title: Extensive VZV Encephalomyelitis without Rash in an Elderly Man.
abstract: Introduction. Varicella zoster virus (VZV) encephalomyelitis with cranial nerve involvement is rare. Characteristically it is preceded by a rash and primarily presents in the immunocompromised. The spectrum of VZV neurologic disease is extensive and it is not uncommon to present without rash. We report the case of an elderly otherwise immunocompetent patient who presented with diverse manifestations of VZV CNS infection all occurring without rash. Case Report. A 78-year-old man presented with 1 week of progressive paraparesis and sensory loss, malaise, and fevers. MRI of the neuraxis demonstrated numerous enhancing lesions: intramedullary, leptomeningeal, pachymeningeal, and cranial nerves. Cerebrospinal fluid (CSF) showed a white blood cell count of 420/ μ L with elevated protein (385 mg/dL). CSF VZV qualitative PCR was positive and CSF VZV immunofluorescence assay detected IgM antibody, confirming the diagnosis of VZV encephalomyelitis. Clinical and radiological improvement was observed after intravenous acyclovir treatment. Conclusion. This is a rare report of an immunocompetent patient with extensive VZV encephalomyelitis. We highlight the importance of considering this diagnosis even in the absence of the characteristic rash, and the potential risk of premature discontinuation of antiviral therapy once HSV has been excluded. Prompt recognition and treatment can dramatically reduce morbidity and mortality in patients.
authors.affiliation: Department of Neurology, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA.
authors.forename: Karen
authors.identifier: 0000-0002-8236-8006
authors.initials: K
authors.lastname: Lynch
authors.affiliation: Tufts University School of Medicine, 145 Harrison Avenue, Boston, MA 02111, USA.
authors.forename: Prakhar
authors.initials: P
authors.lastname: Agarwal
authors.affiliation: Department of Geographic and Infectious Diseases, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA.
authors.forename: Anu
authors.identifier: 0000-0003-4464-5786
authors.initials: A
authors.lastname: Paranandi
authors.affiliation: Department of Geographic and Infectious Diseases, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA.
authors.forename: Susan
authors.identifier: 0000-0001-9419-6590
authors.initials: S
authors.lastname: Hadley
authors.affiliation: Department of Neurology, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA.
authors.forename: Mithila
authors.identifier: 0000-0003-0673-7372
authors.initials: M
authors.lastname: Vullaganti