Acute Herpes Zoster Radiculopathy of the Lower Extremity With Dermatomal Rash and Lumbar Nerve Enhancement on MRI

Abstract

Herpes zoster is a frequent cause of neuralgia and dermatomal vesicular rash secondary to reactivation of latent varicella zoster virus. However, it rarely presents with acute lumbar radiculopathy and the diagnosis can be quite challenging in such cases. Nerve signal abnormalities on magnetic resonance imaging are well recognized in herpes zoster neuropathy or plexopathy affecting the extremities, although gadolinium enhancement is characteristically absent. In this article, we describe a case of acute herpes zoster lumbosacral radiculopathy with characteristic vesicular dermatomal rash and second ever reported finding of gadolinium enhancement of the lumbar nerve on magnetic resonance imaging.

Prevesicular herpes zoster lumbar radiculopathy with transient motor paresis

“…His MRI findings were unremarkable at presentation. Bhushan et al [ 1 ] reported acute lumbar herpes zoster radiculopathy with MRI enhancement to the L5-DRG and the nerve root; however, their patient did not present corresponding motor weakness on L5/S1 myotome. Changa and Jain [ 7 ] reported a case of a patient with posteruption herpes zoster radiculitis accompanied by motor weakness and MRI enhancement along the extraforaminal nerve root.…”

“…Motor nerve root involvement has been suggested to cause motor weakness. [ 1 , 10 ] An increasing number of herpes zoster radiculopathy cases have been reported in the past. [ 2 ] A selective nerve root block injection may help relieve radiculopathy symptoms.…”

Acute herpes zoster radiculopathy mimicking cervical radiculopathy after ChAdOx1 nCoV-19/AZD1222 vaccination

“…Herpes zoster (otherwise known as shingles) results from reactivation of latent zoster infection in the sensory ganglia and its incidence increases with age and immunosuppression. On reactivation, the virus spreads resulting in neuritis, with or without a vesicular rash in the corresponding dermatome 2. Zoster radiculopathy is thought to be an extension of the neuritis from the sensory ganglion into the peripheral motor neurons 3…”

“…The pattern of weakness in zoster radiculopathy is similar to that of spinal radiculopathy, thus the diagnosis is often mistaken as the latter. Vesicular erythematous skin rash of shingles and associated neuralgia are often major clues to the diagnosis, which can be easily overlooked 2. This report presents a case of an older man who presents with unilateral upper limb weakness in C5–C6 distribution, which occurs 3 days after SARS-CoV-2 vaccination and preceded the onset of vesicular rash.…”

Zoster neuritis of lumbar nerves: A clinical, magnetic resonance imaging, and electrodiagnostic evaluation

“…[ 8 ] reviewing MR imaging findings of seven patients with zoster-associated limb paresis (ZALP) found that there was an increased nerve T2 signal with nerve root enlargement, however, none of their patients showed the expected nerve root enhancement. The latter was seen in our patient and also in a case reported by Bhushan et al .,[ 9 ] wherein the patient had the involvement of L5–S1 dermatome and the MRI demonstrated enlargement, T2 hyperintensity, and enhancement of L5 dorsal root ganglion and nerve root. They also noted that so far there are only two other such cases of nerve root enhancement due to zoster involvement, making ours the fourth such case.…”