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Longitudinally Extensive Varicella-Zoster Virus Myelitis in a Patient With Multiple Sclerosis

Cuello, Juan Pablo MD*; Romero, Julia MD; de Ory, Fernando PhD; de Andrés, Clara MD*

doi: 10.1097/BRS.0b013e31829ecb98
Case Report

Study Design. Case report.

Objective. To report this rare varicella-zoster virus (VZV) complication in a patient with multiple sclerosis.

Summary of Background Data. Longitudinally extensive transverse myelitis is a spinal cord lesion that extends over 3 or more vertebral segments. A common feature in neuromyelitis optica, longitudinally extensive transverse myelitis can also occur in several other diseases.

Methods. A 15-year-old boy with relapsing-remitting multiple sclerosis, who has been treated with immunomodulators for 6 months, developed a subacute left brachiocrural hemiparesis with ipsilateral decreased sensation in the trunk and limbs. This was interpreted as a new relapse and was treated consequently. During the evolution, the patient developed a cutaneous rash in the left C8 metameres, followed by asymmetric tetraparesis.

Results. Magnetic resonance imaging demonstrated an extensive cervical-thoracic myelopathy. Cerebrospinal fluid analysis revealed 17 leukocytes per microliter (95% mononuclear), protein 41 mg/dL, and negative VZV-DNA by polymerase chain reaction, but elevated anti-VZV immunoglobulin G cerebrospinal fluid/serum index, with a normal albumin cerebrospinal fluid/serum index, all of which were consistent with intrathecal synthesis of anti-VZV antibody. We were able to rule out all other causes included in the differential diagnosis, namely, vascular disease, tumor, and autoimmune conditions, especially those associated with neuromyelitis optica spectrum disorders.

Conclusion. Awareness of the potentially varied presentation of VZV myelitis can enable earlier recognition and specific treatment.

A patient with multiple sclerosis developed a subacute left brachiocrural hemiparesis with ipsilateral decreased sensation. This was interpreted and treated as a new relapse. During the evolution, he developed a cutaneous rash in the left C8 metameres, followed by asymmetric tetraparesis. Diagnosis workout confirmed infectious myelitis by varicella-zoster virus.

From the Departments of *Neurology; and

Radiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; and

Serology Section, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain.

Address correspondence and reprint requests to Juan Pablo Cuello, MD, Department of Neurology, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; E-mail: juancuelloneuro@gmail.com

Acknowledgment date: March 5, 2013. Revision date: April 21, 2013. Acceptance date: June 1, 2013.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

No relevant financial activities outside the submitted work.

© 2013 by Lippincott Williams & Wilkins