Clinical Picture
Disseminated varicella zoster virus encephalitis Wanxing Chai, Michael Gong-Ruey Ho Lancet 2014; 384: 1698 Published Online July 4, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60755-8 Lahey Hospital and Medical Center , Tufts University School of Medicine, Burlington, MA, USA (W Chai MD) and Carney Hospital, Tufts University School of Medicine, Boston, MA, USA (M G-R Ho MD) Correspondence to: Dr Wanxing Chai, Lahey Hospital and Medical Center, Tufts University School of Medicine, 41 Mall Road, Burlington, MA 01805, USA [email protected]
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A 33-year-old homeless woman presented to the emergency room in September, 2012, with 2 days of dry cough, dyspnoea, and fever, and 1 week of pruritic rash. On examination she had a temperature of 41·0°C, blood pressure of 98/65 mm Hg, heart rate of 85 bpm, respiratory rate of 16 bpm, and O₂ saturation of 47% on room air. She had a diffuse papular rash with vesicles of different ages with haemorrhagic crust affecting the trunk, extremities, face, and scalp, but sparing the palms and soles (figure). She had normal mental status, cranial nerves, motor, and sensory examination. Chest radiograph showed diffuse bilateral airspace opacities. Within a few hours of presentation she suddenly became confused, with flaccid paralysis necessitating intubation and admission to the medical intensive care unit. Electroencephalogram showed non-convulsive status epilepticus. MRI brain showed multiple foci of punctate microhaemorrhages throughout the corpus callosum, both temporal lobes, and left posterior cingulate gyrus, consistent with infectious haemorrhagic encephalitis (figure). HIV testing was positive, with CD4 count 4 cells/μL (normal 348–1456 cells/μL), and viral load was 66 000 copies/mL (normal < 50 copies/mL).
A skin biopsy sample stained positive for varicella zoster virus (VZV), but negative for herpes simplex virus (HSV). Zoster-associated encephalitis from disseminated VZV can develop within days of the disseminated rash, and should be strongly suspected in immunosuppressed patients. Characteristic signs of zoster-associated encephalitis include acute delirium, typical signs of stroke such as headache with acute hemiplegia, aphasia, ataxia, hemisensory loss, or visual changes, dependent on the predominant location of the VZV vasculitis. Intravenous aciclovir 10 mg/kg every 8 h for 7–10 days should be started early if there is clinical suspicion of encephalitis. Our patient was given intravenous aciclovir and multiple antiepileptic drugs to control her seizures. We treated her for VZV pneumonia, aspergillus pneumonia, propofolinduced pancreatitis, Escherichia coli urinary tract infection, and critical illness myopathy. After stabilisation in hospital she was started on antiretrovirals and pneumocystis pneumonia prophylaxis. After 2 months of rehabilitation she could walk independently and communicate without difficulty. At last follow-up in March, 2014, she had made a near full recovery in terms of her cognitive and motor function.
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Figure: Varicella zoster virus rash and encephalitis (A) MRI brain susceptibility weighted images showing innumerable microbleeds in splenium of corpus callosum and (B) microheamorrhages in bilateral temporal lobes. (C) Diffuse papular rash, with vesicles of the left leg.
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www.thelancet.com Vol 384 November 8, 2014
Disseminated varicella zoster virus encephalitis Wanxing Chai, Michael Gong-Ruey Ho Lancet 2014; 384: 1698 Published Online July 4, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60755-8 Lahey Hospital and Medical Center , Tufts University School of Medicine, Burlington, MA, USA (W Chai MD) and Carney Hospital, Tufts University School of Medicine, Boston, MA, USA (M G-R Ho MD) Correspondence to: Dr Wanxing Chai, Lahey Hospital and Medical Center, Tufts University School of Medicine, 41 Mall Road, Burlington, MA 01805, USA [email protected]
A
A 33-year-old homeless woman presented to the emergency room in September, 2012, with 2 days of dry cough, dyspnoea, and fever, and 1 week of pruritic rash. On examination she had a temperature of 41·0°C, blood pressure of 98/65 mm Hg, heart rate of 85 bpm, respiratory rate of 16 bpm, and O₂ saturation of 47% on room air. She had a diffuse papular rash with vesicles of different ages with haemorrhagic crust affecting the trunk, extremities, face, and scalp, but sparing the palms and soles (figure). She had normal mental status, cranial nerves, motor, and sensory examination. Chest radiograph showed diffuse bilateral airspace opacities. Within a few hours of presentation she suddenly became confused, with flaccid paralysis necessitating intubation and admission to the medical intensive care unit. Electroencephalogram showed non-convulsive status epilepticus. MRI brain showed multiple foci of punctate microhaemorrhages throughout the corpus callosum, both temporal lobes, and left posterior cingulate gyrus, consistent with infectious haemorrhagic encephalitis (figure). HIV testing was positive, with CD4 count 4 cells/μL (normal 348–1456 cells/μL), and viral load was 66 000 copies/mL (normal < 50 copies/mL).
A skin biopsy sample stained positive for varicella zoster virus (VZV), but negative for herpes simplex virus (HSV). Zoster-associated encephalitis from disseminated VZV can develop within days of the disseminated rash, and should be strongly suspected in immunosuppressed patients. Characteristic signs of zoster-associated encephalitis include acute delirium, typical signs of stroke such as headache with acute hemiplegia, aphasia, ataxia, hemisensory loss, or visual changes, dependent on the predominant location of the VZV vasculitis. Intravenous aciclovir 10 mg/kg every 8 h for 7–10 days should be started early if there is clinical suspicion of encephalitis. Our patient was given intravenous aciclovir and multiple antiepileptic drugs to control her seizures. We treated her for VZV pneumonia, aspergillus pneumonia, propofolinduced pancreatitis, Escherichia coli urinary tract infection, and critical illness myopathy. After stabilisation in hospital she was started on antiretrovirals and pneumocystis pneumonia prophylaxis. After 2 months of rehabilitation she could walk independently and communicate without difficulty. At last follow-up in March, 2014, she had made a near full recovery in terms of her cognitive and motor function.
C
B
Figure: Varicella zoster virus rash and encephalitis (A) MRI brain susceptibility weighted images showing innumerable microbleeds in splenium of corpus callosum and (B) microheamorrhages in bilateral temporal lobes. (C) Diffuse papular rash, with vesicles of the left leg.
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www.thelancet.com Vol 384 November 8, 2014
