A 27-year-old man with HIV/AIDS was directly admitted to the hospital by his infectious disease specialist for worsening and recurrent headaches accompanied by a multitude of episodic neurologic symptoms, including off-balance sensations, left arm numbness and tingling, left-sided decreased hearing, and slurred speech. He had a history of shingles five months prior which was treated with acyclovir and then valaciclovir. The shingles recurred two months later and he was again treated with valaciclovir. Magnetic resonance imaging of his brain showed multifocal punctate lesions in the right frontal and insular areas concerning for acute ischemia. The radiologist also noted concern for vasculitis given the appearance of the lesions. Lumbar puncture was unremarkable for acute infection. Magnetic resonance angiography of the brain with vasculitis protocol showed enhancement of right and left middle cerebral arteries as well as right anterior cerebral artery compatible with vasculitis. It confirmed that the earlier infarcts on the initial magnetic resonance imaging were due to vasculitis. Cerebrospinal fluid was tested for varicella zoster immunoglobulin G, which was positive, and varicella zoster virus polymerase chain reaction, which was positive with 900 DNA copies detected, thus confirming the diagnosis of varicella zoster vasculitis. The patient was treated with acyclovir and high-dose steroids, with subsequent improvement in his balance, hearing, and headache.
Varicella zoster virus can produce a vasculopathy that classically presents as ophthalmic distribution zoster followed by ischemic stroke with contralateral hemiparesis. However, it can also present as hemorrhagic stroke, aneurysm, ectasia, or dissection. It can also vary widely in symptom presentation, causing headaches, mental status changes, vision loss, ataxia, and aphasia. The risk of stroke is greatest within three months after herpes zoster infection, especially those in the ophthalmic distribution. The diagnosis of varicella zoster vasculitis as the etiology of an acute ischemic stroke is often not considered in the elderly population because the incidence of both varicella zoster and stroke are independently more common after age 60.
This case emphasizes the importance of considering varicella zoster vasculitis in a patient with stroke (or subacute to chronic and remitting neurologic symptoms) and recent shingles infection. Providers must be aware of varicella zoster, especially in an older patient with acute stroke and a history of shingles, in order to begin prompt treatment to reduce morbidity and mortality.