Recurrent polymorphonuclear pleocytosis with increased red blood cells caused by varicella zoster virus infection of the central nervous system: Case report and review of the literature

Abstract

We describe an immunocompetent 45-year-old woman who had four episodes of neurological disease (meningoencephalitis, multifocal vasculopathy, myelitis and inflammatory brain stem disease) produced by varicella zoster virus (VZV) over an 11-month period, all in the absence of rash. The cerebrospinal fluid (CSF) contained anti-VZV IgG antibody, but not VZV DNA throughout her illness, reaffirming the superiority of detection of anti-VZV IgG in CSF compared to VZV DNA in diagnosing VZV infection of the nervous system. Moreover, 3 of 7 CSF samples examined during the 11 months showed a VZV-induced pleocytosis consisting predominantly of polymorphonuclear cells (PMNs), and 4 of 7 samples also contained increased numbers of red blood cells (RBCs). Because increased PMNs and RBCs in CSF can also occur in patients with central and peripheral nervous system disease produced by cytomegalovirus (CMV), the differential diagnosis of chronic nervous system infection with increased PMNs and RBCs in CSF should include analyses for both VZV and CMV.

Fig. 1

MRI brain, T2 Flair axial. (A) Posterior hemispheric swelling and increased signal involving the left medial-occipital gyrus. (B) Gyriform swelling and increased T2 signal involving the right parasagittal parietal and occipital gyri. Left frontal lobe signal is scarring from previous biopsy.

Fig. 2

MRI cervical spine. (A) Sagittal T2 fast-recovery fast-spin echo sequence: abnormal T2 hyperintense signal and expansion involving the medulla and entire cervical spinal cord. (B) Sagittal T1 Flair post-contrast: abnormal leptomeningeal enhancement.