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Proceedings SNO “Percorsi clinici in Neuroscienze”

vation of VZV, such as encephalitis, meningitis, cere-
bellitis, cranial polyneuritis, cerebral vasculopathy,
peripheral motor neuropathy, necrotizing retinitis,
herpes-zoster oticus, herpes-zoster ophthalmicus and
(1)
myelopathy . Neurological complications may fol-
low also ZSH and, interestingly, it has been reported
that VZV myelitis develops without a rash more fre-
quently in immunocompetent patients than in im-
munocompromised patients .
(2)
Thus, for the diagnosis of Herpes-Zoster and, even
more, of ZSH, virological confirmation is mandatory.
Up to date, the most useful instruments to diagnose
VZV infection are quantitative and qualitative PCR,
for the detection of VZV-DNA, and ELISA, for the
detection of VZV-IgM and IgG antibody. However,
also at the beginning of VZV infection, CSF VZV-
IgM antibody is not as sensitive as IgG and it may re-
sult negative. Thus, up to date, current guidelines rec-
ommend that CSF should be analysed for both VZV-
DNA and anti-VZV IgG antibodies in suspected VZV
(3)
infection .
Figure 1. Sagittal T2-MRI showing intramedullary lesion in the
dorsal region (D3-D4). Prompt therapy is crucial in VZV infection and an-
tiviral treatment must be started within 72 hours from
the onset of cutaneous rash. Nevertheless, ZSH may
copie/ml). CSF-PCR was negative for HSV-1, HSV- be missed and misdiagnosed just due to absence of
2, CMV and EBV DNA (Table 2). skin lesions, leading to recurrent infection and possi-
Antiviral treatment with acyclovir was started (500 ble VZV dissemination to CNS with potentially fatal
mg three times a day, adjusted by renal function) and complications . Thus, it is extremely important to
(3)
a progressive improvement in muscular weakness keep in mind the following three key words: early
was observed. Patient was admitted to rehabilitation “suspicion”, “diagnosis” and “treatment”.
department to continue rehabilitative therapy. Finally, it is useful to remember that current guide-
lines from the ACIP recommend a routine single dose
of zoster vaccine for adults aged 60 years and older,
(4)
DISCUSSION to prevent herpes zoster and postherpetic neuralgia .
We report a case of myelopathy due to VZV without
skin lesions, known as ZSH. Clinical suspicion of REFERENCES
myelopathy arose for the presence of right truncal
dysesthesia along with weakness and upper motor 1. Lynch K, Agarwal P, Paranandi A, Hadley S, Vullaganti
M. Extensive VZV Encephalomyelitis without rash in an
neuron signs in the right leg. Dorsal myelopathy was
elderly man. Case Rep Neurol Med 2014: 694750.
attributed to ZSH based on the detection of CSF
VZV-DNA using quantitative PCR analysis, along 2. Hung CH, Chang KH, Kuo HC, Huang CC, Liao MF, Tsai
YT, Ro LS. Features of varicella zoster virus myelitis and
with high level of CSF IgG and OCBs pattern type 3,
dependence on immune status. J Neurol Sci 2012; 318 (1-
consistent with intrathecal synthesis. 2): 19-24.
Typically, VZV reactivation involves immunocom-
3. Zhou J, Li J, Ma L, Cao S. Zoster sine herpete: a review.
promised patients, leading to painful and unilateral
Korean J Pain 2020; 33 (3): 208-215.
vesicular rash in a dermatomal or cranial nerve distri-
4. Oxman MN, Levin MJ; Shingles Prevention Study
bution. CNS and PNS involvement are rare but sev-
Group. Vaccination against Herpes Zoster and postherpet-
eral neurologic complications may follow the reacti- ic neuralgia. J Infect Dis 2008; 197 (Suppl 2): S228-236.

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