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. 2018 May 25;18(1):238.
doi: 10.1186/s12879-018-3137-2.

Varicella zoster virus infections in neurological patients: a clinical study

Thomas Skripuletz  1 , Kaweh Pars  2 , Alina Schulte  2 , Philipp Schwenkenbecher  2 , Özlem Yildiz  2 , Tina Ganzenmueller  3 , Maike Kuhn  4 , Annette Spreer  5 , Ulrich Wurster  2 , Refik Pul  2   6 , Martin Stangel  2 , Kurt-Wolfram Sühs  2 , Corinna Trebst  2
Affiliations

Varicella zoster virus infections in neurological patients: a clinical study

Thomas Skripuletz et al. BMC Infect Dis. .

Abstract

Background: Varicella zoster virus (VZV) reactivation is a common infectious disease in neurology and VZV the second most frequent virus detected in encephalitis. This study investigated characteristics of clinical and laboratory features in patients with VZV infection.

Methods: Two hundred eighty two patients with VZV reactivation that were hospitalized in the department of neurology in the time from 2005 to 2013 were retrospectively evaluated. Results from cerebrospinal fluid (CSF) analysis were available from 85 patients.

Results: Trigeminal rash was the most common clinical manifestation, followed by segmental rash, CNS infection, facial nerve palsy, postherpetic neuralgia, and radiculitis. MRI of the brain performed in 25/33 patients with encephalitis/meningitis did not show any signs of infection in the brain parenchyma. Only one patient showed contrast enhancement in the hypoglossal nerve. General signs of infection such as fever or elevated CRP values were found in only half of the patients. Furthermore, rash was absent in a quarter of patients with CNS infection and facial nerve palsy, and thus, infection could only be proven by CSF analysis. Although slight inflammatory CSF changes occurred in few patients with isolated rash, the frequency was clearly higher in patients with CNS infection and facial nerve palsy.

Conclusion: Monosegmental herpes zoster is often uncomplicated and a diagnostic lumbar puncture is not essential. In contrast, CSF analysis is an essential diagnostic tool in patients with skin lesions and cranial nerve or CNS affection. In patients with neuro-psychiatric symptoms and inflammatory CSF changes analysis for VZV should be performed even in the absence of skin lesions.

Keywords: CNS; Cerebrospinal fluid; Herpes zoster; VZV.

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Conflict of interest statement

Ethics approval and consent to participate

The investigation was approved by the Institutional Ethics Committee of the Hannover Medical School. This is a retrospective study and only data were included that were evaluated for patients treatment. Thus, the local ethics committee waived the need for written informed consent from the participants. Patient’s data were de-identified by authors before analysis.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Distribution of 282 patients with varicella zoster virus reactivation. Patients suffered from trigeminal nerve ganglionitis with segmental rash (V1, V1 + V2, V2, or V3), dorsal root ganglionitis with segmental rash (cervical, thoracic, lumbar, sacral region, or a combination of two segments), facial nerve palsy, CNS infection (encephalitis, meningitis, or myelitis), postherpetic neuralgia, and dorsal root ganglionitis with segmental rash and radiculitis with neuronal affection. In the first two groups (trigeminal and dorsal root ganglionitis), patients were included that presented with skin affection only. Patients with skin lesions combined with facial nerve palsy or CNS infection were included in the last two groups in order to avoid double identification
Fig. 2
Fig. 2
Age and gender distribution of varicella zoster virus reactivation in the study population (a-f). The age distribution shows that predominantly patients above the age of 50 peaking in the eight decade of life were diseased. There was no gender difference. Patients with trigeminal root ganglionitis and dorsal root ganglionitis were predominantly diseased and showed skin lesions only (b, c). In five female patients, dorsal root ganglionitis with segmental skin lesions was accompanied by nerve affection due to radiculitis (marked in c). In the CNS infection group patients with encephalitis, meningitis, and myelitis were marked separately (e). The graph E shows that patients with encephalitis were older as compared to patients with meningitis. Graphs show numbers of female and male patients distributed in life decades
Fig. 3
Fig. 3
Distribution of comorbidities in patients with varicella zoster virus reactivation. a shows the distribution of all comorbidities in patients with varicella zoster virus reactivation. b-j illustrate the distribution of comorbidities separately in patients with varicella zoster virus reactivation. Graphs show the percentage frequency of comorbidities
Fig. 4
Fig. 4
Cerebrospinal fluid results in patients with varicella zoster virus reactivation. Graphs show the distribution of cell count (a), lactate (b), and albumin CSF/serum quotients (c). Bars represent median values in each group. Cell count ≥5/μl and lactate ≥3.5 mmol/l were considered elevated. **P < 0.01, ***P < 0.001
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