An unusual case of vasculitis
G. Offiah, A. Gorman, K. O’Rourke, A. Mohammad
Midlands Regional Hospital Tullamore
Varicella zoster virus (VZV) is a well-known cause of infection in children. After primary infection the virus may remain latent in neurons1. Although uncommon, it may reactivate and manifest as vasculitis/vasculopathy when the virus is reproduced in arteries2.
A 62-year-old immunocompetent male was admitted with a two-day history of intermittent headache, confusion and fever. Romberg’s test was positive, but physical examination was otherwise unremarkable and there was no evidence of a rash. Computed tomography (CT) and magnetic resonance imaging (MRI) of the brain showed non-specific white matter changes in the frontal and occipital lobes. Lumbar puncture revealed a lymphocytic pleocytosis and VZV encephalitis was confirmed by VZV polymerase chain reaction and VZV IgM. He was treated with acyclovir.
After initiation of treatment, he complained of diplopia and right fourth cranial nerve palsy was noted on examination. MRI brain excluded cerebral infarction. Approximately one week later, he developed transient left sided paraesthesia and worsening ataxia. There were no features of worsening encephalitis. Repeat MRI brain confirmed subacute lacunar infarct in the right posterolateral thalamus. He was started on methylprednisolone and aspirin to treat a VZV vasculitis. A one week follow-up MRI angiogram revealed left internal carotid artery dissection and new right frontal and left anterior thalamic infarcts. He subsequently developed chest pain and CT angiogram confirmed pulmonary embolism.
He was treated with a prolonged course of antivirals and steroids for VZV vasculopathy.
Greater than 95% of the world’s population carry latent VZV and half of that cohort will experience reactivation. One third of patients that have developed VZV vasculopathy will not present with a rash3. Thus, it is important to consider VZV infection in immunocompromised patients presenting with cerebral infarction, artery dissection, giant cell arteritis or peripheral thrombosis without any obvious cause.