Recurrent varicella zoster virus myelopathy

Abstract

Myelopathy is an uncommon complication of VZV infection and may develop in the absence of rash. We report the rare recurrence of myelopathy in an immunocompetent adult who initially developed myelopathy after ophthalmic-distribution zoster. Recurrent myelopathy two years later caused by VZV was verified by the presence of new-onset clinical symptoms and signs consistent with myelopathy, new lesions in the spinal cord detected by MRI, and evidence of intrathecal synthesis of anti-VZV IgG antibody in CSF. After virological verification and antiviral therapy, myelopathy did not recur and anti-VZV IgG antibody could not be detected in CSF. In contrast to earlier cases of recurrent VZV myelopathy in immunocompetent adults that developed weeks to months after the first episode of myelopathy, this is the first instance of recurrence years later.

Fig. 1

T2- and enhanced T1-weighted sagittal images of the cervical spine. In 2004, there was high T2 signal in the cord at the cervico-medullary junction and C4-5 (a, arrows) and at C7-T1 (b). The lesion at C7-T1 enhanced (c). In 2005, the T2 signal abnormalities significantly improved (d,e) and enhancement resolved (f). In 2006, there was recurrence of high T2 signal in the spinal cord especially at C2 (g,h) and at C6-7 (g), without enhancement (i).

Fig. 2

T2 axial images at the level of C2 and C7-T1 showing abnormal high signal in the spinal cord on the left at C2 (a) and right at C7-T1 (b). These areas nearly resolved in 2005 (c,d). In 2006, there was recurrent cord signal abnormality bilaterally at C2 (e) and left at C7-T1 (f).