ABSTRACT
RATIONALE: Neurological complications of varicella-zoster virus (VZV) infection include cerebral infarction, meningoencephalitis, segmental sensory disturbance, facial nerve palsy, and myelitis. Chronic myelitis is rarely reported. Diagnosis of VZV infection can be confirmed by elevated anti-VZV immunoglobulin G (IgG) antibody or detection of VZV DNA in the cerebrospinal fluid (CSF), the former reported to be superior. The detection rate of VZV DNA is generally thought to decrease with time after the onset of the condition. The utility of VZV DNA polymerase chain reaction (PCR) is thus thought to be limited to the acute phase of the disease. The presence of skin lesions also helps to render a diagnosis; however, cases of zoster sine herpete (ZSH), the occurrence of segmental symptoms without skin lesions, renders the diagnosis of VZV infection more difficult. Antiviral drugs, such as acyclovir, are the treatment of choice to resolve VZV infections. PATIENT CONCERNS: A 65-year-old Japanese man felt heaviness and a throbbing pain on the ulnar side of the right forearm. He was previously diagnosed with cervical spondylosis, and received nonsteroidal anti-inflammatory drugs with little improvement. Contrast cervical magnetic resonance imaging showed a swelling and an increased signal intensity of the spinal cord, and an enhancing lesion, all of which were suggestive of myelitis. DIAGNOSIS: We found no evidence for diagnoses of sarcoidosis, Behçet disease, multiple sclerosis, or neuromyelitis optica spectrum disorder. The CSF analysis revealed an elevation of the total protein concentration and that the patient was positive for VZV DNA, while anti-VZV IgG was not elevated. The patient was therefore diagnosed with ZSH myelitis. INTERVENTIONS: We administered acyclovir and valaciclovir as the first therapy. At the time of recurrence, we used high-dose acyclovir, vidarabine, and high-dose methylprednisolone pulse therapy. OUTCOMES: The patient's dysesthetic pain in the right upper limb improved following the first antiviral therapy. Two months later, he suffered a recurrence, but the second therapy significantly relieved his symptoms. LESSONS: VZV infection should be regarded as an important differential diagnosis of chronic myelitis. VZV DNA PCR should be performed even in the chronic phase of the condition to introduce the possibility of antiviral therapy as a treatment option.
Subject(s)
Myelitis/etiology , Zoster Sine Herpete/complications , Zoster Sine Herpete/diagnosis , Aged , Antiviral Agents/therapeutic use , DNA, Viral/analysis , Forearm , Herpesvirus 3, Human/isolation & purification , Humans , Magnetic Resonance Imaging , Male , Myelitis/diagnostic imaging , Polymerase Chain Reaction , Recurrence , Zoster Sine Herpete/cerebrospinal fluid , Zoster Sine Herpete/drug therapySubject(s)
Herpes Zoster/diagnosis , Herpesvirus 3, Human/genetics , Herpesvirus 3, Human/immunology , Zoster Sine Herpete/diagnosis , Chronic Disease , DNA/cerebrospinal fluid , Disease Progression , Female , Herpes Zoster/cerebrospinal fluid , Herpes Zoster/genetics , Herpes Zoster/immunology , Herpes Zoster/virology , Humans , Immunoglobulin G/cerebrospinal fluid , Middle Aged , Zoster Sine Herpete/cerebrospinal fluid , Zoster Sine Herpete/genetics , Zoster Sine Herpete/immunology , Zoster Sine Herpete/virologyABSTRACT
After lumbar-distribution zoster, an HTLV-1-seropositive woman developed chronic radicular sacral-distribution pain (zoster sine herpete), cervical-distribution zoster paresis and thoracic-distribution myelopathy. Detection of anti-varicella zoster virus (VZV) IgM and VZV IgG antibody in cerebrospinal fluid (CSF), with reduced serum/CSF ratios of anti-VZV IgG compared to normal serum/CSF ratios for albumin and total IgG, proved that VZV caused the protracted neurological complications. Diagnosis by antibody testing led to aggressive antiviral treatment and a favorable outcome.