Case Presentation: A 74-year-old male with a past medical history of Coronary Artery Disease, Hypertension, and Type 2 Diabetes Mellitus initially presented with a 5-day history of left-sided upper extremity weakness and paresthesia starting in his hand radiating to his shoulder. He denied any lower extremity weakness, incontinence, fevers, or chills. He later divulges a history of left forearm vesicles which started 7 days prior and then crusted over with associated severe neuropathic pain. MRI spine demonstrates a C3-C7 cervical spinal cord lesion measuring 0.7 x 0.5 x 5.3 cm concerning for transverse myelitis. Pertinent history includes Varicella infection as a child, and at least one dose of Shingrix vaccine in 2020. He had no prior or current history of malignancy and was up to date with cancer screenings. On physical exam, patient was alert and oriented to person, place, and time. Patient was afebrile with blood pressure 136/66, heart rate 63, respiratory rate 15, and SpO2 98%. Erythematous plaques were prominent in the C7-8 distribution with associated pain. Neurological exam was significant for weakness with shoulder abduction, elbow flexion, and extension as well as weakness with hand grip strength. Lastly, exam noted diminished bicep deep tendon reflexes. Pertinent labs include white blood cell count of 11.5 K/mcL (4.50-11.00 K/mcL), erythrocyte sediment rate of 60 mm/hr (0-20 mm/hr), C-reactive protein of 40.8 mg/L (0-10 mg/L). Varicella Zoster IgM and IgG were positive. HSV PCR, HIV, Syphilis, and other autoimmune work up were negative. Varicella Zoster Virus (VZV) PCR was positive on skin biopsy. Lumbar puncture yielded an elevated white blood count of 119 mc/L, predominantly lymphocytic, with a positive VZV PCR on CSF studies. Treatment of Zoster myelitis with acyclovir for 21 days and IV steroids for 10 days was initiated by Infectious Disease. The patient was discharged to a rehabilitation facility on a prednisone taper with improving symptoms.
Discussion: This is a unique case of longitudinally extensive transverse myelitis (LETM) from Varicella Zoster (VZV) in an immune-competent host. While posthepatic neuralgia is a common neurological complication of Herpes Zoster (HZ) infection, other rarely recognized complications include VZV meningitis/encephalitis as well as transverse myelitis. A predominant number of case reports of VZV-TM have been seen in immune-compromised or elderly hosts (>80 years old) (2). Varicella-Zoster Myelitis or HZ myelitis is an uncommon manifestation that has an incidence of 0.3% and even less so in patients who are not immunocompromised or elderly (2,3). Furthermore, the presentation of LETM occurring in parallel with VZV infection is also unique in this case. HZ myelitis usually presents after approximately 2 weeks of initial zoster vesicular rash (2). VZV-LETM must be diagnosed early, by magnetic resonance imaging and/or cerebrospinal fluid analysis. Delayed intervention can lead to serious complications and neurological decline.
Conclusions: It’s important to anticipate neurological complications like Transverse Myelitis in individuals that have evidence of disseminated Herpes Zoster and include it on the differential along cranial nerve palsies and encephalitis.