A reinfection with VZV occurs more commonly than previously thought. Varicella infection spreads through the blood-stream, causing pneumonia. Varicella pneumonia results in bilateral pulmonary nodular infiltrations. We herein report a case of varicella reinfection with unilateral varicella pneumonia in which a reduced pulmonary blood flow due to radiation damage was considered to be the cause of unilateral pneumonia. In patients with an asymmetric pulmonary blood flow, careful interpretation of unilateral infiltration is therefore considered to be important with making a differential diagnosis.