Department of Internal Medicine, Thomas Jefferson University, Philadelphia, USA.
Abstracts of the papers presented at the XVIII National Conference of Indian Virological Society at Post Graduate Institute of Medical Education and Research, Chandigarh, India, December 11–13, 2008.
An 85 year old man presented to the emergency with increasing confusion and gait instability of five days duration. Past medical history included diabetes, bladder and prostate cancer, and a stable meningioma. Neurological examination revealed disorientation and generalized hypertonia; serum analysis showed WBC of 16,500/ml with Polymorphonuclear cells 80%, bands forms 2%, Lymphocytes 13%, Monocytes 5% CSF examination revealed clear fluid with 67 white blood cells (79% neutrophils), 360 red blood cells, protein 134 mg/dl, glucose 136 mg/dl, and negative gram stain, fungal and AFB stains and cultures. MRI Brain showed punctate focus of subacute ischemia in the right posterior temporo-occipital junction as well as age related cortical atrophy with moderate microvascular disease. On day 2 of admission, a vesicular rash was noted over the right chest wall. The CSF PCR for Varicella Zoster virus confirmed the diagnosis showing 5,02,000 DNA copies/ml. CSF PCR for HSV, CMV, and CSF VDRL were negative, as were the serum HIV ELISA and PCR. Intravenous acyclovir was started on day 2, with steady initial improvement, and was continued for 21 days to minimize risk of relapse. He had a slow but satisfactory response with mental status returning close to baseline, and no relapse so far. This case describes CNS involvement related to VZV, and also highlights the clinical significance of making a diagnosis with a concomitant classic rash and altered mental status. The most common neurologic complication of herpes zoster is chronic pain (postherpetic neuralgia). Acute or chronic encephalitis, ophthalmic zoster with contralateral hemiparesis, myelitis, polyradiculitis, motor neuropathies, large- and small-vessel arteritis, ventriculitis, and meningitis and a variety of cranial and peripheral nerve palsies, including Bell's palsy and Ramsay Hunt syndrome have all been associated with herpes zoster as well VZV. Encephalitis has been more common in patients with immune suppression or AIDS, but can occur in the immunocompetent individuals as well. Diagnosis is proven by CSF PCR for VZV (sensitivity, 80%–95%, and specificity, >95% in immunocompromised persons). Depending on the immune status of the patient, the duration of treatment with IV acyclovir varies from 14 days in immunocompetent to 21 days in immunocompromised patient. This case also strongly supports the current Center for Disease Control recommendations for vaccinating adults over 60 years of age against Varicella Zoster.
