Varicella Zoster Virus Myelitis in Two Elderly Patients: Diagnostic Value of Nested Polymerase Chain Reaction Assay and Antibody Index for Cerebrospinal Fluid Specimens

Abstract

Background: Myelitis is one of the rarest neurological complications of the varicella zoster virus (VZV) infection. Focal muscle weakness with or without sensory disturbance occurs in approximately 5% of the cases after acute VZV infection, with complete recovery in 50-70%. Case Presentation: This report describes two rare cases of elderly patients with VZV myelitis secondary to dermatomal zoster rash. Patient 1 was a 79-year-old woman who developed paraplegia, numbness and decreased sensation in the left arm and below thoracic (Th)-10 after sacral zoster. Spinal cord MRI showed a high-signal-intensity lesion at the cervical spinal nerve 2 on a T₂-weighted image. Patient 2 was a 73-year-old man who developed right flaccid leg weakness and urinary retention after right dorsal Th 5-8 zoster. Spinal cord MRI showed a high-signal-intensity lesion at Th 3-4 on a T₂-weighted image. In both cases, although the conventional single polymerase chain reaction (PCR) assays all showed negative results, the original nested PCR assay detected VZV DNA in the cerebrospinal fluid (CSF) specimen collected on admission. In addition, the anti-VZV IgG antibody by enzyme immunoassay and antibody index were elevated in the CSF specimens during the clinical courses of both patients. On the basis of these findings, both patients were diagnosed with VZV myelitis and were treated with high-dose acyclovir and corticosteroid. This combined treatment was appropriate and effective for the improvement of their functional outcomes. Conclusion: The detection of VZV DNA in CSF by nested PCR assay and the evaluation of the antibody index to VZV had significant diagnostic value.

A Case of Transverse Myelitis Caused by Varicella Zoster Virus in an Immunocompetent Older Patient

“…In these patients, VZV myelitis may occur without typical skin lesions and can occur far different level of skin lesion [411]. By contrast, in immunocompetent patients, VZV myelitis has a typical presentation (dermatomal rashes followed by myelitis at the corresponding level) and good outcomes [1411]. However, our patient showed an atypical presentation, characterized by generalized and disseminated eruptions on the body.…”

“…Myelitis and encephalitis due to VZV reactivation are more common in immunocompromised patients [1]. In these patients, VZV myelitis may occur without typical skin lesions and can occur far different level of skin lesion [411]. By contrast, in immunocompetent patients, VZV myelitis has a typical presentation (dermatomal rashes followed by myelitis at the corresponding level) and good outcomes [1411].…”

“…The detection of VZV antibodies and VZV DNA in CSF are confirmatory diagnostic tests [111213]. However, Rosenfeld et al reported that patients showed clinical signs of severe VZV myelitis, although the VZV antibody tests and PCR results for VZV DNA were all negative [12].…”

“…Our case and some other cases reported previously also support the advantages of early antiviral treatment for VZV myelitis. We did not use corticosteroids because the additional benefit of the steroid was not clear although the combination of high-dose acyclovir and corticosteroids have shown a good prognosis in previous case reports [11]. …”

Post‐Herpes zoster myelitis in a very old patient: A complication not to be missed

“…First, to our knowledge, the present patient is the oldest case of VZV myelitis ever reported. 1,2 Despite the unfavorable combination of a very old patient and a diagnosis delay, the outcome was positive. Second, as it has frequently been described in the literature, VZV DNA detection in CSF was negative in the present case.…”