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Proceedings SNO “Percorsi clinici in Neuroscienze”

Case report V SESSIONE
“PERCORSI CLINICI COMPLESSI”

Acute myelitis associated with Zoster sine herpete:
a case report

A. CAVALLINI, E. COLOBERTI, M.G. CUZZONI, F. DENARO, R. INFANTE,
E. LEUCI, A. PERSICO, P. POSTORINO, C. RASCUNÀ, R. TELESE, P. TOSI

Stroke Unit, IRCCS “Casimiro Mondino” Foundation, Pavia, Italy

INTRODUCTION progressive right leg weakness with difficulty ambu-
lating. Seven days later, he was unable to walk unas-
Primary infection with Varicella-Zoster virus causes sisted, requiring bilateral support during deambula-
an erythematous-vesicular eruption involving espe- tion. At the beginning, it was supposed an orthopedic
cially face and trunk, known as varicella (chicken- condition and the patient underwent knee radiograph,
pox). After acute phase, VZV became latent in re- resulted to be negative for both fracture and signifi-
gional sensory ganglia, where T-cell-mediated im- cant diseases. Thus, upon suspicion of sciatic nerve
mune response plays a central role in controlling injury, neurologist was asked for advice.
VZV infection and limiting viral reactivation. On neurological examination, there was muscle
VZV reactivation classically involves immunocom- weakness in the right iliopsoas (4/5), quadriceps
promised patients, resulting in a painful unilateral femoris (4/5), tibialis anterior (2/5), extensor digito-
vesicular rash with a dermatomal distribution (Herpes rum longus (2/5) and gastrocnemius (3/5). The knee
zoster, also known as shingles). Nevertheless, VZV and ankle reflexes were markedly hyperactive in right
could spread from sensory ganglia to neuraxis, lead- leg, with clonus. Right plantar response was extensor.
ing to both central and peripheral nervous system There were no sensory abnormalities but subjective
complications, with or without rash preceding neuro- dysaesthesia was reported in right submammary re-
(1)
logic involvement (Zoster sine herpete ZSH) . gion. Support was needed to stand up from a seated
We report the case of an immunocompetent patient position and during ambulation, with paretic right
presenting at emergency department of San Matteo leg.
Hospital with a myelopathy due to VZV, in the ab- Routine laboratory tests were normal. The MRI of the
sence of skin lesions (ZSH). spinal cord revealed an intramedullary lesion in the
dorsal region (D3-D4) (Figure 1). Cerebrospinal flu-
id showed normal count cell, with increased
CASE REPORT CSF/serum albumin ratio (1.4%), high CSF IgG (6
mg/dL) and oligoclonal bands with pattern type 3,
In September 2021, a 87-year-old man presented with consistent with a blood-brain barrier disruption and
a 10-days history of dysesthesia in right submamma- intrathecal synthesis (Table 1).
ry region. Over the next three days, he developed a Quantitative PCR eventually revealed VZV-DNA (80

Corrispondenza: Dr.ssa Cristina Rascunà, Stroke Unit, Istituto Neurologico “C. Mondino”, via Mondino 2, 27100 Pavia (PV), tel. +39-
(0)382-3801, e-mail: cristina.rascuna@mondino.it
Percorsi clinici in Neuroscienze. Clinical Round SIN e SNO Lombardia, 21 gennaio 2022, Desio (Monza e Brianza)
Atti a cura di Paolo Ferroli, Alessandra Protti, Andrea Salmaggi, Ignazio Michele Santilli, Luca Valvassori
Copyright © 2022 by new Magazine edizioni s.r.l., Trento, Italia. www.newmagazine.it ISBN: 978-88-8041-135-2

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