329 - Brachial Plexopathy associated with Varicella Zoster Virus Meningoencephalitis

Case Diagnosis: Zoster Brachial Plexopathy

Case Description: We present a case of an elderly (90+ year old) male with a history of Atrial Fibrillation with Watchman placement, cerebrovascular accident (CVA) without residual deficits, and chronic kidney disease who initially presented with confusion and agitation. Lumbar puncture with cerebrospinal fluid (CSF) analysis showed Varicella Zoster in the CSF. A 14-day course of IV acyclovir was initiated for VZV meningoencephalitis and his mentation slowly improved. Upon admission to an acute inpatient rehabilitation unit, the patient was noted to have isolated right deltoid and biceps paresis with absent biceps brachii reflex. Head and neck imaging ruled out intracranial and cervical pathology. MRI of the right shoulder indicated labral tear and rotator cuff tendinopathy. Electrodiagnostic evaluation of the right upper extremity demonstrated a lesion with axonal and demyelinating features in the upper trunk of the brachial plexus.

Discussions: Brachial plexopathy is a rare complication of Varicella Zoster Virus (VZV) infection which primarily occurs in patients over 60 years old. Nerve involvement from VZV infection typically localizes in the sensory ganglion and extends distally. There are at least 12 reported cases of brachial plexopathy from VZV infection each manifesting with varying clinical presentation.

Conclusions: Based on our literature search, most cases of brachial plexopathy from viral meningoencephalitis was secondary to West Nile Virus. There is a sparse amount of literature documenting a brachial plexus lesion from VZV meningoencephalitis. This case demonstrates a unique presentation of zoster brachial plexopathy as it was preceded by VZV meningoencephalitis.