Definition and management of varicella zoster virus-associated meningoradiculitis: a case report

Abstract

BackgroundThe varicella zoster virus affects the central or peripheral nervous systems upon reactivation, especially when cell-mediated immunity is impaired. Among varicella zoster virus-related neurological syndromes, meningoradiculitis is an ill-defined condition for which clear management guidelines are still lacking. Zoster paresis is usually considered to be a varicella zoster virus-peripheral nervous system complication and treated with oral antiviral therapy. Yet in the literature, the few reported cases of herpes zoster with mild cerebral spinal fluid inflammation were all considered meningoradiculitis and treated using intravenous antiviral drugs, despite absence of systemic signs of meningitis. Nevertheless, these two clinical pictures are very similar.Case presentationWe report the case of an alcohol-dependent elderly Caucasian man presenting with left lower limb zoster paresis and mild cerebral spinal fluid inflammation, with favorable outcome upon IV antiviral treatment. We discuss interpretation of liquor inflammation in the absence of clinical meningitis and implications for the antiviral treatment route.ConclusionFrom this case report we suggest that varicella zoster virus-associated meningoradiculitis should necessarily include meningitis symptoms with the peripheral neurological deficits and cerebral spinal fluid inflammation, requiring intravenous antiviral treatment. In the absence of (cell-mediated) immunosuppression, isolated zoster paresis does not necessitate spinal tap or intravenous antiviral therapy.

Varicella Zoster aseptic meningitis: Report of an atypical case in an immunocompetent patient treated with oral valacyclovir

“…Reactivated VZV can cause wide varieties of neurologic diseases [ 4 , 12 ], including aseptic meningitis even in otherwise healthy and immunocompetent patients. There are reports of several cases where patients with no rash were diagnosed with VZV meningitis.…”

Herpes zoster‐associated paresis of the left arm

“…Despite this, there was no significant improvement in the weakness (Fig. ), supporting the nonsuperiority of IV vs. oral aciclovir treatment for zoster associated limb paresis . The role of corticosteroids in this regard remains unclear .…”

“…Although HZ primarily affects the sensory nervous system, HZ‐associated limb paresis has been recognized as a neurological complication of HZ . It is characterized by a focal, asymmetrical motor weakness, frequently corresponding to the segmental distribution of sensory symptoms .…”

“…To determine the neurological complications of HZ and consequently the adequacy of treatment, a multistep diagnostic approach has been suggested, comprising (i) clinical symptoms, (ii) VZV detection by real‐time PCR in skin lesions and CSF, (iii) identification of intrathecal and serum anti‐VZV antibodies, (iv) imaging (CT, MRI) and (v) electrophysiological studies . CSF inflammation should not be used as a single discriminating criterion between peripheral nervous system (PNS) and central nervous system (CNS) complications of VZV, as mild CSF inflammation is reported in up to 50% of patients with HZ . While the recommendation of IV treatment with aciclovir 10–15 mg/kg every 8 h for 14–21 days is unanimous for CNS complications of VZV, there is no consensus regarding treatment of PNS complications.…”