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Case Reports
. 2022 Oct 1;61(19):2961-2965.
doi: 10.2169/internalmedicine.8413-21. Epub 2022 Mar 5.

Pneumonia and Meningoencephalitis Due to Varicella-zoster Virus Reinfection and Epstein-Barr Virus Reactivation in a Patient with Rheumatoid Arthritis

Noriaki Ito  1   2 , Takeshi Masuda  2 , Kakuhiro Yamaguchi  2 , Shinjiro Sakamoto  2 , Yasushi Horimasu  2 , Taku Nakashima  2 , Shintaro Miyamoto  2 , Hiroshi Iwamoto  3 , Kazunori Fujitaka  3 , Hironobu Hamada  4 , Kazuaki Chayama  5   6   7 , Noboru Hattori  3
Affiliations
Case Reports

Pneumonia and Meningoencephalitis Due to Varicella-zoster Virus Reinfection and Epstein-Barr Virus Reactivation in a Patient with Rheumatoid Arthritis

Noriaki Ito et al. Intern Med. .

Abstract

A 72-year-old woman with rheumatoid arthritis was treated with methotrexate (MTX) and iguratimod. Upon examination of a liver tumor, blisters due to varicella-zoster virus (VZV) infection were observed. Despite oral administration of valacyclovir, she developed varicella pneumonia and meningoencephalitis. A VZV antibody test revealed reinfection. The liver tumor shrank after discontinuance of MTX, and polymerase chain reaction revealed the reactivation of the Epstein-Barr virus (EBV). Therefore, we were unable to deny MTX-associated lymphoproliferative disorder (MTX-LPD). This is the first case of a complication of pneumonia and meningoencephalitis due to VZV reinfection and EBV reactivation.

Keywords: Epstein-Barr virus; meningoencephalitis; pneumonia; rheumatoid arthritis; varicella.

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Conflict of interest statement

The authors state that they have no Conflict of Interest (COI).

Figures

Figure 1.
Figure 1.
Chest computerized tomography (CT) performed on the fifth hospital day showing multiple nodular shadows and ground-glass shadows.
Figure 2.
Figure 2.
Clinical course of the case. ACV: acyclovir, ABPC/SBT: ampicillin/sulbactam, CRP: C-reactive protein, CSF: cerebrospinal fluid, FiO2: fraction of inspiratory oxygen, MTX: methotrexate, PCR: polymerase chain reaction, VACV: valacyclovir, VCM: vancomycin, VZV: varicella-zoster virus
Figure 3.
Figure 3.
Magnetic resonance image performed on the 57th hospital day showing hyperintensity (arrows) at the bilateral posterolateral medulla oblongata and cerebellar peduncle on (a) T2-weighted and (b) diffusion-weighted imaging.
Figure 4.
Figure 4.
Abdominal computed tomography (CT) with contrast performed (A) at the first visit and (B) on the 43rd hospital day showing shrinkage of the liver tumor (arrows).
See this image and copyright information in PMC

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