Abstract Details

Title An Unusual Case of Multiple-Ring-Enhancing Lesions on Brain MRI in Varicella Zoster Virus Encephalitis

Topic Infectious Disease

Presentation(s) P4 - Poster Session 4 (5:30 PM-6:30 PM)

Poster/Presentation
Number 4-013

Objective To report a case of varicella-zoster-virus (VZV) encephalitis in a HIV patient with multiple-ring-enhancing lesions on brain MRI.

Background Multiple-ring-enhancing lesions on brain MRI in HIV are common in toxoplasmosis, tuberculomas, and primary CNS lymphoma, but no reports have been described in VZV encephalitis, which is predominantly a vasculopathy. Ischemic/hemorrhagic infarcts secondary to VZV vasculopathy present as focal neurological deficits and appear as cortical/sub-cortical lesions at the gray-white matter junction on brain MRI.

Design/Methods We reviewed clinical and radiographic reports of our patient. We searched PubMed for literature using terms: MRI & varicella zoster encephalitis and stroke & varicella zoster encephalitis.

Results Fifty-year-old male with HIV, on HAART, presented with generalized-tonic-clonic seizure and post-ictal right-sided-weakness. Patient was loaded with Levetiracetam. No rashes noted. Labs revealed pancytopenia, CD4-8, viral load-102,491. Brain MRI demonstrated multiple-ring-enhancing lesions in bilateral cerebral hemispheres and pons. Toxoplasma serum IgM/IgG negative. CSF analysis revealed WBC-1, RBC-8, glucose-51, protein-68. PCR negative for HSV, EBV, JC virus, cryptococcus, toxoplasma, and enterococci; positive for VZV. Acyclovir was initiated. Repeat CSF analysis and MRI after therapy revealed VZV clearance and significant interval decrease in ring-enhancing lesions, respectively. Patient refused brain biopsy. Patient was discharged on maintenance acyclovir therapy with no recurrences. Searching terms, MRI & varicella zoster encephalitis on PubMed yielded 141 results; nil found ring-enhancing lesions on brain MRI.

Conclusions Multiple-ring-enhancing lesions in VZV encephalitis is an unusual radiographic finding, easily misdiagnosed for toxoplasmosis/tuberculomas due to “framing effect.” Clinicians will likely frame their judgement on “multiple-ring-enhancing” lesions rather than explore other accompanying symptoms. While seizures are common, VZV encephalitis should be included in the differential for HIV patients with focal neurological deficits. Typical rash several months prior to neurological symptoms may be a subtle clue, but not always. Being cognizant of atypical VZV manifestations can lead to timely diagnosis and improve neurological outcomes through early antiviral therapy.

Authors/Disclosures
Tasneem F. Hasan, MD (Tasneem F Hasan MD PC) PRESENTER	Dr. Hasan has nothing to disclose.
Hunaid Hasan, MD	No disclosure on file
	No disclosure on file
	No disclosure on file
	No disclosure on file

��ɫ��

��ɫ��