To report a case and substantiate the association of Longitudinally Extensive Transverse VZV myelitis with hemorrhagic conversion. 

Longitudinally Extensive Transverse Myelitis is caused by a variety of etiologies including infectious agents. Primary hemorrhagic myelitis and hemorrhagic conversion of myelitis are rare entities but have been reported in association with viral infections including varicella zoster virus (VZV) and Herpes Simplex Virus-2. We report a case of cervical VZV myelitis with hemorrhagic conversion in an immunocompromised patient. 

A 56-year-old woman with a history of untreated acquired immunodeficiency syndrome (CD4+ 77) presented with right arm numbness and weakness. The physical exam was notable for right appendicular weakness, loss of vibration and proprioception to the collar, and left-sided loss of pinprick and light touch-up to the collar bone. A cervical spine MRI showed an abnormal signal diffusely throughout the cervical spinal cord with enhancement at C4/C5. CSF studies were notable for VZV infection by PCR. She was started on IV Acyclovir with improvement in her motor function. Three weeks later, she had acute worsening of right upper extremity weakness, and repeat imaging showed hemorrhagic myelitis. There was mild functional improvement after five days of high-dose IV methylprednisolone and ten days of IV acyclovir. 

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To our knowledge, there are less than 5 reported cases of hemorrhagic VZV myelitis. Our case substantiates the previously reported albeit rare association of VZV hemorrhagic myelitis and highlights that hemorrhagic conversion should be considered even in the subacute phase of illness. As with previous cases, our patient did not achieve significant clinical improvement with steroids.