Case of the Month, December 2018

Submitted by  Charlotte Lansky, MD and Thomas Learch, MD

History of Present Illness 

A 77 yo female with history of hypertension and non-Hodgkin’s Lymphoma status post chemotherapy with disease stabilization presents with progressive left foot weakness and left lower extremity paresthesias. One month prior to presentation, she presented to an urgent care with left-sided low back pain radiating down the left leg. She was diagnosed with sciatica and given a short course of steroids with muscle relaxants. About 1 week later, she returned to the urgent care with a painful left lower extremity vesicular rash along the left L4/L5 dermatomes. Viral cultures of the left leg skin lesions revealed varicella zoster. She was treated for herpes zoster (Shingles) with a 7-day course of valacyclovir. Over the following month, she continued to develop progressive left lower extremity numbness/burning and left foot weakness with recurrent falls.

Physical Exam
  • Vital signs within normal limits.
  •  Skin: Left lower extremity swelling from knee to foot. Multiple crusting, papular lesions on the left lower leg and foot, also involving the sole and heel.
  • Neurologic of left lower leg: ⅘ strength proximally. ⅗ plantarflexion and a flicker of dorsiflexion of the ankle and toes. Sensory changes involving the medial left foot. Diminished DTRs.

Figure 1. Vesicular eruptions along the left lower extremity.

Labs

CSF analysis: A few atypical lymphocytes. “In view of clinical history of zoster, a reactive process is favored, although involvement by patient’s low-grade lymphoma cannot be entirely excluded.”

Imaging

The patient underwent MRI of her lumbar spine.

Figure 2a (above)

Figure 2b (above)

Figure 2c (above)

Sagittal T1 images of the lumbar spine pre-contrast (Figure 2a) and post-contrast (Figure 2b) demonstrate enhancement of the cauda equina. Axial T1 post-contrast image at the level of L2 (Figure 2c) also demonstrates enhancement of the cauda equina on the left side.

Figure 3a (above)

Figure 3b (above)

Axial T1 post-contrast images demonstrated enhancement of the left-sided lumbar dorsal root ganglia. Shown are images at L3-4 (Figure 3a) and L4-5 (Figure 3b).

Diagnosis

Right-sided lumbosacral radiculitis secondary to herpes zoster.

The patient was treated with IV acyclovir for 14 days. By discharge, her lower extremity weakness was improving.

Discussion

Primary infection of varicella zoster virus (VZV) causes varicella (chickenpox), after which the virus becomes latent in ganglionic neurons, including dorsal root ganglia, along the entire neuraxis. The immunocompromised are at increased risk for VZV reactivation, which typically results in herpes zoster (shingles) characterized by dermatomal pain and a vesicular rash. Segmental motor weakness develops in about 3% of cases. Diagnosis is usually made based on the temporal relationship between the rash and neurologic complications. 

References
  • D. T. Blumenthal, K. L. Salzman, J. R. Baringer, B. Forghani, D. H.Gilden. MRI abnormalities in chronic active varicella zoster infection. Neurology Oct 2004, 63 (8) 1538-1539
  • Gilden D, Nagel M, Cohrs R, Mahalingam R, Baird N. Varicella Zoster Virus in the Nervous System. F1000Res. 2015;4
  • Hasan A, Rizvi I, Ashraf K, Meitei SP. Myeloradiculitis: An unusual presentation of herpes zoster in an immunocompromised patient. JIACM 2012; 13(4): 322-3
  • Jazba Soomro, Hesham Allam, Aninda Acharya. Varicella Zoster Virus Lumbar Radiculitis: A Case Report. Neurology Apr 2014, 82 (10 Supplement) P2.307

 

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