Resident Physician Penn State Health Hershey, Pennsylvania, United States
Case Diagnosis: VZV Meningitis and Myelitis
Case Description: A 73-year-old man presented to the emergency department with progressive L5/S1 dermatomal distribution, bilateral lower extremity paresthesias over the last 2 weeks and urinary retention. He also reported his son had recently been diagnosed with transverse myelitis of unknown etiology a few years ago without any inciting factor and has been recovering since. He has received his shingles vaccine twice over the past decade. At the hospital, he was found to have a vesicular rash in a unilateral dermatomal distribution. He obtained an MRI that showed abnormal cord parenchymal signal in the dorsal midline and paramedic spinal cord parenchyma at C7- T1, T7-T8, mid T8, T8-T12, with moderate to severe left foramina stenosis at L4-L5 resulting in impingement of the left L4 exiting nerve roots. Lumbar puncture was consistent with aseptic meningitis and was found to be positive for varicella zoster virus (VZV). He received valacyclovir, with gradual symptomatic improvement.
Discussions: Herpes zoster or shingles results from reactivation of latent VZV that gained access to sensory ganglia during varicella infection and is characterized by a painful, unilateral vesicular eruption, which usually occurs in a dermatomal pattern. VZV myelitis may be seen in those who are immunocompromised however is rarely seen as a sudden eruption in immunocompetent individuals who are vaccinated. Interestingly, this patient's infection seemed to mostly impact the dorsal horn given his symptoms. This patient was treated with 21 days of IV acyclovir, which is longer than the usual length of treatment.
Conclusions: The combination of a dermatomal herpetic rash, with new onset sensory deficits should prompt a workup for VZV associated septic meningitis and VZV myelitis. Identification is crucial in order to provide the appropriate treatment. Prompt treatment can also help patients obtain rehabilitation earlier for intervention to improve prognosis.
