Abstract Details

Title A Case of Infectious and Para-infectious Herpes Simplex Virus and Varicella Zoster Virus Radiculomyelitis

Topic Neuromuscular and Clinical Neurophysiology (EMG)

Presentation(s) P2 - Poster Session 2 (11:45 AM-12:45 PM)

Poster/Presentation
Number 9-014

Objective Herpes Simplex Virus (HSV) and Varicella Zoster Virus (VZV) can rarely cause a radiculomyelitis. Here we present a patient with HSV and VZV central nervous system (CNS) co-infection.

Background NA

Design/Methods NA

Results A 77-year-old male with myasthenia gravis (MG) (acetylcholine-receptor antibody positive on pyridostigmine, prednisone, mycophenolate, and monthly intravenous immunoglobulin (IVIg)) presented with three weeks of progressive bilateral lower extremity weakness and paresthesias. Initial examination showed proximal leg weakness worse on the left, sensory loss in a distal to proximal gradient, and lower limb hyporeflexia. Initial cerebrospinal fluid (CSF) analysis showed xanthochromia, protein 273, white blood cell (WBC) 60 (49% neutrophils, 28% lymphocytes), red blood cell (RBC) 36, and positive HSV2 and VZV PCR. MRI showed C5-6 cord hyperintensity, central and dorsal thoracic patchy longitudinally-extensive hyperintensities, and cauda equina enhancement. Skin examination revealed scattered umbilicated crusted papulovesicles, and PCR analysis demonstrated disseminated VZV and genital HSV2. Initial treatment was three weeks of acyclovir and scheduled IVIg, however symptoms progressed to near paraplegia. Hospital course was complicated by encephalopathy, urinary tract infection, and kidney injury. MRI brain two weeks after presentation showed minimal intraventricular hemorrhage. Patient developed signs of myasthenic crisis requiring intubation and five sessions of plasma exchange. Repeat MRI spine showed progression of thoracic spine hyperintensities and continued cauda equina enhancement. Repeat CSF analysis showed xanthochromia, protein 535, WBC 266 (17% neutrophils, 78% lymphocytes), RBC 38,000, and negative HSV2 and VZV PCR. Given concern for para-infectious process, patient was treated with five days of intravenous steroids and IVIg with mild symptom improvement.

Conclusions Our patient presented with HSV and VZV radiculomyelitis co-infection and disseminated skin lesions while immunocompromised. This triggered a myasthenic crisis responsive to plasma exchange; however, his lack of improvement suggests an additional para-infectious process. This case highlights the importance of thorough workup and examination, including skin, in immunocompromised patients.

Authors/Disclosures
Shlok Sarin, MD PRESENTER	Dr. Sarin has nothing to disclose.
Ibrahim M. Alkhodair, MBBS (121 Larchmere Apartments)	Dr. Alkhodair has nothing to disclose.
Rui T. Tang, MD	Mr. Tang has nothing to disclose.
Sarah Venus, MD, PhD (Case Western Reserve University)	Ms. Venus has received research support from NIH National Cancer Institute.
Michel Boustany, MD	Mr. Boustany has nothing to disclose.
Alexander Lewis, DO (University Hospitals Cleveland Medical Center)	Dr. Lewis has nothing to disclose.
Kamal R. Chemali, MD (University Hospitals Cleveland Medical Center)	Dr. Chemali has received personal compensation in the range of $500-$4,999 for serving as a Consultant for CSL Behring. Dr. Chemali has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for CSL Behring. The institution of Dr. Chemali has received research support from Sjögren's Foundation. The institution of Dr. Chemali has received research support from NIH.
Patrick Fagan, MD (University Hospitals)	Dr. Fagan has nothing to disclose.
Komal Sawlani, MD	Dr. Sawlani has nothing to disclose.

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